Clarendon Beechlands

Updated 6 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was conducted by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Clarendon Beechlands is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Clarendon Beechlands is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 23 January 2023 and ended on 27 January 2023. We visited the location on 23 January, 24 January and 25 January 2023.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 13 December 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We sought the views of 9 people living at the service and heard comments from 4 people’s next of kin. We spoke with 17 staff including the registered manager, regional director and associate director. We reviewed a range of records including care plans, risk assessments, medicine records, audits, policies and procedures, training data and recruitment information.

Updated 6 May 2023

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Clarendon Beechlands is a residential care home providing personal care to 18 people at the time of the inspection. The service can support up to 18 people who have a learning disability or autistic people, people with a mental health condition and younger adults.

People’s experience of using this service and what we found

Right Support: People did not receive the support required in a safe way. There was a shortage of staff, and not all staff were sufficiently trained. This meant staff were not always available to administer medicines, and staff did not understand their responsibility to report restrictive practices. This resulted in people experiencing unlawful restrictions on their daily life.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care: People did not always receive care and treatment that promoted their human rights or encouraged and promoted their dignity and privacy.

Right Culture: A lack of leadership allowed a poor culture to develop within the service. Whilst most people were happy to live at the service, and provided some good feedback, the management did not effectively assess areas of safety and quality and facilitate any drivers for improvement. Some areas of the home were not cleaned thoroughly, and other areas needed decorative repair.

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 25 September 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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

We have identified breaches in relation to risks of abuse and harm to people, poor upkeep of the building, a lack of staff and a lack of leadership 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

We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

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.