Clumber House Nursing Home

Updated 25 March 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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors.

Service and service type

Clumber House Nursing Home 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. Clumber House Nursing Home is a care home with 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 not a registered manager in post. A new manager had been in post for 4 weeks and was in the process of submitting an application to register.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 all this information to plan our inspection.

During the inspection

We spoke with 7 people who used the service and 3 relatives about their experience of the care provided. We observed interactions between staff and people living at Clumber House. We spoke with 10 members of staff in various roles, including the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records including 6 people's care records and other recording records relating to people’s care and support. We looked at 7 staff files in relation to recruitment. A variety of records relating to the management of the service was reviewed, including policies and procedures.

Updated 25 March 2023

About the service

Clumber House Nursing Home is a residential care home providing personal and nursing care to up to 41 people. At the time of our inspection there were 38 people using the service.

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

Systems in place to assess and monitor risk were not effective in identifying concerns we observed during the inspection which put people at risk. The manager took actions to address the concerns we raised during the inspection, and improve the management of risk.

Information relating to people’s care and support was not always reflective of observations we made during this inspection, which meant people were not consistently receiving person centred support.

There was a system in place to review accidents and incidents. However this did not always improve safety of the service and mitigate risk.

We found that support dependency for people was high at the service. this meant staff had little time for social engagement as there was not always enough staff to respond to people’s needs quickly. We spoke to the manager about our concerns and made a recommendation they review and monitor staffing levels and deployment.

Although processes were in place to assess people under the Mental Capacity Act (MCA) we found that the service was not always working inline with this. We spoke to the manager regarding our concerns and made a recommendation they reviewed information held on people.

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

Auditing systems were not robust or effective to ensure the management team had oversight on identifying risk and acting on lessons learnt.

The manager was new in post and demonstrated a positive approach to make improvements in the home.

Overall people and relatives spoke positively about the service and communication from the management team.

Staff recruitment processes were followed. Staff received training appropriate to their role, with on-going training given.

Staff spoke positively about working at clumber house and felt well supported by the management team.

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 23 March 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service, concerns received about the management of the service and people’s care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

Enforcement and Recommendations

We have identified breaches regarding how people were supported to stay safe, how the provider ensure they have oversight of , personal centred support and that suitable systems are in place to identify and reduce risk.

We recommend the provider reviewed how staffing is deployed across the service and review systems for documentation relating to the Mental Capacity Act.

Please see the action we have told the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clumber house nursing home on our website at www.cqc.org.uk.