20 February 2023
During an inspection looking at part of the service
Clarendon Gardens is a care home providing accommodation for persons who require nursing or personal care to up to 6 people. The service provides support to people who live with mental health conditions. At the time of our inspection there were 4 people living in the home.
People’s experience of using this service and what we found
The service was experiencing a staffing crisis. There were insufficient staff available to work including at manager and care worker level. The provider had not taken action to address this and the safeguards we found in place were inadequate.
The service did not follow safe recruitment procedures and staff were not sufficiently vetted to ensure they were suitable to support people who used the service. Staff lacked essential training and training records were not kept. Medicines were not always managed safely. Building and environmental checks were either out of date or non-existent.
Overall, the quality assurance monitoring system was not effective to ensure appropriate improvements were made to care for people who used the service. Risks to people were not always adequately assessed. The provider did not have effective systems in place to review care plans and risk assessments.
There were systems in place to protect against the spread of infection.
Staff worked with healthcare and social care professionals, to ensure people had a safe and effective service.
Staff were aware of their responsibilities to report allegations of abuse. People told us they felt safe using the service
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People made decisions about their care, and about matters to do with the running of the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 7 April 2021).
Why we inspected
We received concerns in relation to the lack of staff training, staffing levels and the provider managing the home without sufficient knowledge of people’s needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.
The overall rating for the service has changed from good to inadequate based on the findings of this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement and Recommendations
We have identified breaches in relation to safe care and treatment, staff recruitment, person centred care and good governance at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.