CQC report explained · a nursing home
What the CQC found at Cleveland House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2021
Cleveland House Care Home rated Requires Improvement; inspectors found kind care and enough staff, but serious infection-control and management weaknesses.
This was an unannounced focused inspection on 11 November 2020. Inspectors looked only at Safe and Well-led, after concerns about infection control following a COVID-19 outbreak. They spoke with people, relatives and staff, observed care, and checked care, medicine, staffing and management records.
People generally felt safe and were treated with dignity and respect. Staff knew people well, care plans were clear, and there were enough staff. Relatives and people spoke positively about the care and staff.
However, infection-control practice was inconsistent. Some staff did not use protective equipment correctly, staff did not always keep apart, and one person's clothing increased infection risk. Medicines were not always stored or managed safely, and checks did not reliably identify problems.
The overall rating fell from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected, so their previous ratings were used in the overall rating.
Kind, respectful care
People and relatives spoke positively about the staff and care. Inspectors saw good relationships and positive interactions between staff and people.
“People felt safe living at the home. People seemed relaxed and comfortable and staff knew people's preferences.” from the report
Enough staff
Staffing levels were linked to people's needs, and recruitment checks were completed safely.
“Staff were recruited safely and there was enough staff to meet the needs of people living at the service.” from the report
Individual risk assessments
Risk assessments for areas such as nutrition, falls, hydration and skin care were detailed and kept up to date.
“Risk assessments were in place, up to date and contained detail specific to that person.” from the report
Family contact
Relatives received regular updates, including video calls during COVID-19 restrictions. Staff also spent time with people who were isolating in their rooms.
“Relatives advised us they received regular updates from the service.” from the report
Infection-control practice
seriousProtective equipment, hand hygiene, social distancing and clothing were not consistently managed. Inspectors said this increased the risk of infection transmission.
“Measures were not consistently applied in the management of infection prevention and control which put people at risk.” from the report
Medicine safety
seriousMedicine audits were not robust, storage was not always correct, and a cream was found unlocked and with unclear records about its use.
“The management of medication was not always safe. Robust audits were not completed, and medication was not consistently stored correctly.” from the report
Weak management checks
seriousAudits and spot checks did not consistently identify problems, including infection-control failures and care records that did not involve people sufficiently.
“Tasks such as spot checks, audits and reviews were completed on a regular basis, but these were not robust in picking up weaknesses.” from the report
Incidents not always investigated
needs fixingSome incidents, complaints and allegations were not recorded or investigated, leaving concerns unresolved.
“This left some people's complaints and allegations unresolved and not subject to an internal investigation.” from the report
Care-plan involvement
needs fixingCare plans were clear and person-centred, but people were not consistently involved in creating them and consent was not always sought.
“People had not consistently been involved in the creation of their care plans and consent was not always sought.” from the report
- 01What changes have been made to ensure all staff use protective equipment, clothing and social distancing correctly?
- 02How are medicines, creams and medicine records now checked and stored safely?
- 03How do managers make sure audits identify problems rather than just being completed?
- 04How are incidents, complaints and allegations recorded, investigated and followed up?
- 05How are people and their representatives involved in care plans and asked for consent?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 11 February 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, June 2019
Rated Good; inspectors found safe, kind and well-organised care, with some minor medicines and care-planning records to improve.
Inspectors visited on 11 and 18 June 2019. The first visit was unannounced. They spoke with people living at the home, relatives, staff and healthcare professionals, and reviewed care, medicines, staff and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe, were treated kindly, had their needs met and could take part in activities. Staff were described as well trained, available and knowledgeable about people's preferences.
Inspectors found some minor shortfalls. Dates of opening were not always recorded on some medicines, one person's medicines risk assessment did not match their care plan, and not everyone had an end-of-life care plan. The manager was told about these issues and said action would be taken.
The previous rating was Requires Improvement, published in June 2018, when there were three breaches of regulation. This inspection found enough improvement had been made and the home was no longer in breach.
People felt safe
Inspectors found that risks were assessed and managed, staffing levels were sufficient and medicines were generally handled safely.
“People felt safe living at the home. Risks were well managed. Medicines were managed safely.” from the report
Kind and respectful staff
Staff treated people with dignity, knew them well and supported their choices and independence.
“Staff interacted with people in a kind and respectful manner. People seemed relaxed and comfortable in the company of staff.” from the report
Personalised care
Care records included people's histories, interests, likes and dislikes. Staff said these records helped them provide the right support.
“This detailed what was important to and for the person, their preferences, likes and dislikes.” from the report
Activities and community links
People could take part in activities at the home and in the community, including visits from local children and social events.
“There was a range of activities on offer, both in the home and in the community to help prevent people becoming socially isolated and to keep people active.” from the report
Improved management
The home had improved since the previous inspection. The manager was approachable, monitored the service and acted on feedback and incidents.
“The quality assurance records that we saw demonstrated how the registered manager maintained good oversight of the service.” from the report
Medicine opening dates
needs fixingSome eyedrops and creams did not have their opening dates recorded. The manager was told and said immediate action would be taken.
“We found some medicines, for example, eyedrops and topical creams did not always have the date of opening recorded.” from the report
Handwashing prompts
minorInspectors did not see people being asked whether they wanted to wash their hands before meals. Hand wipes were available and the home had already identified this in its audits.
“We did not observe residents being asked if they wished to wash their hands before mealtimes.” from the report
End-of-life wishes
needs fixingNot everyone had a plan recording their wishes for end-of-life care. The management team had already identified this and agreed to work on it.
“Not everyone living at the service had a plan in place which captured their wishes for end of life care.” from the report
- 01How do you now make sure opening dates are recorded on all eyedrops, creams and other medicines?
- 02How do you check that medicines risk assessments match each person's care plan, particularly when someone self-medicates?
- 03How do you record and review a new resident's wishes about end-of-life care?
- 04How do you make sure people are offered appropriate help with handwashing before meals?
- 05What changes were made after the previous Requires Improvement inspection, and how are these improvements checked now?
This was a planned inspection covering all five CQC questions, following the previous Requires Improvement rating. This explanation was written from the published report of 29 June 2019 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 Cleveland House Care Home
7 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- February 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2017Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 21 March 2011.
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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