CQC report explained · a residential care home
What the CQC found at Cleaveland Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risk assessments and care plans contained the information staff needed to support people safely. They also found suitable arrangements for staffing, medicines, safeguarding, infection control and learning from accidents.
- Effective?
- Good
- People's needs and choices were reviewed, staff had received training and people were supported with food, drink and healthcare. The home was bright, clean, well maintained and suitable for people's needs.
- Caring?
- Good
- Inspectors saw kind and respectful interactions. Staff knew people well, offered choices and supported independence, privacy and dignity.
- Responsive?
- Good
- Care plans were personalised and updated when people's needs changed. People were supported with communication, family relationships, activities, complaints and end-of-life wishes.
- Well-led?
- Good
- The manager and provider had improved audits, investigations, care planning and staff learning. Inspectors found a positive culture and clear management arrangements.
What inspectors found, August 2021
Cleaveland Lodge rated Good; inspectors found safe, kind and personalised care, with major improvements since the previous inspection.
This was an unannounced inspection on 29 July 2021. Two inspectors spoke with six people, five staff members and a visiting healthcare professional. They reviewed care and medicine records, staff recruitment and supervision records, training information, audits and other management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that risks were assessed, medicines were managed safely, staffing was sufficient and infection control arrangements were in place. People were supported with food, healthcare, activities, communication and end-of-life choices.
The previous rating was Inadequate and the home had been in Special Measures since November 2020. Inspectors found that improvements had been made and the home was no longer breaching regulations or in Special Measures.
Improved safety systems
Risk assessments and care plans had been improved, with clear guidance about falls, pressure sores, diabetes, moving and other risks.
“Risk assessments contained all the information staff needed to support people safely.” from the report
Kind and respectful care
Inspectors saw positive interactions and found that staff knew people's preferences. People were supported to make choices and remain as independent as possible.
“We observed staff were kind and caring towards people and there was positive interactions between staff and people.” from the report
Good healthcare support
The home worked with healthcare professionals and made prompt referrals when people needed help.
“The staff are fantastic, they are prompt at calling us in and making referrals.” from the report
Personalised care and activities
Care plans included people's life stories, preferences and communication needs. People could take part in varied activities and maintain family relationships.
“Care plans contained such information as people's 'life story', and care was personalised and specific to each person.” from the report
Recent history of serious shortfalls
needs fixingThe previous inspection rating was Inadequate, and the home had been in Special Measures. These issues were reported as improved at this inspection, but families may want to check how the changes are being sustained.
“The last rating for this service was Inadequate (published 11 November 2020).” from the report
- 01How do you now check that people's risk assessments and care plans remain up to date when their needs change?
- 02How do current staffing levels compare with the needs identified by your dependency tool?
- 03What checks are made on medicines, and how are any problems found in audits followed up?
- 04How are improvements from the previous action plan monitored and kept in place?
- 05How will you support and record my relative's personal preferences, activities and end-of-life wishes?
This was an unannounced focused re-inspection to check the previous action plan and legal requirements, including infection prevention and control; it was not the last comprehensive inspection. This explanation was written from the published report of 24 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2020
Rated Inadequate and placed in special measures; inspectors found people were at risk of avoidable harm because safety and leadership systems were not working.
This was an unannounced focused inspection over five days. Inspectors observed care, spoke with staff and relatives, reviewed care, medicines, recruitment and management records, and checked infection control arrangements. They could not speak directly with people because of their complex needs.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while caring was Requires Improvement. Inspectors found missing or weak risk plans, poor oversight of falls and injuries, unsafe infection control practices during the pandemic, unreliable staffing information and gaps in recruitment checks.
Some routine medicines were being given as prescribed, and staff had safeguarding training. However, the report says the home remained in breach of several regulations. The service was placed in special measures, with further monitoring and a planned re-inspection.
Routine medicines
Records showed that routine tablet medicines matched the stock for all but one person. This supported the finding that most prescribed medicines were being given as intended.
“A review of Medicine Administration Records (MAR) found people's routine medicines in tablet form tallied with the stock for all but one person.” from the report
Safeguarding awareness
Staff said they had completed safeguarding training and could describe what they should do if they had a concern.
“Staff told us that they had undertaken on-line training in safeguarding and described what action they should take in response to any concerns.” from the report
Testing access
The inspectors were assured that testing was available for people using the service and staff during the pandemic.
“We were assured that the provider was accessing testing for people using the service and staff.” from the report
People's risks were not properly managed
seriousSome people had no care plan, and existing plans lacked clear instructions about falls, pressure ulcers, catheters, diabetes and moving and handling. Staff said they did not have access to care and risk plans.
“Not everyone had a care plan in place. Where care records had been produced and risks to people's welfare and safety had been identified, there was a lack of risk management plans with actions for staff to protect people from harm.” from the report
Infection control was unsafe
seriousInspectors found staff were not always using PPE correctly. They also found poor social distancing, limited hand sanitiser, shared soap, rusty commodes and no infection control lead or audits.
“We were not assured that the provider was using PPE effectively and safely. We observed staff not following NHS and Government guidance in the wearing of PPE.” from the report
Staffing and recruitment checks
seriousThe provider could not show how staffing numbers and skills were based on people's needs. Some recruitment files lacked proper references and explanations for gaps in employment.
“We found no evidence that people had been harmed however, the manager was unable to evidence how dependency levels were considered in determining staffing levels.” from the report
Leadership did not improve repeated problems
seriousQuality systems had failed to identify or address concerns found at earlier inspections. The report says incidents were not always recorded or acted on, and 13 falls involving injuries had not been notified to CQC as required.
“There has been repeated breaches of regulations and the provider has failed to learn and put effective measures in place to monitor the quality and safety of the service.” from the report
- 01What has changed since the inspection to make sure every person has a clear care plan and risk assessment?
- 02How are falls, pressure ulcers, catheter care, diabetes and moving and handling risks now monitored?
- 03What infection control arrangements are now in place, including PPE changing areas, hand sanitiser, social distancing and infection control audits?
- 04How do you decide how many staff and what skills are needed on each shift?
- 05How will relatives be told promptly about falls, injuries, changes in wellbeing and care plan decisions?
This was a focused inspection of Safe, Caring and Well-led only, including infection prevention and control; Effective and Responsive were not assessed in this inspection. This explanation was written from the published report of 11 November 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Cleaveland Lodge
6 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- August 2021Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Inadequatedown from Requires improvementSafe: InadequateCaring: Requires improvementWell-led: Inadequate
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 1 July 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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