Date of assessment: 25 November to 18 December 2025. Claremont is a residential care home providing accommodation and personal care. At the last inspection, the service was in breach of regulations relating to risk management, consent and governance. At this assessment we found the provider had made improvements and was no longer in breach of regulations. The provider now managed risk effectively; risk assessments were reviewed regularly and the home was clean and generally well maintained. Where aspects of the property required repair, plans were in place to address this. Care plans were more comprehensive and the provider had introduced a new electronic care planning system. People usually received person-centred care, in line with their needs and preferences. However, there were still occasions when staffing levels impacted on flexibility to support people with individual community-based activities. People’s independence also needed to be promoted more consistently. Staff worked in accordance with the Mental Capacity Act and respected people’s choices and decisions. People’s capacity to consent to decisions had been assessed and there were now records in relation to any restrictions or decisions made in people’s best interests. The provider made further improvements to these records during the course of our assessment. Governance systems were more robust and audits were regularly completed. We noted though there were still some anomalies in record keeping and minor issues which had not been picked up in the audits. The registered manager took prompt action in response to our feedback and was keen to continue improving the service. Staff were safely recruited and they received training, supervision and competency checks. Staff were caring and knowledgeable about people’s needs. Staff told us the registered manager was supportive and we received positive feedback from visiting healthcare professionals. Appropriate referrals had been made to other health professionals when needed. There were systems in place to ensure people received their medicines in line with their prescriptions. Most staff told us there was good teamwork and felt morale at the home had improved. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. Overall, the provider was working in line with these principles and ensured people were respected and treated well. Following the service’s last inspection, we issued a condition on the provider’s registration. This condition has now been removed.
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Claremont was rated Inadequate overall following an unannounced inspection in September–October 2022, with multiple continued regulatory breaches across safe care, staffing, safeguarding, consent, person-centred care and governance. The service was placed in special measures due to widespread and significant failings, including a closed culture, absence of a registered manager, and failure to address shortfalls identified at the previous inspection in 2021.
Concerns (13)
criticalSafeguarding: “Staff had not had training on how to recognise and report abuse. We found multiple incidents which had not been identified as safeguarding concerns and reported by staff.”
criticalStaffing levels: “provider told us 2 staff were needed for a safe fire evacuation, but we observed multiple periods where only 1 staff member was working. This put people at a continued risk of harm.”
criticalGovernance: “The provider had failed to notify the CQC of notifiable events and incidents in a timely manner. Additionally, they had failed to submit their Provider Information Return as required.”
criticalStaff training: “Staff had not received training in topics which had been highlighted by the provider as mandatory, such as fire safety, safeguarding and challenging behaviour.”
criticalConsent / capacity: “There was a stairgate in use at the service, restricting people's movements but staff, including the new manager, didn't know why this was in place and if people had consented to it.”
criticalLeadership: “The service had indicators of a closed culture, this put people at increased risk of harm. Managers and staff failed to identify poor practice and safeguarding concerns.”
criticalIncident learning: “Staff did not appropriately identify and record incidents which occurred at the service. Lack of management oversight meant incidents we identified during inspection had not been identified.”
moderateCare planning: “People had care and support plans that were not personalised, holistic, strengths-based and did not reflect their needs and aspirations.”
moderatePerson-centred care: “People did not receive person-centred care. Staff told us they did not have the time to provide personalised care and were task focused.”
moderateRecord keeping: “Information and records relating to people's needs were not accurate or reviewed regularly. This meant people were receiving inconsistent care, sometimes contrary to specialist advice.”
moderateInfection control: “Clinical waste such as used Personal Protective Equipment (PPE) was still not being disposed of correctly. Staff we spoke with were not aware of the process to do this safely.”
moderateSupervision / appraisal: “Staff had not consistently received support in the form of continual supervision and appraisals. However, staff had very recently started to receive supervision following a new manager in post.”
minorCommunication with families: “The service had not fully implemented the Accessible Information Standard to identify, record, flag, share and meet the information and communication needs of people with a disability.”
Strengths
· People's medicines were safely managed and people received their medicines as prescribed.
· People were able to personalise their rooms and were included in decisions relating to interior decoration.
· People had end of life care plans documenting their preferences and wishes.
· Some relatives felt involved and engaged with the service.
· One family member who raised a complaint was satisfied with the outcome.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Preventing and controlling infectionInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Using medicines safelyGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Claremont, a four-person residential care home, improved from Inadequate to Requires Improvement following a focused follow-up inspection, exiting Special Measures after demonstrating progress in safeguarding, infection control and recruitment. Continued regulatory breaches in risk management (Reg 12), consent and mental capacity (Reg 11), and governance (Reg 17) remain, with a condition imposed on the provider's registration.
Concerns (10)
criticalMedication management: “there continued to be times when there was not staff on duty suitably trained to administer emergency medication to people in line with their care plans.”
criticalConsent / capacity: “Capacity assessments and best interest decisions were still not always completed when required.”
criticalConsent / capacity: “one person required a best interest decision specific to leaving the service. This had not been carried out.”
criticalCare planning: “Risks to people continued not to be fully managed and mitigated. Risk assessments were not always in place when there were risks to people.”
criticalGovernance: “Auditing systems were now in place, however they needed to be developed and sustained...this was the third consecutive inspection that a breach of regulation 17 had been identified.”
moderateMedication management: “we observed on one occasion a person not received medicines in line with the prescriber's instruction and some records had not been completed in line with best practice.”
moderateCare planning: “one person's care plan stated they should be weighed weekly, however we saw from records they were weighed monthly.”
moderateRecord keeping: “The provider had not always kept contemporaneous, up to date, accurate records.”
moderateStaffing levels: “work was still required to establish people's individual hours and ensure they received these. Further oversight was needed of the rota to ensure there was sufficient staff at all times.”
moderatePerson-centred care: “further work was required to ensure people received fully individualised care and their skills were supported.”
Strengths
· Improvements made to fire safety with appropriate documentation now in place to support safe evacuations.
· Safeguarding training completed; staff confident in reporting abuse and referral systems now in place.
· Sufficient staffing levels improved; one relative noted increase from 1-2 staff to mostly 3 staff on duty.
· Safe recruitment checks now carried out to ensure staff are of suitable character.
· Infection control improved: PPE stored safely, clinical waste bins in place, home described as clean and tidy.
Quality-Statement breakdown (15)
safe: Assessing risk, safety monitoring and management; learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Using medicines safelyRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced diet