Clarendon Care Home

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

We assessed all quality statements within the safe key question. We found improvements had been made since the previous inspection in January 2023. The service was no longer in breach of regulations relating to assessing risk, safety monitoring and management, learning lessons when things go wrong, using medicines safely and staffing. This meant people were safe and were not at risk of avoidable harm. Safe systems were in place to manage risks. People, family members and external health and social care staff told us they felt the service was safe.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a robust process in place to monitor incidents, accidents and near misses. This ensured all accidents or incidents were individually reviewed and prompt action could be taken where required. Incidents and accidents were analysed every 3 months; the last analysis (July to September 2023) demonstrated a reduction in falls. Since the last inspection a number of improvements have been made and new policies, procedures and quality assurance processes have been introduced. These have resulted in an improvement in the overall quality and safety of the service and demonstrates organisational learning and continued improvement.

The providers spoke about the past difficulties they had, which resulted in the previous rating. They were open and transparent and it was evident they had worked hard to improve the service to provide people with safe, effective and person-centered care.

People and their relatives spoke positively about the staff and management team. They told us they could approach them with any ideas, worries or concerns. They had confidence action would be taken.

People were supported to attend external health appointments. A family member told us how the providers had taken a person for a hospital appointment. This meant any relevant information could be provided to the hospital staff and the service would be aware of any changes required following specialist appointments.

There was a comprehensive admission process which helped ensure that only people whose needs could be safely met at Clarendon Care Home would be admitted. Care records evidenced contact with the person, family members, external professionals and others involved in the person’s care as part of the pre-admission process.

External health and social care professionals were positive about their involvement in the service and felt staff and providers worked with them to ensure people received a safe and effective service. For example, an external health professional said, “Plans and recommendations that are made at the (monthly Multi Disciplinary Team) meeting are followed through by the team at Clarendon. Where clarification or further review is required Clarendon staff appropriately contact the team or resident’s GP. Another external professional told us, “The home works well in collaboration with myself and where feedback and recommendations have been given these have been followed quickly and appropriately.”

Staff had access to clear and up-to-date information relating to people's health and care needs.

People and their family members said they felt safe. A family member told us, "I couldn’t have left him in safer hands, as I can’t look after him myself anymore.”

Staff had received safeguarding training and knew how to prevent, identify and report allegations of abuse. One staff member described the actions they would take if they witnessed or suspected abuse may have occurred. They told us, "If I had concerns, I'd go to provider. I could also go to you (CQC) or social services if needed."

Appropriate systems were in place and followed, which protected people from the risk of abuse. The providers understood the actions required should they have a safeguarding concern. Where these had occurred, they had been reported appropriately to CQC and the local safeguarding team.

We observed staff supporting people safely and with kindness.

Risks were managed in a way to ensure people were able to be as independent as possible and could enjoy activities they liked doing. A family member told us how the risk of falls was managed for their relative. They said, “There is a sensor in his room, so they know if he’s on the move.”

Staff understood the risks in people's care and knew how mitigate risk to keep people safe.

Staff were available to offer support to people. We observed staff supporting people safely and with kindness.

At the last inspection we identified the provider's systems and procedures to assess and manage risks for service users were not sufficiently robust. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 12. Risks had been assessed and recorded, along with action staff needed to take to mitigate the risk. For example, risk assessments were in place for people at risk of falling, managing their medicines, nutrition and hydration. Daily records of care showed staff were following risk mitigation measures.

People spoke positively about the home and their bedrooms.

At the last inspection we identified the provider had failed to effectively assess, monitor and mitigate all risks's relating to the environment. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 12. Systems were in place to identify and manage foreseeable environment risks within the service. This meant people, visitors and staff were effectively protected from the risk of harm. Equipment was monitored and maintained according to a schedule. In addition, gas, electricity and electrical appliances were checked and serviced regularly. Fire safety risks and risks posed by asbestos and from water systems had been assessed by a specialist and where necessary action taken to ensure the environment was safe.

People appeared at ease in the service. Staff used equipment appropriately to promote people's safety, for example they responded promptly to call bells and sensor alarms.

Staff had received fire awareness training and understood the actions they should take should a fire occur.

People felt there were enough staff. One said, “They get to know you (staff), and they’re ever so nice, I know some really well, but I like them all.”

Staffing levels were appropriate to meet people's needs and there were sufficient numbers of skilled and experienced staff deployed to keep people safe. We observed staff were available to people and responsive to their requests for support. There was a relaxed atmosphere in the home and staff had time to chat to people and support them in a calm and unhurried way.

Staff told us staffing levels were sufficient to meet people's needs and provide people with the support they required. Staff felt supported in their roles and received one-to-one sessions of supervision and regular training.

At the last inspection we identified there were not enough staff appropriately deployed at all times to meet people's needs and there had been a failure to ensure staff received appropriate training. This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 18. The service considered people’s needs and abilities before admission to the service. This helped ensure there were appropriate numbers of staff available who had the skills required to support people. There were safe and effective recruitment procedures in place to help ensure only suitable staff were employed.

People and relatives were happy with the cleanliness of the home and the standard of laundry.

The home was clean and the provider was promoting safety through the hygiene practices of the premises with housekeeping staff completing regular cleaning in accordance with set schedules. We observed staff using personal protective equipment (PPE) including disposable masks, gloves and aprons appropriately.

Appropriate arrangements were in place to control the risk of infection. Staff had been trained in infection control techniques and had access to personal protective equipment (PPE). The provider's infection prevention and control policies and procedures reflected current best practice guidelines. They understood where and how to seek advice should they have an infection control concern. An external healthcare professional told us, “Staff are knowledgeable about signs of contagious diseases, how to seek advice and what appropriate barrier nursing to use.”

Staff had received training in infection prevention and control.

People received their medicines as prescribed and they could request 'as required' (PRN) medicines when needed.

Staff had been trained to administer medicines and had been assessed as competent to do so safely. The provider's procedure ensured this was reassessed at least yearly using a formal approach. Guidance was in place to help staff understand when to give people their medicines and in what dose.

At the last inspection we identified the provider had failed to protect people from the risks associated with the unsafe management of medicines. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 12. Suitable arrangements were in place for obtaining, storing, administering, recording, disposing safely of unused medicines and auditing of medicines systems. The provider undertook to review the procedures for recording temperature storage of medicines to ensure these would always be kept at the correct temperature and therefore safe to use. Systems were in place to ensure that when additional medicines such as antibiotics were prescribed, these were obtained promptly meaning there were no delays in commencement of administration. Audits of medicines were undertaken to identify any discrepancies with stock levels and ensure records of administration were fully completed.