Clarence House Care Home

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

We identified some areas of risk and concern within the quality statements assessed for Safe, resulting in breaches of regulations 12, 13 and 18,.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe and well cared for living at Clarence House. We observed staff to offer kindness and reassurance of people were upset or anxious, and this helped to build a meaningful rapport between people and staff. In turn people told us they felt able to speak with staff if they were worried about anything. One person told us about their experience of not caring for themselves properly when living in their own home. They told us moving into Clarence House offered them routine and much needed structure, and within weeks they were feeling better in themselves and less at risk of self-neglect. The person credited the care and support of the staff for making this possible.

Staff and leaders were able to talk us through the safeguarding reporting processes in place at the service if they identified or suspected people to be experiencing abuse or harm. The service had posters and information in place throughout to prompt and remind staff to be mindful of safeguarding policies and procedures, and how to report and escalate any concerns.

The service provider had a safeguarding log in place. From reviewing this alongside accidents and incidents which occurred within the service, we identified examples of incidents which met the threshold to be reported to the local authority safeguarding team and to CQC, which had not been actioned by the service. This did not demonstrate implementation of the provider’s own policies and procedures into staff practice. Weekly manager reports were sent to the provider. These provided an overview of incidents and accidents which had happened in the service over the previous week. This did not demonstrate that the provider was reviewing this information and ensuring onward reporting was completed where the threshold to make safeguarding referrals had been met but not acted on by the management team at the service to maintain people’s safety.

People were not being protected from the risk of harm, in relation to unsafe storage of items such as razors, personal care products, denture cleaning tablets, prescribed creams. This was of particular risk for those people living with dementia, who were reliant on staff to maintain their safety. We observed people living with dementia to walk in and out of other people’s bedrooms, without staff supervision, increasing the risk of them accessing unsecured items and placing themselves at risk. People’s care records contained varying levels of detail, to ensure staff knew how to safely meet their needs and assessed risks. Risk information was not being consistently recorded across relevant sections of people’s care records, or we found inaccuracies between sections making it unclear whether staff were following up to date guidance. People’s care records did not demonstrate staff were completing post falls head injury monitoring, where falls, including unwitnessed falls had occurred, to ensure people did not require follow up medical attention. There were 2 people with 1:1 staffing hours in place to maintain their safety and meet assessed risks. From reviewing the records in place for those people with 1:1 staffing, we identified examples of where these people experienced unwitnessed falls when their 1:1 staff member should have been present. From reviewing care records for people which stipulated the timing of their welfare checks during the day or overnight or repositioning to reduce the risk of developing pressure ulcers, the records contained multiple gaps and did not demonstrate the stipulated time intervals were being followed, placing those people at increased risk of harm.

Leaders gave us examples of support they provided to a person who did not wish to receive support with aspects of their personal care routines. They gave us examples of actions and approaches used to encourage the person to accept support to protect their dignity and the condition of their skin. However, when we reviewed the corresponding care records, none of this information was reflected within the person’s care records to ensure staff had access to this guidance.

We observed the shift handover meeting between night and day staff. We were concerned to identify a lack of detail and risk being discussed at this meeting to ensure key information about changes in people’s risks and care needs was being escalated between staff teams and follow up actions completed where required. We observed people to be reminded to use their walking aids, given reassurance not to rush when mobilising, and checks of their footwear were recorded in daily notes to encourage people to safely move around the service and reducing their risk of falls. We observed an emergency situation to be dealt with professionally and calmly by staff, to ensure decisive action was taken, without impacting on the care and emotional wellbeing of other people seated in the area. We observed a number of rooms containing hazardous items to be found unlocked during our assessment visit. This was brought to the attention of leaders during the morning, but remained unresolved when we rechecked in the afternoon.

The provider had checks in place for equipment safety such as the use of bed rails, to prevent people rolling out of bed, and the use of moving and handling equipment to assist people to transfer safely. However, we identified examples of additional equipment used on people’s beds was not being routinely checked, and the safety certificates for the moving and handling equipment were out of date. The provider was responsive to our findings and took action to address these shortfalls. However, we were concerned action may not have been taken if we had not identified these issues as a part of the assessment process. Staff and leaders completed daily walk arounds of the care environment. These records identified issues with the safe storage of items such as personal care products and prescribed creams. The records indicated that in some bedrooms, there was not a lockable cabinet in place. The records also identified a number of rooms being left open which were meant to be kept locked. These risks remained when we completed our assessment visit and did not demonstrate the provider was acting on the findings from checks in place to manage environmental risks and protect people from harm.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not always having their needs met by sufficient numbers of staff. Staffing numbers had not been reviewed in relation to people’s support needs in the event of an emergency such as a fire, to ensure there were sufficient numbers of staff on shift overnight. This was of particular concern as some people once evacuated could not be left alone, impacting on the overall number of staff to respond to an emergency situation, with bedrooms across 2 floors.

We were told the service was working to higher staffing numbers, particularly during the day than their assessed dependency tool stipulated. However, from reviewing staffing rotas we identified a number of staff who were working between 40 and 70 hours per week. Whilst there would be an element of personal choice, due to the level of care and support required, particularly where staff were needing to provide 1:1 care, they needed to be alert and responsive for the duration of their shift. We were concerned staff working up to 70 hours a week would be placing themselves and people at risk due to fatigue. This was of particular concern as prior to our assessment we had received concerns from the service regarding staff being found asleep on duty. Staff and leaders told us they did not use any agency staff, and the 1:1 staffing was provided from their own core staff team. This offered familiarity for the people receiving care. However, from reviewing the staffing rotas, we identified provision of 1:1 hours was not being reflected in the staffing rotas.

We observed staff to be responsive to people’s needs during the assessment visit. Multiple staff were present at meal times to support people with eating and drinking as well as encouragement. The registered manager was observed to lead by example, helping out care staff, responding to call bells and spending time speaking with people and their relatives. Staff gave positive feedback about the registered manager and support provided.

We reviewed staff employment files and identified multiple examples of staff commencing employment prior to having a Disclosure and Barring Service (DBS) checks in place. Whilst the provider implemented risk assessments, we identified examples of where these had not been followed to maintain the safety of people living at the service, as well as the member of staff. Some staff had not had a DBS in place for up to 3 months and worked alone with people during that time to meet the requirements of their roles. Staff received supervision and appraisals, and their competencies were checked in relation to administering people’s medicines. However, we identified concerns in relation to staff member’s skills and competencies in relation to the administration of medicines, resulting in them needing to repeat their training and competencies as an outcome of this assessment. We identified where staff were meant to be having enhanced levels of supervision and oversight while awaiting their DBS checks, records did not demonstrate this had happened.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We observed the medicine round and we identified the need for staff to take the trolley to people’s bedrooms rather than staff carrying unsecured medicines around the service. The service had medicine round signature sheets in place, however, these did not include the times of administration for time-sensitive medication such as for Parkinson’s disease; or where pain relief was required at 4-hourly intervals. We identified a numerical discrepancy for a person’s blood thinning medicine, and evidence that an incorrect dose was administered the day prior to our assessment site visit. We identified that a person who had pain-relief patches applied to their skin, which needed to be reapplied every 7 days were recently not administer for nine and ten days, impacting the effectiveness of their medication. Staff were not consistently recording patch application and removal sites to prevent the risk or skin irritation. Where people had when required ‘PRN’ medication, corresponding guidance for staff to follow when considering giving someone PRN medicines were not consistently in place, or lacked cross-referencing where someone had more than 1 PRN medicine for the same purpose to be clear which order they needed to be taken in. The PRN protocols for laxatives lacked details of when to contact the GP, in the event use of laxatives had not been effective, placing people at increased risks relating to constipation. When staff gave people PRN medicines the corresponding records were not consistently being completed, impacting on ability to determine the justification for use. We identified improvements were required to arranging for the collection of excess controlled drugs to ensure these were safely disposed. The provider was not ensuring regular audits of people’s medicines were in place, at the time of our assessment there had been audits completed in February 2024 and August 2023.