Archived: Cleeve Court Nursing Home

Updated 8 February 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 21 & 22 October 2015 and was unannounced. The inspection team consisted of two inspectors and one expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. Their area of experience was older people’s care.

Prior to the inspection we reviewed the Provider Information Record (PIR) and previous inspection reports. The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed the information we held about the service and notifications we had received. A notification is information about important events which the service is required to send us by law.

During the inspection we spoke with eight people who used the service, two relatives, six staff, the registered manager, two nurses and two chefs. In addition we observed care and support in communal areas and looked at four people’s care records. We also inspected a range of records. These included six staff files, training records, medication records, staff duty rotas, meeting minutes and the services quality assurance systems.

Updated 8 February 2016

We inspected this service on the 21 & 22 October 2015. This was an unannounced inspection. At our last inspection in December 2013 no concerns were identified.

Cleeve Court is a nursing home and provides accommodation for up to 29 people. At the time of this inspection there were 16 people living at the home. Cleeve Court has 22 bedrooms, a lobby kitchen, dining room, lounge, office, medication and treatment room, sluice, laundry room, gardens and patio area.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager joined the inspection on both days for a few hours.

People were living in a building that was not being adequately maintained or secure. Carpets were frayed, dirty and ill fitting. Some walls were crumbling and had mould and fungus growing and not all doors and windows had restrictors or fire safety devises fitted. During our inspection the front door to the property was left unlocked and there was a lack of security on checking visitor’s identification. The provider confirmed following the inspection the front door is now locked.

Medicine were not being safely managed or stored. Records were not accurate confirming if medicines had been collected or administered. Environmental risks were not being assessed and there were no support arrangements in place to prevent or reduce the risk of incidents occurring. Recruitment procedures were not always robust to ensured people were supported by staff who had adequate checks or that there was adequate paperwork in place. People who were at risk of developing pressure sores had care plans in place to ensure their position was regularly changed but there were no records confirming they received this assessed need.

People who were unable to consent to care and treatment had completed assessments and best interest decision paperwork in place. People did not always receive personal care that reflected their individual wishes. People were able to receive visitors whenever they wished and relatives were able to visit as often as they liked. Staff demonstrated they knew what to do if they suspected abuse. All people and staff we spoke with felt safe. Posters were displayed in areas throughout the home informing people what to do should they suspect abuse.

People were not supported by staff who received regular supervision or training to ensure they were competent and skilled to meet their individual care needs. Staff morale was low and they did not feel well supported. Although people and relatives felt supported by staff who demonstrated a caring and compassionate manner.

People, relatives, staff and health professional’s views were sought however there was no clear action plan in place that identified how the service planned to make improvements to the feedback provided. People and relatives felt happy to raise a complaint and were aware of the provider’s complaints policy. There was a lack of information relating to investigations or what learning had taken place to prevent similar issues occurring. Quality assurance systems were not ensuring they monitored the quality and safety of the service or identified areas for improvement with an action plan. The homes records were not always well organised or accessible.

You can see what action we told the provider to take at the back of the full version of the report.