Clapham Lodge Care Home

At our last assessment we found some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. Systems were either not in place or robust enough to demonstrate safety was effectively managed. The provider had not protected people from the risk of falls and lessons were not learned from incidents. The provider had failed to ensure there were sufficient numbers of staff deployed. This placed people at risk of harm.

Following the assessment, we received assurances from the provider and a new manager was recruited. At this assessment we found improvements had been made.

People were safe at Clapham Lodge and this was reflected in their comments and feedback. Staff had a knowledge of safeguarding, how to recognise the signs of potential abuse and reported this appropriately. A relative told us, “A couple of the staff who were quite intimidating have gone and been replaced with genuinely caring staff, adding to a great team.” There was guidance available to staff to promote people’s safety without restricting them unnecessarily. The environment was clean and tidy, with safety check having taken place. There were enough staff of the right skill set to keep people safe and meet their needs. People and their relatives spoke positively about staff and how they were responsive to each need. Medicines were managed safely and delivered in a way which met people’s preferences. The registered manager had oversight of this so any issues could be identified.

At our last assessment we found widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The manager did not promote a positive and inclusive culture which promoted good outcomes for people. They did not understand their responsibilities to raise concerns and record safety incidents. The provider had not followed their responsibilities under the legislation and had not ensured that all significant events were notified to the Care Quality Commission. The provider had not ensured that effective systems and processes were in place to assess, monitor and improve the quality and safety of the service. Systems were not in place to demonstrate the service operated effectively to ensure compliance with the regulations. The provider did not have systems in place to receive or review feedback about the service effectively and had not used informal feedback to improve the quality of care provided.

Following the assessment, we received assurances from the provider and a new manager was recruited. At this assessment we found improvements had been made.

Improvements had been made regarding the governance, quality assurance and management of Clapham Lodge. However, some of the planned measures to quality assure the service had not been completed. The registered manager was aware of these shortfalls and told us they were committed to making improvement. The registered manager had a comprehensive plan of quality assurance checks which they had begun working through. They told us that these checks would be used to identify any areas of development and then used to create an action plan to drive improvement at the service. There was an open culture at the home and staff spoke positively about the level of support they receive from the registered manager.