St Clare House

Updated 15 July 2022

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

The inspection was completed by one inspector and a medicines inspector.

Service and service type

St Clare House 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. St Clare House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the CQC to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection, there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used information the provider sent us in the provider information return. 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 four people who used the service, four people’s relatives and two visiting professionals about their experience of the care provided. We spoke with six members of staff including a director, the registered manager, senior carers, care workers and the chef.

We reviewed a range of records. This included five people’s care records and a range of records relating to the management and administration of people’s medicines. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 15 July 2022

About the service

St Clare House is a residential care home providing accommodation and personal care for up to 29 older people who may be living with a physical disability, mental health needs and/or dementia. At the time of our inspection, 28 people were using the service.

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

People gave very positive feedback about the service and the care and support staff provided. However, there were inconsistencies in how risks were identified and managed.

People’s care plans and risk assessments had not been reviewed and updated as their needs changed. Whilst people’s medicines were mostly managed safely, action was needed to ensure good practice guidance was consistently followed. There were some environmental risks, which needed to be addressed. For example, to ensure robust window-opening restrictors were in place and to check and make sure all areas of the service were thoroughly cleaned.

We could not be certain people were supported to have maximum choice and control of their lives or that staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We made a recommendation in relation to the Mental Capacity Act 2005.

The provider and registered manager were extremely responsive to feedback and took immediate action to address concerns. Whilst no one had been harmed because of the concerns we found, we spoke with the provider and registered manager about developing their approach to auditing to ensure issues would be proactively identified and addressed in future.

People felt safe living at the service. Staff were safely recruited, and sufficient numbers of staff were deployed to meet people’s needs.

The registered manager was very approachable and with people, their relatives and professionals to help ensure people’s needs were met and improve their quality of life. They were committed to providing person-centred care and promoted a person-centred culture within the service.

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

Rating at last inspection

The last rating for this service was good (published 19 December 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service. This was a focussed inspection. This report only covers our findings in relation to the Key Questions safe and well-led.

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 to requires improvement. This is based on the findings at this inspection. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Clare House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.