Clement Court

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

People were kept safe from abuse as people told us they felt safe, staff understood their responsibilities and safeguarding referrals had been made. The service was working within the principles of the Mental Capacity Act 2005 (MCA) and if needed, appropriate legal authorisations were in place, or had been applied for, to deprive a person of their liberty. People told us they were well supported by staff and staff could tell us about people’s needs. However, we observed plans were not always followed to reduce the risk to people and plans were not always reviewed and updated following incidents. Improvements were needed to ensure risks were appropriately assessed and planned for and to ensure was learning from incidents. The home environment needed improving to ensure it remained safe as some areas which could pose a risk to people had not been identified and risk assessed such as oil-filled radiators, incorrect-height stairgates, external areas and one free-standing fireplace. Infection control in relation to the maintenance of the home needed improving, however a refurbishment plan was already in place and progressing. There was mixed feedback from people and staff about staffing levels and we observed some people had to wait for support. Staff were generally recruited safely however improvements were needed to ensure a full employment history was recorded, or gaps were explained. Staff received training and supervisions. Medicines were not always managed safely, and people were not always having them as prescribed. Staff were not always confident when using the electronic medicines system. The provider failed to ensure medicines were safely managed and failed to ensure risks to people’s health and wellbeing were sufficiently assessed and mitigated.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us staff supported them well. One person said, “I feel safe, no issues.” Another person told us, “Staff never hurt me, and I feel safe.” Another person commented, “Staff know how to handle me.”

Staff understood their safeguarding responsibilities. They were able to tell us about different types of abuse, how to recognise potential abuse and they knew to report their concerns. Staff knew they could report their concerns externally if needed.

Appropriate referrals had been made when abuse was suspected, and a safeguarding tracker was in place to monitor the outcome of referrals. The registered manager had started looking at lessons learned to reduce the risk of concerns arising again, although this was a new process and was not fully embedded. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place, or had been applied for, to deprive a person of their liberty. The registered manager was implementing a new tracker in order to have a more up to date oversight of this.

People told us staff supported them well. One person said, “I feel safe, no issues.” Another person commented, “Staff know how to handle me.”

Staff told us they knew people well. They were able to tell us about people’s needs and risks they needed to be aware of to keep people safe and to keep themselves safe. However, our observations did not always confirm this was correct.

We observed one person was supported in bed with their breakfast, however their care plan stated they should be supported in a chair for meals as there was a choking risk. We observed people were supported safely with moving and handling.

People generally had care plans in place to match their needs. However, it was not always clear there was learning following incidents to update people’s care plans and some plans would benefit from having more detail. One person had experienced symptoms of being unwell and no risk assessment or plan had been put in place to guide staff how to support the person, following this episode. Following our feedback action was taken to address this and we saw it had been put in place. In another example, a person had experienced extremely distressed behaviours and there was a lack of evidence there had been learning following this as their care plan had not been updated. Another person had conflicting information in their care plans about their dietary needs, which could put them at risk if the wrong information was followed. Another person had minimal detail about how staff should support them when they were distressed. Other people had appropriate care plans and risk assessments in place.

We observed parts of the home were not always safe. We observed one exposed and broken radiator which was hot to touch and could pose a risk to people. There were other oil-filled radiators in some people’s bedrooms. They were generally not switched on so were not posing a burn risk at that time, however they were a hazard if a person fell on to them. There was a free-standing fireplace which had not been secured to the wall so could pose a toppling risk. There were also several stairgates which were not at the correct height so could also pose a toppling risk to people. The external areas to the home were not always safe. Parts of the home need refurbishing as they were in poor condition, such as one room which had a toilet which was not attached to the floor and curtains damaged in another person’s room. Following our feedback, action was taken to address concerns. However, other safety measures were in place such as window restrictors.

Risks had not always been assessed to ensure measures in were always appropriate. The use of stairgates and oil-filled radiators had not been risk assessed. The external spaces had not been assessed to ensure fire or emergency escape routes remained safe and effective to use. A refurbishment plan was in place to address the need for improvements throughout the home. This was ongoing.

People had mixed feedback about whether they had regular staff. Most people felt they saw regular faces and most felt staff knew what they were doing. Although there was some feedback about there being staff changes. One person said, “There are some changes of staff, you get used to someone then they go.” A relative said, “There are changes of staff…. But the regular staff know my relative well.”

There was mixed feedback from staff about staffing levels. Staff told us people had to wait for support at times, as there were not always enough staff, or staff with the right skills and experience, to support people in a timely way. One staff member said, “It can be hit and miss. There are days with enough and not enough staff and the impact of that - residents waiting longer for things they want, like drinks and toileting. It could be waiting until the afternoon to get up.” Whereas another staff member said, “We could do with more regular staff, rather than agency. We’re lucky because we do get the same agency, though.” Another staff member told us, “There are enough staff, we do use regular agency staff who know people well.”

We observed people had to wait for support to get out of bed, as there were a number of people who were able to get out of bed, who were not supported out of bed until nearly lunch time. We also observed people’s experience at lunch time differed – some waited a long time for support and food was left to go cold, and others were supported swiftly.

Staff were generally recruited safely, although some improvements were needed. Staff had checks on their suitability to work with those who used the service, including criminal record checks, identity checks, references and employment history. However, there were sometimes unexplained gaps in staff employment history and evidence the reference from the most recent employer had been requested were not always available. Agency staff had profiles in place to advise the recruitment information in place collected by the agency. The registered manager took action when there was evidence staff had not been performing at the necessary level. Staff training was generally up to date, however as there were so many issues with medicines, we could not be sure the medicine-related training was always effective. Staff received supervisions and engaged in team meetings to discuss concerns and receive updates about expectations.

We observed the clinical rooms were not in good condition, which would make effective infection control difficult as surfaces could not always be cleaned, such as untreated wood and damage to walls, for example. The home was being refurbished so some areas needed further work, such as exposed walls when radiators had been removed. However, other areas of the home appeared clean.

The provider had an electronic system in place to record the administration of medicines. Staff told us they were not always confident using the electronic system. The registered manager explained there had been difficulties when training staff on the new system due to lack of individual laptops for staff to use, so not all staff had sufficient access to the system in a training environment prior to using it when administering people’s medicines.

Medicines were not always managed safely, and people were not always having them as prescribed. People had missed medicines due to staff failing to recognise the prescription instructions were not being followed. One person had returned to the home from hospital and staff had failed to add the medicines the person was discharged with onto the medicine system, so the medicines had not been administered. This put the person's health at risk. Another person was prescribed a medicine to help them go to the toilet – this was both a regular daily dose and a ‘when required’ dose. Staff had failed to administer this as a regular dose for a prolonged period and the person had experienced periods of struggling to go to the toilet, which could put them at risk and could lead to discomfort. Topical creams were not always effectively recorded so we could not be sure these were being applied. One person had a cream in their room which had been opened, but this was not being recorded on either the provider’s medicine system or on the care notes system. Another person had medicine patches applied. These patches should not be applied on the same area of skin. Staff were not recording where these patches were being applied, so there was a risk they could be applied to the same area of skin, which put the person at risk of experiencing side effects. Stock levels often did not match records so we could not be sure people were having their medicines as prescribed.