Clare Mount

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 in the well-led key question and found poor governance and oversight at the service. We found breaches of 4 regulations during this inspection. The management team completed checks and audits of the service, however these auditing systems were not effective at improving care and ensuring people’s safety. The service has now been rated overall requires improvement or inadequate for the fourth consecutive inspection.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us the registered manager was fair and approachable to all staff. The registered manager told us staff were good and commented, “they are very positive given that we have MAC meeting and are being supportive. They can approach me anytime and can report anything; there’s nothing to hide.” The registered manager told us the last CQC report was discussed with families and that they “never hide anything here”.

We observed a notice in one corridor advertising a weekly open door surgery with the registered manager and we saw evidence that team meetings were being held. However, we had concerns about the transparency of some of the information we were told and supplied with. For example, the registered manager told us they were present at the home on a full time basis and we were later informed they visited the home just two days per week. When asked specific questions about their duty of candour to ensure they act openly and transparently with people when something goes wrong, the registered manager did not demonstrate an understanding of this requirement of their registration.

Staff told us they were well supported by the registered manager and supported in their personal circumstances. Staff we spoke with told us nothing could be improved with the care people received.

The registered manager told us they carry out regular supervisions with the staff. We were not assured the registered manager was visible around the home and accessible to staff on a full time basis during the week. We were not assured the registered manager was fully aware of their requirements under their registration to manage the home as they did not always demonstrate their knowledge and legal obligations around care and support for people.

Staff told us they knew how to whistle blow about concerns and felt that if they raised any concerns with the registered manager that action would be taken. The registered manager told us staff can approach them and all staff have completed the training on how to whistle blow and how to safeguard people from harm. Despite staff completing safeguarding training, we found 3 people at the home required safeguarding and staff had not identified they were subject to abuse and poor care. We were not assured about how open the registered manager was during the inspection as we were not always given accurate information.

The complaints procedure was displayed in the home for people and relatives to have the information on how to comment on their care and treatment. There was a suggestion box placed in reception of the home; however, it was unclear if this box was for staff or visitors. The suggestion box was labelled with “Suggest Me. How can we make our home more beautiful.” We found this label was unclear as to whether the box was for staff or visitors and for what subject suggestions were being invited. We requested several policies and procedures were emailed to us; however, these were not all received, including the home’s service user guide, whistleblowing policy and complaints policy. We did not see any evidence of quality surveys for people or their families to gain feedback. No surveys for people or families were evidenced or produced for our review.

The staff we very positive about working at Clare Mount and how supportive the work environment and registered manager were. The registered manager did not demonstrate their knowledge around equality, diversity and inclusion and when we asked, they told us staff received the same training and the same opportunities. However, they were not able to give any further details or examples of how they ensured equality, diversity and inclusion within their workforce.

We requested the home’s equality and diversity policy; however, this was not received and therefore we were not assured a policy was in place. The workforce were almost exclusively from overseas and we had concerns about the staff’s understanding of the English language used by all the people living at the home, and the effectiveness of staff training to give an understanding of people’s individual cultural needs.

The registered manager told us they completed daily walk arounds of the home. However, we were informed these walk arounds were usually completed by a senior member of staff or the area manager as the manager is often absent. The registered manager told us they carry out regular audits of the service and also “randomly pick up paperwork to check it”. They also told us the area manager double checks their audits. We found these audits to be ineffective and a tick box exercise that had not identified many of the concerns we found on inspection. For example, we found care plans and risk assessments were inaccurate and not reflective of people’s current needs despite the registered manager telling us that monthly reviews and audits of these documents took place.

We were not assured of the integrity of information supplied to us during the inspection. Quality checks and audits were poor and had not identified and not actioned the concerns found on this inspection and we identified a breach of regulations. We identified a total of 4 breaches of regulations during this inspection relating to safety, consent, person-centred care and governance of the home. This inspection identified the service requires improvement overall and this is the fourth time the service has been rated requires improvement or inadequate. In 2021 the service was rated inadequate and enforcement action was taken and the service made improvements. However, we found many of the same concerns in this inspection and this demonstrates a failure to ensure improvements are embedded and sustained. The registered manager supplied us with their quality assurance policy; however, we found this referred to a different, unconnected, care service. Care documents were not always stored securely and confidentially as we found daily notes and monitoring charts were stored in an unlocked cupboard in the main communal lounge area.

We did not receive any feedback from relatives regarding partnership and community involvement. However, we found people did not always experience good partnership working between the home and other services as timely referrals were not always made.

Prior to this inspection, we were informed the service was being closely monitored by other agencies due to concerns about the care and safety at the home; these included local infection, prevention and control teams, local authority commissioners and local nursing teams. The registered manager told us they were working closely with these agencies to improve the service and a service improvement plan was in place.

The service was under a multi-agency concerns (MAC) process at the time of our inspection and they had alerted us to their concerns. Feedback on these meetings from other health and social care professionals involved in the home was that they were concerned about the care people received at the home. The local authority was closely monitoring the home and conducting a number of ongoing safeguarding investigations at the home and other professionals were working closely with the home's management to ensure the safety of people at the home.

Although the home was currently under scrutiny from the current local multi-agency concerns teams process, there was limited evidence of partner working and effective communication regarding working together to meet people’s needs outside of the scope of the MAC process. We were not assured that people received timely medical attention from other healthcare agencies, such as, the community dietician. We did not see evidence of any community involvement at the home.

The registered manager told us they were working with partner agencies under the MAC process to make the improvements needed within the service. However, at the time of our inspection this was not yet fully implemented or embedded. The registered manager told us they aspired to have a good CQC rating and to ensure residents receive the best care and a happy life.

We did not see evidence of a robust system in place to ensure the effective review of safety concerns, incidents and safeguardings. We were not assured that all incidents were reported and addressed appropriately. We were not assured that previous concerns identified and raised led to continuous improvement and learning shared across the home. This placed people at the risk of harm and we were not assured people were always safe and receiving good quality and effective care that met their needs.