Clement Court

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

The service was in breach of legal regulation in relation to people not always being treated appropriately, in a way that met their needs or reflected their preferences.

This service scored 45 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always treat people with kindness, empathy and compassion, or respect their privacy and dignity.

A relative told us, “They [staff] are kind but looked rushed.” They went on to say, “They [staff] always speak to my relative, when I am here, kindly.” Another relative said, “I can honestly say now everyone is fantastic and make a fuss of my relative.” We observed terminology such as ‘grumpy’ being used by staff to refer to people’s demeanour in front of them which was not kind. However, there were instances of people not always interacting with staff in a kind manner, but staff remained calm and responded appropriately. We also observed many kind and caring interactions by staff. For example, when offering a person a drink, a staff member woke them gently, got down to their level, spoke nicely and offered the person a protective cover for their clothes – the person responded by hugging the staff member and saying thank you. We observed staff explaining things to people, most of the time, such as when someone was being hoisted or being moved to another room. There were some instances when someone had their eyes closed and staff did not interact with them to let them know they were being moved to another room.

Staff explained to us how they would maintain people’s dignity. One staff member said, “I talk through what I am going to do, cover them. I say, ‘You wash your face, can I do under your arms?’ I do their top first, then onto bottom half. I don’t fully strip [undress] people unless they are having a bath.”

The provider did not always treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. They did not always take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

We observed staff were task oriented in order to tick tasks had been completed on the provider’s electronic system where people’s care was documented. One staff member said, “The system has set times for tasks, rather than it being based on the last time it was completed.” This led to staff prioritising completing tasks, rather than taking a holistic, person-centred approach to people’s needs. On each day of our visit, people were left in bed until later in the day, when they did not always need to be in bed. One relative told us they were concerned about the amount of time their loved one was in bed, and their loved one seemed happier and more alert when they had been supported out of bed, but this was not often. Staff gave us differing accounts for why people had been left in bed. On each day of our visit, we found people were supported to remain in bed until later in the day, even when there was no clear evidence they needed to do so. One relative told us they were concerned about the length of time their loved one spent in bed and said their relative appeared happier and more alert when supported out of bed, although this did not happen often. In addition, staff provided inconsistent explanations for why people were being supported to remain in bed. This meant we could not be assured people were consistently supported in line with their individual needs or supported to maintain their independence and wellbeing.

We were told of 3 people who were not able to get out of bed at the same time, as they were sharing 1 specialist wheelchair. No action had been taken to address this to avoid people being left in bed unnecessarily. Following our feedback, the provider started to try resolve this. We will review this at the next inspection to ensure people are not left in bed unnecessarily due to lack of equipment.

People were supported with their meals, but the level of support was not always consistent depending on people’s individual needs. For example, 1 person could eat relatively independently, and they had a plate guard on the edge of their plate so they could do so. Others were able to eat independently. However, we observed an instance of 2 people who were sitting down being supported with their meals by 1 standing staff member at the same time, alternating mouthfuls of food to each person. In another example, a person was given their lunch but had no cutlery. This was not dignified. Their care plan indicated they sometimes threw their cutlery or crockery, so they should only be given plastic items. However, the person was not provided with this. This was not following the person’s care plan.

The provider did not always promote people’s independence, so people did not always know their rights and have choice and control over their own care, treatment and wellbeing. People were not always supported enough with meaningful engagement and activities to help maintain their wellbeing.

Relatives and staff did not always feel activities were sufficient or suitable. One staff member commented, “No there isn’t enough to do for people, if I’m honest. I think they could be given more funding. It’s hard to get some residents engaged. They do arts and crafts, flower arranging, baking. It does happen. We could have a sensory room. We try to do activities. Arts and crafts, ball games, armchair exercises, we have dogs coming in.” They went on to say, “We don’t get to go out on day trips. There are some people who could do trips. Activities [staff] do the best with what they’ve got.” Another staff member told us, “Residents need more meaningful activities.”

We observed some activities were taking place, including 1-1 sessions such as nail care, group exercise/balloon activity and a visiting pet. People were cramped in communal space on the ground floor when multiple people were supported in there. This did not allow for activity (other than watching TV) once more people were in the room.

Staff offered people the opportunity to wear protective clothing during lunch and we observed people’s choice was respected. People needing support with their meals had the food explained to them prior to staff putting it in their mouth, so people were aware of what they were eating.

The provider did not always listen to and understand people’s needs, views and wishes. Staff did not always respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

One person was observed showing distressed behaviours in their bedroom for an extended period of time during 1 afternoon. This person was shouting and concerned their baby had died. While staff periodically went in to the person, this was not sufficient to comfort the person. The provider had dolls in the service, which we observed being used in another part of the home. Staff did not try using a doll to comfort the person, despite their focus being on the loss of a ‘baby’. During our feedback to the provider, we were told concerns had been raised about this person’s care in 2025 by a visiting professional and sufficient action had not been taken to document and address this in order to improve care to the person. Therefore, the person’s immediate needs were not always being addressed.

Another person was vocalising loudly during lunch time downstairs, while they waited 46 minutes to be supported with their lunch. This vocalisation was causing distress to some people nearby. Staff had not considered the situation to attempt to decrease the distress to some people. The lunch time experience was not always managed well. Staff had set tasks which they did not deviate from, despite having the time to be able to. This meant people who were able to eat independently were left waiting for extended periods to receive their meals, while others were left with their food without encouragement or support to eat. Consequently, some meals went cold, and people were not consistently supported to have a positive mealtime experience.

We spoke with a person in their bedroom and they said, “Staff don’t bother with me, I'm not used to people speaking to me, no one cares.” People did not always have access to call bells despite some people being able to use their call bell according to their care plan, or staff telling us people should have a call bell. This meant they did not have an easy way of summoning assistance; at the point they felt they needed it.

However, people in communal areas had their needs met more speedily as a staff member was always generally present. Staff were allocated each shift to remain in a communal area, so they were available to support people. For example, getting drinks, snacks and fetching a jumper when someone was cold.

Staff were diligent in trying to complete scheduled tasks which they were reminded to complete by the electronic system. Tasks included supporting people to the toilet, repositioning and checks on continence aids. However, while these tasks were important to help people remain well, these checks often took precedence over other support needs such as being supported out of bed or having complete personal care. A staff member told us, “They [staff] change someone at 7am due to them being incontinent, but they’ve not done personal care, it’s not done at the same time. You may have to change someone’s pyjamas if you change their [continence aid], it doesn’t make sense to me.” Therefore, people were regularly being supported out of bed late in the day, once other tasks had been completed.

The provider did not always care about and promote the wellbeing of their staff. They did not always support or enable staff to deliver person-centred care.

There was mixed feedback from staff about how supported they felt, due to how well the staff team worked together on each shift.

One staff member said, “Most of the time, we’re a good team. Certain days’ work better than others. Depends which staff [are in].” Another staff member said, “In the last month I like the deputy manager. They [the deputy manager] thanks you, they make me feel proud, they bring me up again. Before I hated working here.” It was acknowledged by staff they felt they had more confidence in the new management team to make improvements and support them.

Staff told us of a counselling application (known as an ‘app’) they could access on their phone if they needed this. Staff had supervisions and the provider had a system in place to track when supervisions had been completed.