The inspection took place on the 11 June 2018 and was unannounced. The inspection continued on the 12 June 2018 and was announced.

At our previous inspection in May 2017 we found breaches in regulation of safe care and treatment and good governance. People had not been protected from the risk of avoidable harm and medicines had not been administered safely. We also found that systems and processes to safeguard people were not being followed. Also systems and processes had not been effective in monitoring and reducing risks to people related to their health and welfare. We asked the provider to take action to make improvements and this action has been completed.

Following the last inspection we asked the provider to complete an action plan to show us what they would do and by when to improve the key questions, is the service safe and is the service well led, to at least good.

Clarence House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide care for up to 29 people. At the time of our inspection 23 older people, some of whom were living with a dementia, were residing at the service.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Assessments had been completed that identified risks to people such as malnutrition, dehydration, skin damage and falls. Actions in place to manage risk to prevent avoidable harm were understood by the staff team and being followed. Risks were reviewed at least monthly and included input from people and their families. When risks were being managed people’s freedom and choices had been respected.

People had their medicines ordered, stored, administered and recorded appropriately. When people had medicines prescribed for ‘as and when required’, protocols were in place with detailed information to enable medicines to be administered appropriately. A new process for topical creams had been introduced which included a body map and clear instructions for care staff as to where creams needed to be applied and how often. Staff had completed records to demonstrate this had taken place in accordance with people’s prescriptions.

Staff had completed safeguarding training and understood their role in identifying and reporting concerns. Accidents and incidents were reviewed by the registered manager who understood their role in reporting safeguarding concerns to external agencies when appropriate.

Auditing processes had been strengthened and included the registered manager evaluating risks to people weekly. Auditing tools had been reviewed and were effective in highlighting areas where improvements were needed. When actions were identified they took place in a timely way.

People were supported by staff who had undertaken a recruitment process that included checks on their suitability to work with vulnerable people. Staffing levels were regularly reviewed and met people’s care needs. Staff had inductions, on-going training and support that enabled them to carry out their roles effectively.

Prior to admission, assessments had been completed with people to gather information about their care needs and choices. The information had been used to develop person centred care plans that reflected people’s individuality and included end of life wishes. Staff had a good knowledge of people and their communication needs and provided care with kindness, patience and empathy. People had their privacy, dignity and independence respected.

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This inspection was carried out on 4 May 2017 and was unannounced. The inspection continued on the 5 May 2017 on an announced basis.

Clarence House is registered to provide accommodation for up to 29 people who require personal care. At the time of our inspection there were 23 older people living at the service some of which were living with a dementia. The home provides single room accommodation over two floors with the facilities to provide shared accommodation when required. Rooms have en-suite facilities and there is also a specialist bathroom on each floor.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not consistently protected from the risk of harm in relation to dehydration, malnutrition or skin damage. Actions and processes had been put in place to minimise these risks but these were not being consistently followed. People were not being protected from the risk of deteriorating skin or health conditions that were treated with topical creams and other medicines as these were not being managed as prescribed. Although there were auditing systems to ensure risks were safely managed they were not operating effectively.

Reportable incidents such as skin damage had not always been shared with other external agencies. This meant that processes designed to provide oversight and additional safeguards for people were not always being followed.

People using the service told us they felt safe and that their right to make choices about the risks they lived with were respected.

People were supported by enough staff that had been recruited safely as checks had been made to ensure they were safe to work with vulnerable adults. Induction, on-going training and supervision provided staff with the skills to carry out their roles.

The service was working within the principles of the Mental Capacity Act. This meant that people were supported to make decisions and when they had been assessed as not being able to decisions were made in their best interest with the involvement of family and other professionals.

People were supported to eat and drink when required. They were offered nutritious meals with snacks and light meals always available. People had choices of what to eat and where to take meals. When it was assessed that people required specialist equipment this was provided to support people to eat and drink independently.

People and their families described the staff as caring and kind. Staff had a good knowledge of people and the ways they were able to communicate which meant they were able to support people appropriately to make choices and decisions about their day to day lives.

Care and support plans provided clear information to care workers about how people needed to be supported. People felt involved in their care and supported by staff who understood their care needs. Activities were available both in the home and the community and were often linked to people’s interests. A complaints process was in place which people and their families were familiar with and felt able to use if needed.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

We used a number of different methods to help us understand the experiences of people using the service. We observed care being delivered to people, spoke with staff and relatives and looked at records related to care delivery.

We looked at five care records and spoke with seven people who use the service. We also spoke with seven people about their relative’s care. We spoke with six members of staff and three visiting health professionals. We saw that people’s care plans were clearly set out and people’s needs met. The care plans included people’s preferences and choices and detailed guidance on how people should be supported.

We saw that people were treated with consideration. All the people we spoke with felt they were treated well, one person told us that “they look after me very well, all very kind”. Relatives of people who use the service told us they were very pleased with the care provided. One relative said “treat with respect, very kind, couldn’t wish for anything better’; another relative told us that their relative was “always well cared for, staff really know her”.

Staff felt supported and that they received appropriate training to support them in their role. Staff were able to describe the agency’s safeguarding procedures and their role in keeping people safe.

The views of people who used the service were surveyed and systems were in place to monitor the ongoing performance of the service.

Our inspection of 24 April 2012 found that people’s care records did not contain accurate information and there was a risk of them receiving inappropriate or unsafe care. We also found that the provider did not have effective systems to monitor and learn from incidents which had the potential to result in harm to people. We asked the provider to supply a plan detailing how they would make the required improvements. We carried out a follow up inspection on 18 September 2012 and found that sufficient improvements had not been made. We served a warning notice which required compliance with the standards by 24 October 2012.

During this inspection we found that a new system of recording incidents and analysing trends had been developed and was in use. The necessary changes to people's care were made in light of identified incident trends. For example, changes had been made to people's falls care plans in light of them experiencing a number of falls.

We saw that the provider was in the process of introducing a new format for people's care records. Although not all people's records had been transferred into this format all existing records relating to people had been reviewed to ensure they were accurate.

We spoke with people using the service who told us staff met their needs, One person told us “They look after me well, I get all the help I need, the staff are very good”. Staff were knowledgeable about people's needs and how to deliver their planned care.

People told us they felt safe at the home. One person told us “I feel safe here, I’m quite happy”. Staff were able to recognise the signs that people may have been abused and detail types of abuse. Staff were aware of what action to take if they suspected or witnessed actual abuse. The majority of staff had received training in safeguarding adults from abuse.

Incidents which had resulted in harm to people or had the potential to do so had not been analysed to identify trends. There was a risk that necessary changes to people's care may not have been made due to this lack of analysis.

People's care records were not always accurate in relation to how care should be delivered or as to the person's abilities.

People told us that they were cared for by skilled staff who treated them with dignity and respect. One person told us “the staff are very pleasant, they know how to look after me”. People were engaged in daytime activities. One person told us “we’ve got a very good entertainments person, we would be lost without her she’s marvellous. There are a variety of activities for us to get involved in”.

People were able to raise concerns and complaints, one person told us “the staff are lovely I couldn’t ask for better, I could approach them for anything”. People’s views were regularly sought by the provider one person told us “I have made suggestions at the meeting and they have been sorted out straight away”.

We saw that people were treated with consideration and their privacy and dignity was maintained while they were supported with personal care. We found people’s care plans occasionally lacked detail and were inconsistent in places which may have put people at risk of receiving inappropriate care. We also found that an analysis of incident data had identified trends which were not fully explored and documented in the people’s care records. This may have put people at risk of harm.

This inspection took place on 27 and 28 November and 1 December 2014 and was unannounced. Clarence House provides accommodation and personal care for up to 29 older people, including people with dementia. There were 26 people living there when we visited. There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Staff sought people’s consent to care and support and respected people’s choices; however, formal processes and systems needed to be followed more consistently to ensure the service operated within relevant legislation and guidelines at all times. People received care from staff who had the knowledge and skills they needed to carry out their roles and responsibilities effectively.

People were supported to have sufficient to eat and drink, and to maintain a balanced diet. People were supported to maintain good health, to access appropriate healthcare services and to receive ongoing healthcare support.

People’s care and health needs were responded to effectively. The service had appropriate systems in place to learn from any concerns and complaints raised by people or their representatives.

People were supported by staff who were trained to recognise different forms of abuse and respond appropriately to safeguarding concerns. There were sufficient numbers of suitable staff working to keep people safe and meet their needs. The service had effective systems in place for the safe management of medicines. We identified a small number of specific concerns related to cleanliness and hygiene. The manager responded immediately to address the specific concerns. They also took steps to minimise the future risk of infection for all people using the service.

People told us the staff were caring, which matched our own observations made during the inspection. Staff spoke warmly and knowledgeably about the people in their care. People’s privacy and dignity were respected and promoted, and they were involved in making decisions about their own care.

The provider and manager had created a culture that was person-centred, open, inclusive and empowering. They were visible and readily accessible, which helped inspire staff to provide a quality service. The service had appropriate quality assurance systems in place, which helped to identify necessary improvements and to maintain the quality of the care provided.