Clarendon Beechlands

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

At our last inspection, the provider was in breach of Regulation 12 (Safe Care and Treatment), Regulation 13 (Safeguarding), Regulation 15 (Premises and Equipment) and Regulation 18 (Staffing) and needed to make significant improvements to the service. At this assessment, the whole staff team demonstrated they had worked very hard to implement positive changes within the service and were now meeting the standards expected. This meant the provider was no longer in breach of regulations 12, 13, 15 and 18. People felt safe living at the service. Relatives were pleased with the care their loved ones received. Risks to people were now effectively assessed and mitigated where possible. The provider had invested heavily in redecoration works and domestic staff, resulting in a clean, sanitary, and homely environment for people to live and staff to work. Sufficient numbers of staff were now in place, and staff had received the necessary training to allow them to competently complete their roles. People told us staff were readily available. People’s rights were now upheld, and staff had increased knowledge of safeguarding issues and procedures. Some minor issues were identified with medicines, however no one at the service was impacted. The registered manager took immediate action to remedy the issues and we were assured by this.

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.

People told us they felt safe living at the service. One person said, “I am very, very happy here, I love it!” Relatives told us their loved ones were safe at Clarendon Beechlands.

Staff knew how to report any accidents or incidents. The regional manager explained how they also reviewed these to identify if any themes or trends were prevalent.

The Registered Manager was confident in the process they would follow in the event an incident or accident had occurred. To ensure learning was taken from events, any incidents would be analysed to examine if action could be taken to prevent a reoccurrence, and the outcomes were discussed with staff. People’s care records were also updated where appropriate.

People received joined up care when they needed to be transferred to another service, for example a hospital admission. A relative praised staff for their support during a recent hospital admission for their loved one. They said, “The staff called me to say that they were calling an ambulance, so I went over to the home. The staff were marvellous with [name] while we were waiting, taking observations and everything. I accompanied [name] to hospital, and when they were discharged. The staff welcomed [name] back with open arms, it all went well."

The registered manager advised medicine records and important information would go to a new service with the person, for example, a hospital admission.

The service received positive feedback from paramedics who attended the service. They described the senior care staff member on duty that day as informative and that the staff “rapport with residents is amazing."

The provider had processes in place for events such as hospital admissions. For example, staying in contact regularly with the hospital and liaising with family members.

At our last inspection, there were significant concerns about people being deprived of their liberty without lawful authorisation. People were withdrawn and non-communicative. At this assessment, it was clear the provider had made profound improvements. People’s rights were now being upheld, and people were given privacy and treated with dignity. One person who had been particularly affected and would not communicate with inspectors at the previous inspection, was alert, smiling and engaging at this assessment. They were happy to speak to inspectors and said they, “feel safe and like it here."

Staff knowledge on safeguarding matters had significantly improved since the last inspection. Staff could now confidently describe incidences in which they would report to safeguarding, how they would raise it, and to whom. The registered manager confirmed they discussed safeguarding as an agenda item at all staff meetings and spent time discussing this in depth during staff supervisions and appraisals.

We observed posters on the backs of doors to remind staff about safeguarding principles, and in people’s bedrooms with contact details if they wished to raise a safeguarding concern. We also observed staff respecting people’s protected characteristics.

Staff completed regular safeguarding training and described how policies and procedures were in multiple places to promote easy access to the documents. The Nominated Individual told us they regularly review all safeguarding alerts across the organisation, and share any lessons learnt with all homes.

People told us they were well supported at Clarendon Beechlands. Relatives feedback mirrored the feedback of people. One relative said “I’ve never had to raise any concerns about [name’s] care.

The registered manager described the process they used to support people to take positive risks. They said, “We sit down with [name] and ask them what they want to do, we go through the pros and cons with them, allowing them to make the decision, and support them to do it in a way that minimises risks."

Staff knew people well and we observed they responded quickly when a person became emotional and distressed. The person was observed to be feeling much calmer after their interaction with staff.

At our last inspection, we identified risks to people and staff due to a lack of care planning and guidance for staff. At this assessment, the provider had worked hard to reevaluate all people living at the service. Robust risk assessments were now in place to assess and reduce the impact of any potential risks to people and staff.

People lived in a safe environment, which was clean and sanitary. A relative said, “I think the house is really clean. They clean [name] ensuite every day."

The registered manager explained all of the safety checks which were completed at regular intervals such as Portable Appliance Testing, and the servicing of other equipment within the service.

The provider had undertaken a full audit of the environment, following our last inspection, and the changes made were noticeable immediately on this inspection. The service now employed specific domestic staff to complete cleaning tasks, and the provider had invested a significant amount of money into renovating all areas of the home. All 18 bedrooms had been redecorated to a high standard and had brand new ensuite bathrooms fitted, which were now free from mould and much easier to clean properly. A further new bathroom had been installed on the ground floor. A lot of work had also gone into decorating and improving communal areas.

The provider had a maintenance book in place used to report any maintenance issues and we observed this being used during our visit. The maintenance team’s visit fell at the same time of the inspection, and the repair was actioned in a timely manner. The registered manager completed a daily walk around to check the cleanliness, safety, and condition of the service.

People told us staff were readily available. One person said, “Staff are always available in the day and night.” Relatives told us there were enough staff at the service, including in the evenings and at the weekend. One relative said, “Staff have enough time to spend with [name]. If he needs something, he will go and find them, but I know that when I have been there, they have knocked on his door to check on him."

The registered manager illustrated how they assessed core staffing levels based on people’s needs and the number of staff needed to ensure the smooth running of the service. Some staff, such as senior care staff members were supernumerary. The registered manager also described how staffing levels had recently been changed in response to a person’s needs increasing.

We observed sufficient numbers of staff on duty during our inspection, including when we arrived to conduct an unannounced out of hours visit.

All levels of the management team had access to the staff training matrix. This ensured that training was completed in a timely manner by staff members. Competency checks were in place, and staff received regular supervision and annual appraisal.

People felt the home was clean and well maintained. One person told us, “Staff keep the home very clean and tidy."

The registered manager stated staff completed infection prevention training, and food hygiene training. Staff confirmed they received this training regularly.

During our visit, we observed a marked difference in the cleanliness of the service from our previous inspection. We witnessed staff using appropriate Personal Protective Equipment (PPE) when required.

Domestic staff followed cleaning schedules to ensure that all areas of the home were cleaned regularly, including cleaning high touch points frequently. The registered manager’s daily walk around checked that cleaning was being completed to a high standard. Spot checks were conducted with staff to ensure correct PPE was worn, for example when preparing food, or when administering medication.

People received their medicines safely. One person said, “Staff assist me with my medication, there have been no mistakes since I have been here."

The registered manager told us the medicines inspector identified 1 box of paracetamol which had recently passed it’s expiration date. These had not been administered to anyone at the service. They advised they had called a staff meeting and altered the way dates on medicines are checked to ensure this did not happen again.

During the assessment, a minor issue was identified with the fridge temperature check process. There were no high-risk medicines in the fridge, so this did not impact people at the service. The registered manager acted immediately and implemented an updated process.