Clement Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Teamwork was not always effective to ensure a person-centred culture was embedded.

Staff had mixed views on the culture of the service. One staff member said, “It’s about caring. We do [care] but it’s what staff we’ve got.” They went on to say they would not recommend working at the home, “Not at present. Even though we’ve got less residents, it’s harder, it’s all these flags [tasks on the electronic system].” Another staff member said, “The [electronic] system flags and it has set tasks. I think that is a lot of the issue. The device is good, its reliable, that’s the problem. Staff will tell you that’s what they are frustrated with. When constantly [needing to tick a task is complete].” Another staff member said, “Staff do not work well as a team some are really good, but some are not.” Another staff member said about teamwork, “It depends who is on, [it’s] not always [good teamwork].” Two of the staff members said they were “not sure” if they would recommend working in the home.

Another staff member said, “It’s about person-centred care, dignity, maintaining safety, fun.” The same staff member said they would recommend working in the home.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

There was a new management team in place, but there was not a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. There was an interim manager in place covering this role in the home until a permanent manager could be recruited. A new deputy manager had started, and they told us they felt supported in their role.

Staff were positive about the new management team in place, so far. A staff member said, “The deputy manager is doing everything at the moment. The deputy manager seems very approachable. They are always coming up [to staff] saying well done and thank you.” Another staff member said, “We’ve got a good team in management now with [the deputy manager]. [The deputy manager] is trying their hardest to get things in place, they are really understanding, approachable, listens, takes things on board.” Another staff member said, “The deputy manager seems to be supportive, but they have only just started.”

The interim manager and provider were aware of their Duty of Candour. The interim manager said, “It’s being open, honest, transparent, getting on board and apologising when things go wrong, contacting relatives, completing correct documentation, learning lessons.” The management team were open and honest during the inspection and acknowledged there were areas needing work, including medication management, DoLS and care plans, for example.

However, the new management team had not been in post for long enough to affect enough improvements to ensure people were always receiving good care. Processes and a new culture had not yet been embedded. While the provider had identified many areas for improvement and had commenced action prior to our inspection, the provider had not identified all the concerns we had found during our inspection.

People did not always feel they could speak up and that their voice would be heard. However, the provider did have a policy in place.

Staff told us they felt able to speak up, but there was some mixed feedback. One staff member said, “I would [speak up]. I’d miss the nurse and go to management, HR, CQC or [the local] safeguarding [authority].” Another staff member told us they reported concerns and told us the issue “was dealt with.”

Staff told us they had team meetings or surveys they could complete to feedback, if they wanted to. One staff member expressed they did not complete these surveys as they did not trust they were truly anonymous. When we asked them why they wanted the survey to be anonymous, they said it depended on the questions they were asked.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were a range of different staff and job roles in the service, reflecting diversity. The provider also completed health risk assessments with staff when needed, to identify any health or emotional support needs, helping ensure staff received appropriate adjustments and support to carry out their roles effectively.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider medication auditing system had not identified the concerns we found during our inspection. These included poor, missing (in 1 instance) or incorrect protocols for ‘when required’ medicines, inconsistent administration of ‘when required’ medicines, an out-of-date medicine, stock discrepancies, an unlabelled opening date on 1 medicine and issues with the medicines fridge. In addition, the provider’s medication policy was also not always followed regarding ‘when required’ medication. However, the provider had identified some areas for improvement which had not yet been fully actioned and embedded at the time of the inspection. There was a missed opportunity to learn and improve people’s care as incidents were not always recorded, and behaviour records were not always reviewed. This gap had not been identified by the provider. Infection control or health and safety audits had failed to identify the concerns we found with the environment and the poor cleanliness of 2 people’s wheelchairs. Following our initial feedback, the provider gave us an action plan to address concerns. However, this action plan did not sufficiently address all areas. People’s distressed behaviours and the lack of their review was not referenced and action taken had not been effective for 1 of the dirty wheelchairs we observed, as it continued to be dirty on the second day of our inspection. There were gaps in the recording of the care provided to several people, such as evidence of oral care support, skin integrity checks, lack of detail in behaviour records and a missing incident record for 1 person. Some people’s care plans had missing information, or contradictions. This could lead to confusion for staff or incorrect support to people.

Some of the provider’s audits had identified areas for improvement, but these had not yet been fully addressed.

There was a lack of clear leadership and oversight on each floor of the home to ensure people were supported in a timely manner and appropriately. The provider’s systems had failed to fully identify the concerns we found.

The provider understood their duty to collaborate and work in partnership. However, the provider did not always share information and learning with partners or collaborate for improvement.

A professional told us, “I have found it frustrating when I email the home and no one responds (although this has recently improved). I know there have been difficulties with previous managers, and I have found it difficult on occasions to work with them as they were not approachable, and they did not respond to emails etc. However, most recent contact has resulted in an adequate response, and they appear to be more willing to work together with me.”

The provider was open and responsive to feedback; however, there had been input from multiple organisations and professionals to support and monitor the home, and this had not always been acted on to improve people’s care in a timely manner.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The provider had been under increased scrutiny in order to ensure people were safe, but the provider had failed to improve enough to ensure people received good care. While some improvements had been made at this inspection, the provider had breached regulations at the last 3 inspections (including this inspection), so people had been exposed to poor care for a prolonged period of time, and the provider had not demonstrated sustained learning or improvement.

The provider acknowledged mistakes do happen and recognised the need to learn from these. They said, “People make mistakes, people have challenges, we work with human beings. As long as people are honest, there’s nothing we shouldn’t be able to learn from, but we do have to hold people accountable.”

The provider told us they we in the process of establishing a stable management team following staffing changes and felt this would support improvement. We will check whether improvements have been made at the next inspection.