CQC report explained · a nursing home
What the CQC found at Tanglewood Cloverleaf
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and risks such as falls and skin damage were assessed and managed. However, earlier staff shortages meant some people had to wait for care, including help to use the toilet.
- Effective?
- Good
- People's health, nutrition and care needs were assessed and monitored. Staff had suitable training, although one staff member said more training on challenging behaviour would be helpful.
- Caring?
- Good
- People and relatives described staff as caring, thoughtful and supportive. Inspectors saw respectful interactions and found that people were involved in decisions about their care.
- Responsive?
- Good
- Care was personalised and people could choose activities and daily routines. Inspectors noted that the electronic care plans were not always as detailed about individual preferences as best practice would suggest.
- Well-led?
- Good
- The management team was open and used audits and incident reviews to improve care. There had been three registered managers and high staff turnover since the home opened, so the current manager was working to improve stability.
What inspectors found, August 2021
Tanglewood Cloverleaf was rated Good overall; inspectors found kind, safe care, but noted earlier staff shortages and some care records could be more detailed.
This was an unannounced comprehensive inspection on 7 July 2021. Three inspectors spoke with people, staff and relatives, observed care, and checked care, medicine, staffing and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People were protected from abuse and avoidable harm, their health and nutrition were supported, and medicines and infection control were managed safely.
Inspectors found that people were treated with kindness and respect. Staff listened to people's choices, supported activities and relationships, and provided caring end of life support.
The inspection was prompted partly by concerns about staffing. There had been sickness, staff leaving and times when people waited for care. Staffing was sufficient on the inspection day, and the management team had recruited and was continuing to recruit.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed caring interactions that protected people's privacy, dignity and independence.
“People and their relatives told us the staff team treated them with care and respect, and their views on their care were listened to.” from the report
Safe care systems
Risks were assessed and steps were taken to reduce them. Inspectors also found that medicines and infection prevention were managed safely.
“People's medicines were safely managed and there was clear infection prevention practices in place to protect people from possible infections such as COVID-19.” from the report
Good health and nutrition support
People's health needs and weights were monitored, and staff worked with health professionals when needs changed. People were offered food choices and healthy snacks.
“People's health needs were well managed, and they were encouraged to live healthy lives.” from the report
Personal choice and activities
People were involved in care planning and daily decisions. They could take part in activities, celebrate events and maintain contact with relatives.
“People received person centred care in a way of their choosing.” from the report
Active management oversight
The management team used audits, incident reviews and feedback to identify issues and take action. Inspectors found managers responsive when concerns were raised.
“There was a comprehensive quality monitoring system in place at the service.” from the report
Earlier staff shortages
needs fixingSickness and staff leaving had caused periods when staffing levels were below the planned number. People sometimes waited for care and staff said they had felt rushed.
“Both people and staff told us there had been some shortages of staff which had resulted in people having to wait for the care they needed.” from the report
Care plans not always detailed
minorThe electronic care plans did not always record individual preferences in as much detail as best practice. The provider recognised this and planned improvements.
“As a result, care plans were not always as detailed about individual preferences as is best practice” from the report
Staff stability
needs fixingThe home had experienced three registered managers and a large staff turnover since opening in 2019. The current management team was working to create more stability.
“The service had had three registered managers since opening in 2019 and there had been a large turnover of staff during this period.” from the report
- 01What are the current staffing levels on each shift, and how do you cover sickness and staff leaving?
- 02Have the electronic care plans been improved so that each person's preferences are recorded in detail?
- 03What further training has staff received on managing challenging behaviour?
- 04How has the home improved staff stability since the inspection?
- 05How do you check that people receive timely help when they need personal care?
This was the home's first comprehensive inspection; Safe, Caring and Well-led had been rated Good at an earlier focused inspection, while Effective and Responsive were inspected and rated for the first time. This explanation was written from the published report of 4 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, October 2020
Inspected but not rated; inspectors were assured that infection prevention and control measures were in place.
This was an announced, targeted inspection on 28 October 2020. Inspectors looked only at infection prevention and control because the home was planned as a designated setting for people discharged from hospital with Covid-19.
Inspectors found separate areas and staff teams to reduce the spread of infection. The home had entry checks, safe admission arrangements, enough protective equipment, regular testing and thorough cleaning.
The home was rated inspected but not rated overall, and safe was also inspected but not rated. This does not give a full rating of the quality of care across all five areas.
Separate infection control areas
The home had a designated area and separate staff arrangements to reduce the chance of infections spreading.
“The provider had identified a specific area within the home to ensure effective use of cohorting and zoning to reduce the potential for the infection to spread.” from the report
Safe entry and admissions
People entering the home had temperature checks, a questionnaire and hand disinfection. People admitted from hospital with Covid-19 could use a separate lift and stairwell.
“There was a detailed entry system into the home, with temperature testing, contact questionnaire and hand disinfection on entry.” from the report
Protective equipment and testing
Inspectors saw a plentiful supply of protective equipment being used properly. Staff and residents took part in regular Covid-19 testing.
“The provider had ensured there was a plentiful supply of personal protective equipment and we saw staff used this appropriately.” from the report
Cleaning and staff support
The home used approved cleaning products and had risk assessments for people and staff at higher risk. Staff also received information and access to wellbeing support.
“Areas were thoroughly cleaned and disinfected with approved products to reduce the potential of transfer of infection.” from the report
Inspectors raised no specific concerns in this report.
- 01How have the infection prevention and control arrangements changed since the inspection on 28 October 2020?
- 02How would you separate people and staff if someone arrived from hospital with Covid-19 or another infection?
- 03How often are staff and residents tested when there is a risk of infection?
- 04How do you make sure there is always enough protective equipment and that staff use it correctly?
- 05How are cleaning, entry checks and hand disinfection monitored?
This was a targeted inspection of infection prevention and control measures only; it did not provide ratings for the other areas of care. This explanation was written from the published report of 31 October 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 Tanglewood Cloverleaf
Each visit the CQC has published, newest first, back to the day the home was registered.
- August 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020Inspected but not ratedSafe: Inspected but not rated
- October 2020Inspected but not ratedSafe: GoodCaring: GoodWell-led: Good
- October 2019
Registered with the Care Quality Commission on 7 October 2019.
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.
Weigh the report against the rest
Fees, photos and reviews from families
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9 live-in carers within about an hour of Lincolnshire
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.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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.