Clarendon Care Home

Clarendon Care Home is a residential care home providing personal care to up to 20 people. The service provides support to older people, most of whom live with dementia. At the time of our inspection there were 19 people using the service.

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

Risks associated with people’s health conditions and support needs had not been assessed, monitored or mitigated effectively. Environmental risks were not always safely managed and regular monitoring of some aspects of the environment did not take place.

We were not assured people received their medicines as prescribed because there were gaps in medicine records and the stock counted did not tally with records.

There were not enough staff deployed to safely support people throughout the day and ensure their needs were always met. Recruitment practices were mostly safe.

Safety incidents did not always promote improvement to reduce the likelihood of incidents of a similar nature reoccurring.

The provider had safeguarding processes in place but some concerns that we found throughout this inspection indicated some people may be at risk of abuse that had not been identified by the provider.

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.

Not all staff had received appropriate training to ensure they had the skills and knowledge to effectively support people.

Pre-assessments were not always completed prior to people moving into the service. This meant the provider may not have all the information they needed to support people safely and effectively.

The environment needed improvement to make it dementia friendly. We have made a recommendation about this.

People received enough to eat and drink and told us they enjoyed the food. The provider worked well with external health and social care professionals to help people to have good health outcomes.

People were not always treated with dignity and respect and it was not clear how people were supported to make choices about their care.

During our inspection we saw people were treated in a kind and caring manner and we mostly saw positive interactions between people and staff.

People did not always receive person-centred care. Care plans were not detailed, and people told us there was not enough for them do.

We have made a recommendation about the provision of end of life care. This was because people’s end of life wishes had not been recorded and staff had not been trained to support people at the end of their lives. The registered manager told us they worked with external professionals at this time to ensure people were properly supported.

Most people and their relatives told us they understood how to complain and would feel comfortable to do so.

Quality and safety monitoring systems were not adequate, and we found there was a lack of governance processes and systems in place to help ensure the safe running of the service. The lack of robust quality assurance meant people were at risk of receiving poor quality care.

Staff enjoyed their work and spoke warmly about the people they supported.

The home had been taken over by the new provider approximately 4 months prior to our inspection. The nominated individual and registered manager were open, honest and told us they were committed to make the necessary improvements to ensure the service provided safe, compassionate and well-led care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 2 September 2022 and this is the first inspection.

The last rating for the service under the previous provider was Good, published on 27 February 2019.

Why we inspected

The inspection was prompted in part about concerns we had in relation to the registered managers understanding about the Mental Capacity Act 2005. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Clarendon Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified six breaches in relation to privacy and dignity, safe care and treatment, staffing, consent, person-centred care and good governance.

We have imposed a condition on the providers registration which requires them to submit a monthly report to the Care Quality Commission on the actions being taken to ensure improvements are being made to the quality and safety of the service.

We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.