Clarendon Care Home

On this page

• 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 assessed all quality statements within the well-led key question. We found improvements had been made since the previous inspection in January 2023. The service was no longer in breach of regulations relating to having effective systems to assess, monitor and improve the service and maintaing an accurate, complete record in respect of each person. This meant leaders and the culture they created supported the delivery of high-quality care. Systems were in place to monitor quality, with learning and action taken to address any shortfalls. There was a capable and compassionate management team who, with staff, fostered a culture that delivered good quality care for people in partnership with external professionals. People, family members and external health and social care professionals told us they fet the service was well-led.

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.

Through observation and general discussion with the providers, it was evident that they wanted to provide a good quality, person-centred service. They placed high value on the wellbeing of people and their staff team. Throughout the inspection they demonstrated a good knowledge of the people living at Clarendon Care Home, showing they had taken time to get to know them all individually. People and family members were aware of who the providers were and said they would feel comfortable speaking to them about anything. External professionals said they felt the providers were responsive and they felt confident to raise any concerns to them.

The provider explained they had an open-door policy and an inclusive culture to ensure staff, people and relatives could raise concerns or make suggestions. The management team ensured all people and staff were treated fairly and were not discriminated against due to any protected characteristics.

During the inspection the providers were open about the past difficulties they had which resulted in the previous rating. They were honest and open about the current situation and it was evident they had worked hard to improve the service and to provide people with safe, effective and person centered care.

The providers were involved in the day-to-day running of the service. There was no registered manager at the time of the inspection. The providers described how they planned to strengthen the management structures with the deputy manager applying to become the registered manager alongside one of them.

The management team ensured everyone was treated fairly and were not discriminated against due to any protected characteristics. Feedback questionnaires had been completed by visiting professionals, staff and relatives. Whilst these could have been completed anonymously everyone had identified themselves showing they were confident to express their views to the providers. During our site visit a family member came to the office. It was evident they felt able to speak with the providers and stated they were confident anything they raised would be resolved. There was no evidence of a closed culture at the service.

Staff were proud of the service. All of the staff spoken with said they would recommend the Clarendon Care Home as a place to work. They said they would be happy if a family member received care there. They also said they felt able to raise anything with the providers and felt they would be listened to.

Staff all said they enjoyed working at Clarendon Care Home and would recommend it as a place to work. Staff said the providers were open to suggestions and they felt confident that any issues raised would be listened to and considered. New staff said they had felt welcomed into he home and were given enough information and training to enable them to undertake their roles.

The home was fully staffed. The duty roster showed staff working various hours indicating flexible working, as far as is practical within a care home needing to provide round the clock cover. The nominated individual confirmed staff received regular face to face supervisions and provided evidence of these. Supervisions provided an opportunity for staff to discuss any concerns or thoughts related to career progression. Since the last inspection, improvements have been made and new policies, procedures and quality assurance processes have been introduced. These have resulted in an improvement in the overall quality and safety of the service and demonstrates organisational learning and continued improvement.

There was a positive culture where people felt that they could speak up and that their voice would be heard. Since the previous inspection, staffing levels had been increased and an activities person was now employed. All staff lived locally and showed a genuine enthusiasm for working at Clarendon Care Home. The home was fully staffed at the time of the inspection.

At the last inspection we identified the provider's quality monitoring and governance procedures have failed to improve the quality and safety of the service. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 17. Since the last inspection improvements have been made and new policies, procedures and quality assurance processes have been introduced. These have resulted in an improvement in the overall quality and safety of the service. All issues identified in our previous inspection report, where the service was rated inadequate, have been addressed. Quality monitoring procedures were in place. These included a wide range of audits covering all aspects of the service such as care records, infection control, medicines, the environment and accidents and incidents. These were completed by the management team or senior staff and then reviewed and approved by the nominated individual. A service improvement plan was also in place which provided an opportunity for the management team to monitor and oversee all aspects of the service. This showed continuous improvement. Policies and procedures were in place to aid the smooth running of the service. The provider had a range of policies, procedures as well as audit and monitoring tools which were updated whenever required by changes in best practice guidance. Policies and procedures were available to staff at all times.

The providers were positive about their links with local health and social care teams. They expressed an open positive attitude to receiving support and understood how and where they could access support.

External professionals were all positive about the staff and management team at Clarendon Care Home. Regular collaboration and partnership relationships helped ensure services worked seamlessly for the benefit of people.

People benefited from the collaborative relationships staff at the home had developed with external professionals and services.

The providers had clear responsibilities, roles, systems of accountability and good governance. These were used to manage and deliver good quality, sustainable care. They understood and acted on the best information about risk, performance and outcomes and shared this securely with others when appropriate. Safety events were investigated and reported appropriately. Where necessary lessons were learnt and changes made to continually identify and embed good practices.

The providers shared the improvements made to policies, procedures and quality assurance processes since our last inspection. These have resulted in an improvement in the overall quality and safety of the service. An external social care professional told us, “The owners are extremely open to feedback which allows for continuous improvements and communication and willingness to work in partnership with professionals is great. I have no concerns about this service at present.”