Clipstone Hall & Lodge

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

People received safe care and support from a consistent team of staff. The registered manager was working towards a reduction in agency staff usage to further improve people’s experience following feedback. Staffing levels had been increased and maintained since our last assessment, and people and staff commented this had improved safety and care quality. People received their medicines safely and in a person-centred way. The hygiene of the home was maintained to a high standard and high-risk areas of the home, such as sluice rooms, were now consistently locked to ensure people’s safety.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People consistently told us they felt safe living at the home. People commented on improvements staff had made in the service. For example, improved response times when call bells were pressed. One person said, “Sometimes there is a slight wait, especially at night, but the majority of the time staff come straight away, it’s definitely better.”

Staff told us lessons had been learnt since our last assessment, especially regarding staffing levels and visibility of staff. One staff member said, “It’s better already but [the registered manager] is making even more improvement by separating the areas of the home even more, we have differently learnt and improved.”

We reviewed care plans and audit records completed and maintained by the provider. We saw evidence of continued improvement to identifying concerns and actions being implemented to keep people safe. For example, where people experienced falls, lessons had been learned and actions taken to support people such as sensor mats and increased hourly checks. This has resulted in a reduction in falls for people.

People we spoke with told us they had a positive experience when transitioning into the home. People and their relatives described being welcomed to spend time in the home prior to deciding whether to move into Clipstone Hall and Lodge. One relative said, “We did look at about 4 other homes, but we liked it here and felt [name] would be safe.”

Staff had good knowledge of how health and social care professionals supported people. Staff were able to explain when these professionals visited, and what type of support they offered. For example, if a person required daily support with their diabetes care from district nurses.

Partners we spoke with did not provide any feedback of concern about safe systems, pathways and transition.

Where people required external health and social care support, documentation showed that suitable referrals had been made. For example, where a person had an increase in the number of falls, professional advice had been requested. This helped to keep people safe.

People told us they were protected from the risk of avoidable abuse and harm. We asked one person to tell us what made them feel safe living at the home and they stated, “I feel safe. The windows have locks and the doors are covered by staff, the staff check the people that come in.” Everyone we spoke with told us they would feel confident to raise a safety concern with staff and or the management team.

Staff were knowledgeable about safeguarding and stated they received training and ongoing support to recognise signs of harm and abuse. All staff we spoke with confirmed the registered manager was responsive to any concerns they raised to ensure people remained safe.

We observed staff supporting people with kindness, compassion and dignity in ways that encouraged and supported people to remain safe. For example, we observed a staff member supporting a person who was living with dementia during a period of crisis that resulted in agitation and frustration. Staff remained calm and reassuring with the person and deescalated the situation. This provided reassurance to the person and protected them from avoidable harm.

Policies and guidance were in place to support staff in identifying and raising their concerns regarding people’s safety. We saw management had a log that monitored when these concerns were raised and actions that had been taken to mitigate risk to people. We saw evidence that these logs were evaluated by the registered manager and notifications to the local authority and CQC were made where appropriate.

People and their relatives told us they were supported to manage risks. People told us they were included in their care plan creation, and these were updated regularly to ensure risks were identified and mitigated. One relative said, “I’m always included.” A person living at the home said, “There have been improvements, staff support me 3 times a day to do my exercises.”

Staff were knowledgeable about people’s identified risks and told us they had enough time to support people appropriately. Staff stated there had been improvements since the last assessment and they now had time to access people’s care plans to remain up to date with people’s needs as they changed. One staff member said, “We have daily handovers which tell us about the changes, but we now have time to read the [care] plan if needed. The registered manager is very responsive if we identify new risks.”

We observed improvements to the way the home managed risks and supported people to remain safe. Areas of the home that presented risk to people such as store cupboards and sluice rooms were now locked. We observed staff supporting people with risk safely. For example, one person who required assistance with their mobility was seated in a communal area and attempted to stand and mobilise on their own. Staff immediately offered assistance and support which prevented a possible fall.

Care plans we reviewed showed comprehensive risk assessments had been completed to support people to mitigate risks such as falls, weight loss and mobility. Care plans also included clear guidance for staff on how to support people safely and in line with their wishes which ensured safe person-centred care.

People told us the environment was safe and they enjoyed living at Clipstone Hall and Lodge. One person said, “I have a nice room accessible to the garden, I can see the birds. The staff clean daily and do the bathroom and they also do my bedding.”

The registered manager told us they were currently without a maintenance person; however, they showed us records that ensured checks such as water temperatures and fire alarm tests had continued during this period which ensured people remained safe.

Where people used equipment, such as hoists and wheelchairs, these were clean and well-maintained. The home was safe in the event of fire. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment which was maintained and inspected on a regular basis.

The environment was kept safe by regular checks and maintenance. We saw there had been regular checks to ensure the home was safe in the event of a fire (for example, by checking the alarm systems). Systems were in place to ensure water quality was maintained to reduce the risk of water-borne bacteria (like legionella.) The gas heating system was regularly serviced to prevent harm to people. The registered manager completed a daily walk around of the home to identify issues which also included speaking with people to gain feedback. Staff had been upskilled to complete these checks in the absence of the registered manager to ensure people were consistently safe.

We still received mixed feedback from people about staffing levels, however people did state there had been improvements since our last inspection. Some people commented on the difference of care standards between agency staff and the home’s permanent staff members. One person said, “That’s when you notice the difference. [Agency] staff sometimes talk in their own language, so I don’t know what they are saying, and they don’t come and help you as quick, especially at night.” People said they was now enough staff for them to be able to have bath or a shower when they chose. One person said, “I have a shower every day now with staff support.” Another person said, “I love a bath and I can have one when I want.”

Staff told us there had been improvements to staffing levels. One staff member said, “Obviously we would always like even more staff, but things have definitely improved. There is an additional staff member on day shift now and the registered manager is looking to improve recruitment even further, they always keep us up to date on their staffing plans now.”

We observed the lunchtime meal service, and our observations supported the feedback people gave. We observed an agency staff member only communicating in their own language which caused agitation and confusion for some people who were being supported. We reported this to the management team who took immediate action to address the situation.

The management team had completed a full review of all staffing levels, recruitment processes and records since our last assessment. All staff had the required employment checks in place, including DBS and reference checks. Staffing levels were regularly reviewed with the support of a dependency tool which accurately reflected people’s needs. We reviewed staffing rotas that consistently showed staffing in line with this dependency tool. Where agency staff were used, records showed they received a comprehensive induction into the home and had the required levels of training to ensure support was delivered safely.

People we spoke with praised the domestic team and told us they happy with the cleanliness and hygiene of the home. One person said, “They [staff] never stop, cleaning is always happening.” Another person said, “The staff wash my clothes and clean my room. I have a dress in the wash, and I have asked them if I can iron it, they said they will get me an ironing board and an iron so I can do it myself.”

Staff were knowledgeable about infection prevention control and told us standards were now easier to maintain since staffing levels had increased. Staff told us they were provided with training and managers undertook competency checks on the home and staff practices to ensure compliance and safety.

We observed staff wearing personal protective equipment appropriately whilst supporting people and disposing of this in line with best practice guidance. This ensured people were protected from the risk of catching infections. All staff were proactive in ensuring the home environment was clean and tidy and we witnessed care staff supporting by cleaning communal areas after mealtimes. Best practice guidance was on display. For example, there was hand washing guidance in bathrooms.

The provider had an infection control and prevention policy and completed regular audits to ensure the organisation’s compliance to this policy. The registered manager completed daily walk rounds as well as auditing departmental reports such as domestic cleaning schedules and spot checks.

People and their relatives told us staff were knowledgeable about their medicines and ensured they received them on time and in their chosen way. For example, one person said, “I take quite a lot of medication and staff explain them all for me.” Another person gave an example of how staff were responsive in keeping them safe with medicines, “The staff called the doctor recently as I was allergic to the antibiotics they gave me. I saw a specialist nurse really quickly.”

Staff were knowledgeable about people’s medicines and confirmed they had completed training in administering medicines safely. One staff member we spoke with said, “We don’t stock homely remedies so if people need additional support, we always seek GP advice, this is because we don’t know how these react with their regular medicines, doing it this way keeps people safe.” A homely remedy is a medicine used to treat minor ailments. They are purchased over the counter and do not need to be prescribed.

Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff did regular checks of the number of medicines in stock. This ensured that suitable stock levels were always in place, and more medicines could be ordered from the pharmacist as needed. Some people required ‘as needed’ medicines and staff had clear written guidance on how this should be administered. Although senior staff were responsible for administration of this medicine, guidance was clearly written in care plans, so all staff knew how and when to help someone request ‘as needed’ medicines.