CQC report explained · a residential care home
What the CQC found at Cleggsworth Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention, PPE, testing, cleaning and outbreak management. They also considered COVID-19-related staffing pressures, but did not give a rating.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed in this targeted inspection.
What inspectors found, March 2022
Cleggsworth Care Home: inspected but not rated; inspectors found strong infection control, but visiting guidance was not fully up to date at the time.
This was an unannounced, targeted inspection on 22 February 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
Inspectors found effective measures to reduce infection risks. The home was clean and well maintained. Staff used protective equipment properly, and people and staff were tested regularly.
The inspection was not given an overall rating. The Safe question was also marked “Inspected but not rated”. The other areas were not assessed in this inspection.
Infection control
Inspectors found effective measures to reduce the risks from COVID-19. Staff used protective equipment properly and government guidance was being followed.
“There were effective measures in place to minimise the risks around COVID-19.” from the report
Clean environment
The home was clean, hygienic and well maintained. Cleaning schedules, audits and regular cleaning of high-touch areas were in place.
“The environment was clean, well maintained and hygienic.” from the report
Testing and vaccination
People living at the home and staff were tested regularly. The report says everyone had been vaccinated against COVID-19.
“People and staff were tested regularly for COVID-19, in line with government guidance.” from the report
Risk planning
The home had risk assessments and policies for managing COVID-19 risks, and the registered manager kept in contact with local authority and infection control teams.
“The service had risk assessments and policies and procedures in place to manage the risks of COVID-19.” from the report
Visiting guidance
needs fixingAfter a recent COVID-19 outbreak, visiting arrangements had not yet fully followed the updated guidance when inspectors visited. The home agreed to implement the guidance after the inspection.
“The provider was facilitating visits for people living in the home, but had not fully implemented the updated guidance following a recent Covid-19 outbreak.” from the report
- 01How are visits currently arranged, including what happens if there is an infection outbreak?
- 02How do you keep relatives updated when visiting guidance changes?
- 03What measures are in place if COVID-19-related staffing pressures occur?
- 04How often are people living here and staff tested when there is an infection risk?
- 05When were the other areas of care last inspected and rated?
This was an unannounced targeted inspection focused on infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not rate the other four areas of care. This explanation was written from the published report of 29 March 2022 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 2021
Rated Good; inspectors found kind, safe care, but identified environmental safety and staff training shortfalls.
This was an unannounced inspection over two days. Inspectors spoke with residents, relatives, staff and health professionals. They reviewed care records, medicines records, staff files, training information and management records.
The home was rated Good overall. Safe, Effective and Well-led were also rated Good. Inspectors found people were treated kindly, their risks and care needs were recorded, medicines were managed safely and staff responded promptly to call bells.
Inspectors did identify some maintenance problems that created a safety risk. The manager dealt with these during the inspection. Some staff training was out of date, and not all staff had completed safeguarding training, but the manager was taking action.
Kind and respectful care
Staff knew residents well and treated them kindly. Inspectors saw people being given time to make choices and support that promoted independence.
“Staff knew people well and were kind and considerate when delivering care.” from the report
Medicines managed safely
Residents received their medicines as prescribed. The home carried out regular medicine audits to look for errors.
“Medicines were safely managed. People received their medicines as prescribed and in line with guidance.” from the report
Infection control improvements
The home had made changes to improve infection prevention. Inspectors found it clean, with personal protective equipment available and staff using it.
“We were assured that the provider was using PPE effectively and safely.” from the report
Responsive management
The manager acted quickly when inspectors identified problems and was open to feedback from external professionals and staff.
“The manager and provider had been proactive in making changes in the home following recommendations by the local authority infection control team and environmental health.” from the report
Maintenance safety risk
seriousInspectors found environmental shortfalls that created a risk to residents' safety. The manager took immediate action, and later assured inspectors the environment had been made safe.
“During the inspection, a risk to people's safety was identified in relation to environmental shortfalls, the manager took immediate action along with the maintenance person to address the risk.” from the report
Training was not fully up to date
needs fixingSome staff training was out of date. Not all staff had completed safeguarding training, although the manager was taking action.
“Some of the staff training was out of date. The manager was working with staff to address shortfalls in the mandatory training” from the report
Safeguarding training gaps
needs fixingTraining records showed that some staff had not completed safeguarding training at the time of inspection. This had been identified and was being addressed.
“The training records showed that not all staff had completed safeguarding training however this had been picked up by the manager and was being acted upon.” from the report
- 01What maintenance problems were found during the inspection, and what evidence can you show that they were fully fixed?
- 02Which staff still needed safeguarding or other mandatory training after the inspection, and has this now been completed?
- 03How do you check that the environment remains safe and that maintenance problems are identified quickly?
- 04How do you ensure agency staff are familiar with residents' needs and care plans?
- 05How do residents and relatives give feedback, and what changes have been made as a result?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the report says previous ratings were used for the overall rating. This explanation was written from the published report of 19 November 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.
Every inspection of Cleggsworth Care Home
5 rated inspections over 6 years: the service has improved, from Inadequate to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2021GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- February 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015Goodup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015InadequateSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 3 December 2010.
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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