Clarendon Manor

Updated 28 April 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.

This was a targeted inspection to check on concerns we had received about infection prevention and control and safeguarding.

Inspection team

The inspection team consisted of two inspectors.

Service and service type

Clarendon Manor 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. Clarendon Manor 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 Care Quality Commission 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 the inspection

This inspection was unannounced. Inspection activity started on 24 March 2022 and ended on 30 March 2022. We visited the location's service on 24 March 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority. 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 three people about their experiences of care and six members of staff. This included the registered manager, deputy manager, senior care worker, care workers and the chef. We looked at four people's care records, multiple medicine records and a variety of records relating to the management and governance of the service.

After the inspection

We spoke with six relatives for feedback and continued to seek clarification on the evidence found on inspection.

Updated 28 April 2022

About the service

Clarendon Manor is a residential care home providing personal and nursing care to up to 35 people. The service provides support to older people and younger adults including those living with dementia. At the time of the inspection 33 people were using the service. The home provides accommodation in one adapted building with shared dining rooms and lounges. Some of the bedrooms have private gardens.

People's experience of using the service and what we found

Relatives told us they felt their loved ones were well looked after and received safe care from staff who were kind, caring and proactive. Some of the staff team had worked at Clarendon Manor for a long time so were able to provide consistent care. However, due to staffing pressures the home was relying on a lot of agency staff which sometimes impacted on the quality of care provided.

Staff had good knowledge of keeping people safe and managing risks to their health and safety. Overall, risks were assessed with guidance to support people contained in risk management plans, but we found some risk management plans for catheter care required further detail.

Although some quality assurance processes and audits took place, improvements were needed to ensure they were effective and helped mitigate risks to people. A new pressure mattress audit was implemented during the inspection and the registered manager planned to introduce audits of accidents, injuries and falls in response to our feedback.

Feedback from people, their relatives and staff about the management of the home was positive and management were described as approachable and supportive. When relatives reported any issues or concerns to management, they felt those concerns were listened to and acted on.

Staff felt they worked well as a team. They enjoyed working at Clarendon Manor and described the home has having a friendly atmosphere.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at the last inspection

The last rating for this service was good (published 23 March 2019).

Why we inspected

The inspection was prompted in part due to concerns received about infection prevention and control in relation to COVID-19 and safeguarding. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 remained the same.

We have found evidence that the provider needs to make improvements. Please see the well led section of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clarendon Manor 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.