CQC report explained · a nursing home
What the CQC found at Cleveleys Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk records were not always correct or up to date. Inspectors also found problems with emergency evacuation plans, medicine storage, bedrail checks, weight records and reviews of pressure sore or malnutrition risks.
- Effective?
- Requires improvement
- The home did not always assess or record people’s ability to consent, or follow best-interest processes for restrictive care. Some staff had not completed all required training before starting work, although food and health professional support were positive.
- Caring?
- Good
- People and relatives described staff as kind, respectful and compassionate. Inspectors saw positive interactions and people being involved in everyday choices, although some staff used labels instead of person-centred language.
- Responsive?
- Requires improvement
- Staff knew people well, but some care plans lacked important detail. The activity notice did not match what was happening, and people staying in their rooms were not receiving one-to-one activities or stimulation.
- Well-led?
- Requires improvement
- Quality checks had not found or fixed repeated problems in care planning, risk management and consent records. The provider was working with the local authority on an improvement plan and had introduced new management and care coordination arrangements.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found kind care and safer medicines, but ongoing risks in records, consent, staffing and oversight.
Inspectors visited on 17 and 26 October 2023. The first day was unannounced. They spoke with people, relatives, staff and health professionals, observed care, walked around the home and checked care, medicines, recruitment and management records.
People were generally treated kindly and with respect. Inspectors saw people looking happy and relaxed with staff. Medicines were administered safely, the home was clean, and people’s food and health needs were supported.
However, records and checks were not reliable enough to show that risks were always managed. The home did not always follow the law when people could not consent to care. Staffing deployment, activities, care planning and quality checks also needed improvement.
The overall rating remains Requires Improvement. The home was also rated Requires Improvement for Safe, Effective, Responsive and Well-led, and Good for Caring. This was the third consecutive inspection with an overall Requires Improvement rating.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff laughing and joking with people, respecting privacy and supporting everyday choices.
“People told us they were listened to, were treated with kindness and had positive relationships with staff.” from the report
Medicines had improved
The home had improved wound care and medicines administration. Staff followed good practice when giving medicines and people said they received them as prescribed.
“We saw medicines administration and found staff followed best practice and were person-centred in their approach.” from the report
Clean and hygienic home
Inspectors found good infection control arrangements, including effective use of protective equipment. The home had a food hygiene rating of 4 out of 5.
“We were assured the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Support from health professionals
The home worked with health professionals and the local authority. Inspectors noted improvements in wound care records and relatives said staff sought medical advice when people became unwell.
“Following local authority oversight, there had been improvements in wound management.” from the report
Risk records were not reliable
seriousSome personal emergency plans, care records, weight records and safety checks were incomplete, incorrect or out of date. Inspectors said this placed people at risk of harm, even though they found no evidence that anyone had been harmed.
“However, documentation and systems were not in place or robust enough to show risk was effectively managed.” from the report
Consent and best-interest decisions
seriousThe home did not always assess people’s capacity to consent or record who should make decisions. Best-interest processes were not followed for a restrictive practice.
“The provider did not protect people's rights under the Mental Capacity Act.” from the report
Staffing and activities
needs fixingStaff deployment did not always match people’s needs, and some people had to wait for personal care. Inspectors also saw little time for activities, with no one-to-one stimulation for people who stayed in their rooms.
“Our observations showed people had to sometimes wait for support with personal care.” from the report
Weak quality checks
seriousAudits did not identify repeated problems with care plans, risk management and consent records. The provider remained in breach of governance requirements after the previous inspection.
“Audit systems and processes had not identified the shortfalls we found.” from the report
Care plans and activities were not always current
needs fixingSome care plans lacked detailed information about health conditions and behaviours. The activities list did not reflect what actually took place.
“There was a list of activities on a notice board in the main hallway, but this did not reflect what took place.” from the report
- 01How have you made sure every person has a current and accurate risk assessment, including an emergency evacuation plan and bedrail checks?
- 02How do you assess capacity, record consent and complete best-interest decisions when a person cannot make a particular decision?
- 03What staffing changes have you made to prevent waits for personal care and to provide safe support during mealtimes?
- 04What regular activities and one-to-one stimulation are now available for people who stay in their rooms?
- 05How do your audits now identify and correct problems in care plans, risk records and consent documentation?
This was a follow-up inspection prompted by the previous action plan and concerns about risk, staffing and governance; inspectors reviewed all five ratings, infection control, care and management records, and observed care. This explanation was written from the published report of 28 December 2023 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, May 2023
Cleveleys Nursing Home is Rated Requires Improvement; inspectors found people felt safe and cared for, but medicines records and management checks were not reliable.
The inspection took place on 24 and 29 March 2023. One inspector spoke with six people, four relatives and eight staff. They looked around the home and checked care records, recruitment files, medicine records and management records.
People said they felt safe and received help when they needed it. Staff were kind and respectful. The home worked with health and social care professionals and responded quickly when infection risks were identified.
However, medicines were not always managed safely. Records of medicine checks, temperatures and some doses were incomplete. Other records, including weights, moving and handling information, daily care and fluid records, were not consistently accurate or overseen by managers.
The overall rating remains Requires Improvement, as it was at the previous inspection. The Safe and Well-led ratings were both Requires Improvement. The CQC found breaches of regulations about safe care and treatment and good governance.
People felt safe
People said they felt safe and received help when they needed it. Staff knew how to report abuse and said they could raise concerns.
“People told us they felt safe, and staff were effectively deployed so people received support when they needed it.” from the report
Kind staff
Inspectors saw staff treating people with kindness and patience. People said they liked the staff and received good care.
“Staff were kind and respectful with people and were patient when they supported them.” from the report
Positive culture
People, relatives and staff described a positive atmosphere. The provider sought feedback and worked with health and social care professionals.
“People we spoke with described a positive, caring environment.” from the report
Infection arrangements
Inspectors were assured that the home used protective equipment safely and had arrangements to prevent and manage infection outbreaks.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Medicine safety
seriousMedicine records and checks were incomplete. This included temperature records, stock records and records showing exactly which tablets had been given.
“Documentation was not always completed to evidence safety checks had taken place.” from the report
Weak management checks
seriousAudits and checks did not consistently identify problems or lead to improvement. Some daily care and fluid records did not show reliable oversight.
“Audits and checks had not been embedded effectively after the last inspection or consistently identified shortfalls and driven improvement.” from the report
Recruitment records
minorSome staff files did not contain a full employment history or evidence that gaps had been explored. The CQC made a recommendation about recording this information.
“However not all recruitment files contained a detailed employment history and there was no documentation to show this had been explored.” from the report
Parts of the building need updating
minorInspectors said some parts of the home needed updating and refreshing. The provider said they knew what was needed and would take action.
“Parts of the home required updating and refreshing.” from the report
- 01What has changed since the inspection to make sure medicine administration records, stock checks and fridge temperatures are completed every time?
- 02How do managers now check that weights, moving and handling records, daily care records and fluid charts are accurate and properly overseen?
- 03What evidence can you show that the repeated concerns about medicines and record keeping, also found at the previous inspection, have been fixed?
- 04How are recruitment files checked to make sure they include a full employment history and explanations for any gaps?
- 05What work has been completed to update and refresh the parts of the home identified by inspectors?
This was a focused inspection of Safe and Well-led, including infection prevention and control; ratings for the other key questions were carried over from the previous inspection. This explanation was written from the published report of 17 May 2023 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 Cleveleys Nursing Home
8 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2022Requires improvementup from InadequateSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- September 2021Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- March 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- July 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 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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85 live-in carers within about an hour of Lancashire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 78 can care for a couple. 11 years' experience on average.
“She understands the needs of an elderly person in the early stages of dementia and has treated my mother with great kindness and skill.”
“Thanks to Tracy, Dad was always immaculately dressed and clean, his meals were all home cooked and nutritionally well balanced and his home was always kept really clean and tidy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.