Clarence House Care Home

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• 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

We identified some areas of risk and concern within the quality statements assessed for Well-led, resulting in breaches of regulations 17 and 19.

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.

Staff and leaders consistently gave positive feedback about working for the care provider and being part of the care team at Clarence House. This was also reflected in staff supervision and appraisal feedback seen as part of the assessment process. We identified staff, including those from overseas to be working a high number of hours each week. Whilst part of this would be based on individual choice, we felt a greater level of oversight was required by the provider to ensure individual staff welfare was being monitored. Staff demonstrated they worked well as a close team, and our observations and findings were supported by feedback received from staff. However, we identified areas of improvement with communication required to ensure risk information was being appropriately shared between staff during shift handover meetings. The registered manager explained that they were arranging for overseas staff to receive training face to face, to further aid their levels of learning and understanding, but also to offer those staff an external support network with people having similar experiences. The registered manager was clear they wanted to ensure overseas staff felt fully supported to develop and have equal access to training and development opportunities.

Meetings minutes and feedback from staff and leaders demonstrated staff were encouraged to give feedback and contribute their ideas to the development and running of the service, as were people and their relatives. New staff were given a full induction, with shadowing opportunities of a more experienced member of staff, to ensure the new staff member was familiar with the care environment, people’s assessed needs and risks before working alone. Where staff members had individual health conditions or risks, had ongoing reviews of their support needs to ensure reasonable adjustments were made where required.

We reviewed many quality audits and checks completed by the registered manager, provider and delegated members of staff. We identified some of the audits to be of poor quality and not be identifying risks and shortfalls found during our assessment visits, for example audits of care records had not identified discrepancies and inconsistencies in risk information within records that we found. Not all audits were completed in full, or only with limited detail and those with corresponding action plans showed many action points were rolling over from one month to the next without being addressed. Where risks and concerns were identified from audits and walk around checks, these were consistently not being acted on by the provider, to ensure changes and improvements to areas of safety were made. For example daily walk around records repeatedly showed issues with prescribed creams being left unsecured, and the provider’s own audits recorded a lack of lockable cabinets in place, but these findings remained an unresolved risk on both days of our assessment visits. Where checks were delegated to other members of care staff by the registered manager, these records contained no indication of final sign off and approval by the registered manager. This did not demonstrate the registered manager had good oversight of tasks such as the checking of window restrictors, health and safety checks and the maintenance and oversight of equipment. Improvements to the governance and oversight of accidents, incidents and safeguarding concerns was identified. Whilst weekly manager reports were being sent to the provider, and provider level reports were completed as an outcome of visits to the service, these were not identifying where incidents and accidents had met the threshold to be reported to the local authority safeguarding team and to CQC, to maintain people’s safety, and to safeguarding the staff team.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager and deputy manager demonstrated clear leadership and passion for their roles throughout our assessment visits. keen to develop their own knowledge and skills, and to drive improvements at the service. They both showed unwavering support for the staff team on the days of our assessment visits and imparted their experience and skills onto the staff team. The registered manager was clear they felt well supported by the provider but were also given full autonomy for the day to day running of the service. Lessons learnt following incidents as well as sharing positive feedback and compliments was in place within the service. The registered manager demonstrated an openness to our feedback and desire to continue to improve and develop the service, with the care and support needs of people living at the service at the heart of their plans. The registered manager has provided updates following our site visits to confirm actions taken as an outcome of our feedback.

Where concerns had arisen for example regarding individual staff practice, we saw evidence of the registered manager proactively addressing this, meeting with staff members and agreeing a plan of approach to mitigate the risk of reoccurrence.