Clement Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed and cleanliness of some people’s equipment.

This service scored 53 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The recording of incidents which could result in harm needed improving. For example, we observed 2 different incidents involving the same person. When we later checked the records for these, only 1 of these incidents had been recorded. An incident of the person being found on the floor was not recorded.

In another example, 1 person’s incident form did not clearly identify whether a person’s fall was witnessed or unwitnessed, so we could not be sure the response to this incident would be reviewed and learning embedded into the person’s care. In other examples, when people had tried to communicate their feelings using distressed behaviours, records did not always contain much information about what had prompted the behaviour, how the person was supported and there was no review of these records. The provider’s electronic system had forms in place for staff to record the support people received. Staff did partially complete these, but the system also prompted a review of these, and this review was not being completed. These types of incidents did not form part of the overall review of accidents and incidents or any other type of review so there was a missed opportunity to learn and improve people’s care.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

A relative told us, “My relative is definitely safe. My relative has the staff looking in on them regularly. We feel reassured.”

Professionals told us there were appropriate referrals to their organisations. One professional said, “Referrals and outcomes are quite good and established but that is because the clinical lead deals with things.”

There was monitoring in place of people’s health needs and the provider worked with other health professionals to try to keep people well. People had their weight, fluid intake, food intake and other health activities monitored. The deputy manager explained there was a ‘governance report’ completed every night about which person was to be monitored closely ‘(on watch)’ due to not having enough fluid intake so it could be distributed to the staff team. There was a daily ‘stand up’ meeting involving multiple departments in the home to ensure there was sharing of information about people. For example, when someone’s dietary needs changed there was a process in place to ensure kitchen staff were informed to ensure they prepared appropriate food for a person. There was a weekly report given to staff and daily checks at the ‘stand up’ meeting.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

The provider was not always protecting people’s rights as some people were being restricted in bed. Some people were not always supported out of bed in a reasonable time each day, and some remained in bed as they did not have sufficient equipment to support people to utilise the communal areas. The provider could not be assured that people were being restricted to bed lawfully.

Staff were generally able to tell us about the different types of abuse. However, staff awareness needed strengthening as 1 staff member was not able to tell us about different types of abuse, and 2 staff were not able to tell us about DoLS. Staff were aware of how to report concerns; however, it was important that staff were able to recognise different types of abuse to ensure they could identify concerns and report them appropriately.

There had been instances where incidents had not been recorded, so we could not be sure all concerns would be recorded and picked up by the management team to enable them to report concerns. However, the provider had an appropriate policy and process in place to respond to and address safeguarding concerns.

Relatives told us they felt their loved ones were safe. One relative said, “My relative always seem to be comfortable with staff, they seem to be joking with staff.” Another relative said, “We feel settled as we feel it’s the right place for my relative.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was mixed feedback from staff about the reasons people remained in bed and 1 relative said they were concerned about the amount of time their loved one was in bed. Care plans and risk assessments did not always clearly detail the reasons for people being in bed.

We observed safe moving and handling using equipment, except for 1 occasion of a person’s feet being knocked while another person was being hoisted, due to the lack of space in the communal area downstairs. We also observed those who needed a pressure cushion or a sensor equipment where they sat had these in place.

However, other than the reasons for people remaining in bed, staff knew people’s other needs. For example, staff understood how people used behaviour to communicate and what might cause them to become distressed and how they could be supported to remain calm.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The Health and Safety Executive (HSE) have guidance in place about the temperature water should be in care homes.Checks were made on the temperatures of hot water in showers, baths and sinks used by people. These checks showed some outlets were a dangerously high temperature which could put people at risk. Following our feedback, the provider took action to address these to ensure they were a safe temperature.

Radiator covers were in place to try to keep people safe from hot surfaces; however, many of these were not secured to the wall so could be easily removed, exposed the hot surface beneath. Following our feedback, the provider took action to address these to ensure they were secured in place to reduce risk to people.

Window restrictors were in place to reduce the risk of people falling from windows; however, some of these restrictors did not have tamper-proof fixings in place, so there was an increased risk people could undo these restrictors. Following our feedback, the provider took action to put tamper-proof fixings in place to reduce the risk to people.

A small service lift which was unsecured at the last inspection had now been secured; however, the external lock appeared broken. The provider told us this was resolved following our feedback.

The provider did not always make sure there were enough qualified, skilled and experienced staff deployed to meet people’s needs. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People told us they had to wait a long time when they pressed their call bell. One person said, “I press it and hope!” Relatives also told us they struggled to find staff. One relative said, “You can never find anybody, when we’re going, we have to find someone to let them know we are going so they know my relative is on their own.” Another relative said, “I can walk to my relative’s room and not see a soul. I do wonder if there is the right ratio [of staff].”

Staff told us they were not always working effectively to meet people’s needs. One staff member told us, “We do struggle sometimes [to get people out of bed]. A lot are hoisted, 2 needed for each hoist. We get the 08:30 repositioning and pad [incontinence aid] checks done before getting people out of bed.” The same staff member went on to say, “We’ve not got [person] out [of bed] today, we’re that far behind.” Another staff member told us, “Yes, sometimes [people are left in bed] but we do get to everyone by lunch time.” The same staff member also said, “We don’t have enough staff today. Yesterday was a good day. We need to save money; we are always rushing.” Another staff member said, “It [staffing] could be better, but we do manage. Overall, its pretty good.”

A professional said, “I think there are enough staff, but staff do seem rushed.” Another professional told us, “There has been times when we have had to wait due to staff being very busy and possibly understaffed on the day.”

We observed and were told staff were not always working effectively. For example, staff told us staff designated as team leaders would support delivering continence pads to people’s rooms following deliveries to the home. Whilst this task needed completing, this was not always an effective use of a team leader’s time, as they could have been supporting people with personal care or repositioning. This task could have been undertaken by another staff role within the home. In another example, a staff member told us care staff were having to support someone to access outside space multiple times a day. They said, “We have to stop doing personal care which is important to take [person outside], but it puts pressure on us.” Another job role may be able to support the person to avoid taking carers away from delivering personal care to people.

When we asked the provider about this, they said, “We remain confident that staffing levels are suitable to meet residents’ needs. However, we acknowledge that delegation can still be an issue. [The deputy manager and interim manager] continue to support and coach the team to ensure appropriate delegation and effective support for each resident.”

There was a relatively stable staff team, with minimal agency use, so people had consistency with the staffing team. Staff were recruited safely. Checks were made on their suitability to work with people who used the service, such as employment history, references, right to work and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff told us they had received training to be effective in their role, and records confirmed this. Staff also told us their competency was checked, to ensure they understood their training.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

One relative said to us, “That is something I have brought up with them before, a table can have crusted dinner on and sometimes the floor can be a bit dusty. I have mentioned it a few times when my relative’s duvet is crusty and dirty and they have come straight away but I shouldn’t have to mention it.”

Two people were using wheelchairs which were not suitable for use due to how dirty they were. One of the people’s chairs was also damaged so there was exposed foam so it could not be cleaned hygienically. Following our feedback, the damaged chair was replaced by our second visit. However, the other person’s wheelchair remained unclean.

We observed slings being used when people were supported with hoisting; however, 10 of these slings were visibly unclean and did not have clear labelling to identify which person they belonged to. This was not effective infection prevention and control. We observed a staff member picking up tablets with a bare hand which had been spat out by a person, which could put the staff member at risk through absorption and there was no consideration of infection control. We also observed a staff member involved in the support of people who had long nails, which could pose infection control issues and could cause discomfort for people being supported.

Despite these issues, staff told us they had access to Personal Protective Equipment (PPE). The home appeared clean and there were no lingering malodours. A professional told us the home was clean whenever they visited. Food hygiene checks were in place and appropriate.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Guidance for staff in relation to ‘when required’ medicines (also called PRN medicine) were often poor or incorrect. Therefore, we could not be confident people were always receiving their ‘when required’ medicine at the time it was needed. A PRN protocol for a rescue medicine to be used at a time of emergency was not in place prior to this being requested by the CQC, at which point the protocol was written. Protocols for medicines used to support people with constipation were not always appropriate, and medicines administration records showed these medicines were not always given in a consistent way.

We checked multiple medicines stock levels to check they matched records. Two thirds of the medicines stock levels matched records; however, 1 third of the medicines stock levels did not match records so we could not be sure they were administered correctly. This put people at risk. All medicines we checked which required extra checks on stock levels, were stored securely and locked away stock levels matched the records.

We checked 2 different eye drops for people. One eye drop had the opening date on; however, another did not so there was a risk it may be no longer safe to use as there was a manufacturers guidance to dispose of it after a certain length of time.

We could not be sure medicines needing refrigeration were always stored appropriately as the fridge temperature monitoring equipment was not always rest correctly and when the maximum temperature had been identified, no further action had been taken to address this. Following our feedback, action was taken.

The provider told us there was not a clear medicine cycle in the home and there had been some issues with other organisations involved with the medicines in the home which had contributed to some of the medicine concerns. The provider was taking action to address concerns with medicines.