Clare Hall Nursing Home

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

The management team knew people well and were passionate about making changes to improve people’s lives. They talked openly and honestly about the culture at Clare Hall Nursing Home. They told us they offered an open-door policy, and that staff were encouraged to whistle blow if they felt the need. The provider had policies and procedures to make sure staff were fairly recruited and treated. At the last inspection new systems and processes had been introduced to monitor the service. These were now embedded and were more effective in identifying and addressing shortfalls in a timely way. The management team completed daily walk arounds and worked alongside staff. They had a clearer oversight of care provision at the home. Where gaps in records were observed, action was taken quickly to ensure people were not placed at risk.

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.

The management team and staff knew people well and were passionate about making changes to improve people’s lives. The management team were clear about the direction for the home and staff felt this was communicated to them. We saw there had been improvement within the service, and the management team were open about the need for continued development.

The registered manager, nominated individual and deputy manager were working at the home daily to support the staff team and provide consistency. The management team led with integrity, openness and honesty to ensure care and support was delivered in line with people’s wishes and the values of the organisation. People and relatives told us the management team had an open-door policy and made time to talk with them. After our site visit the registered manager left their position. We were given assurances by the nominated individual that they, along with the deputy manager would ensure management stability at the home.

The registered manager said they were supported by an experienced nominated individual and deputy manager who they worked closely with to implement new systems and processes to improve the quality of care. Staff spoke highly of the registered manager and deputy manager and said the management team were visible and were easy to approach. People gave us mixed feedback about the registered manager, many not being aware who they were. Comments included, “I know the manager and she is approachable,” “I don’t know the manager” and, “I am not sure who is the manager.” The registered manager felt this was because she worked alongside staff and conducted a daily walk around the home, and they did not recognise their position. Support systems were in place to ensure the registered manager had the required knowledge and skills to lead the service effectively.

The service was supported by an experienced management team who understood their management responsibilities. They were knowledgeable and experienced in supporting the needs of the people who lived at the service. They worked closely together and discussed daily any changes or actions needed. The management team completed visits to the service out of their normal working hours to monitor the service.

Staff said that the management of the home were very approachable, and they would be comfortable to share any worries or concerns. People said if they had any complaints, they would be comfortable to discuss them with their relatives and the management team. The management team talked openly and honestly about the culture at Clare Hall Nursing Home. They told us they offered an open-door policy, and that staff were encouraged to whistle blow if they felt the need.

The management team operated an open-door policy, to enable staff to speak with them if they needed to. Systems were in place for staff and people to raise concerns. This included individual supervisions, in team meetings and via whistleblowing and complaint procedures.

Staff felt fairly treated and respected by the management and their colleagues. The management team told us they ensured staff equality and diversity was maintained through their safeguarding and HR policies and procedures.

The provider had policies and procedures to make sure staff were fairly recruited and treated. The registered manager recorded in the provider information return when asked what work they had done in the past 12 months to ensure equality and inclusion for their team, ‘Cultural understanding and appreciation as Clare Hall has a high number of staff from different cultures. Additional training and support. Staff recognition by celebrating every member of staff's birthday. Positive impact promoting teamwork, which the home will continue to focus on by developing strategies to further enhance teamwork and workplace satisfaction.’ Training records reflected staff had undertaken training in equality and diversity, to promote inclusion within the staff team.

Staff and the management team felt there had been real improvements in the home since our last inspection. Staff told us they liked working at the home and the management team were supportive and approachable. Staff we spoke with were confident that they could discuss any concerns with the management team, and these would be acted on, they were aware of how to escalate concerns to outside of the organisation.

The provider had commissioned 2 mock inspections since our last inspection by an external company and acted upon areas identified for improvement. They had also worked with the local authority quality team who recognised the improvements made. The provider had an audit programme in place. Regular audits were undertaken by the management team. If audits identified any areas of concern, actions were identified and actioned when required. At the last inspection new systems and processes had been introduced to monitor the service. These were now embedded and were more effective in identifying and addressing shortfalls in a timely way. Services providing health and social care to people are required to inform the CQC of important events that happen in the service. The management team had correctly submitted notifications to CQC. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so.

People and relatives told us they were aware staff worked in partnership with other agencies to meet people’s needs. No one raised any concerns about access to specialist services. The staff worked with other professionals and groups to meet people’s needs and promote their wellbeing.

Staff felt they had good relationships with local professionals which enabled them to meet people’s needs. They worked with local professionals to support people’s health and wellbeing. This included GPs, social workers and pharmacists.

A visiting professional said, “Staff work with me.”

The provider had policies and procedures to ensure information was effectively shared with appropriate agencies. This included sharing concerns with the local safeguarding team.

The provider had an electronic signing in and out system at the entry of the home. Professionals, relatives, people visiting, and staff were given the opportunity to record any concerns or compliments. The nominated individual told us any feedback was addressed quickly and used to make improvements. For example, a relative had commented about food which was investigated. Staff told us they could share ideas with the management team and felt they were listened to.

Processes had been improved since the last inspection. There were systems in place to support learning and improvement in the home. A long with the providers opportunity to feedback on the electronic signing in and out system at the entry of the home, there were other opportunities to ask for feedback. This included, quality assurances surveys, relatives and resident’s meetings, staff meetings, staff supervisions and the complaints procedure. One person told us, “I was given a survey asking me what I thought.”