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Archived: Cleeve Hill Nursing Home Good

Inspection Summary

Overall summary & rating


Updated 6 November 2015

This inspection took place on 7 and 8 October 2015 and was unannounced. Cleeve Hill Nursing Home provides accommodation for up to 50 people. At the time of our inspection there were 39 people living there. Up to six people can be cared for in the Winchcombe Unit which provides intermediate beds for people needing end of life support or rehabilitation. The staff employed in this unit were recruited, supervised and trained by a local hospital.

There were four people in the home living with dementia and 10 people with short term memory loss. All bedrooms, apart from three, had en suite facilities. People had access to shared bathrooms and shower rooms as well as living and dining areas. People staying at the Winchcombe Unit had single rooms with en suite facilities.

Cleeve Hill Nursing Home is currently registered to provide the regulated activity, Transport services, triage and medical advice provided remotely. This regulated activity was no longer being provided from this location and was not inspected as part of this comprehensive inspection. The provider is in the process of removing this regulated activity from Cleeve Hill Nursing Home and registering this regulated activity at another location.

There was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run. A manager had been appointed and they were in the process of applying to become registered with CQC.

People living at Cleeve Hill Nursing Home received personalised and individualised care which reflected their wishes, likes, dislikes and preferences. They had accommodation which was maintained to a high standard and which was due for further refurbishment. People enjoyed a range of activities both inside and outside of the home seven days a week. Activities co-ordinators were employed to deliver these alongside external providers who delivered Zumba and Tai-Chi. Individual activities were provided for people who preferred to remain in their rooms. People had meals provided to a restaurant quality and with a wide range of choice. People who had specific dietary needs were catered for.

People staying for a short period of time at the Winchcombe Unit had care records which clearly identified their treatment and any changes in the health or well-being. Upgrades to the environment had been made by Cleeve Hill Health Care in response to infection control issues. They enjoyed catering supplied by the care home.

People’s health and well-being was monitored and when changes occurred referrals were made to health care professionals. Relatives said they were kept informed of any changes and involved in decisions about their loved one’s care. People had personal profiles in their rooms reflecting those important to them, their wishes for care and support as well as end of life care. When people needed help to make decisions, their legal representatives were involved and any decisions taken were made in their best interests. People said they felt safe living in the home and relatives were reassured that they were well looked after.

People were supported by sufficient numbers of staff to meet their needs. Staffing levels were flexible and monitored closely to make sure they responded to people’s changing needs. Staff had access to a range of training to equip them with the skills and knowledge to support and care for people. They said they were well supported to develop in their role and spoke positively about working together as a team.

People were involved in quality assurance processes to give feedback about their experience of their care. This feedback along with feedback from their relatives, staff and community professionals was used to make improvements to the service. Relatives and staff spoke highly of the manager and recognised the need for consistent management to embed improvements.

Inspection areas



Updated 6 November 2015

The home was safe. People were kept safe from harm. Accidents and incidents were responded to promptly and the appropriate strategies put in place to prevent the risk of injury.

People were protected against known risks. Systems were in place to respond to emergencies.

People were supported by enough staff to meet their needs. When people’s needs changed staffing levels reflected this. Robust recruitment procedures ensured the necessary checks had been completed before staff started work.

People’s medicines were managed safely. Infection control measures were in place to prevent the spread of infections.



Updated 6 November 2015

The service was effective. People received care and support from staff who had the opportunity to acquire the skills and knowledge they needed to carry out their roles.

People’s ability to make decisions was assessed and decisions were made on their behalf if needed.

People’s health and well-being were monitored and they were supported to stay well. People were provided with meals of a high standard which reflected their dietary needs.



Updated 6 November 2015

The service was caring. People were supported with kindness, compassion and warmth. Staff understood their preferences, lifestyle choices and backgrounds. They treated people with respect and encouraged them to be independent.

People were given information about the service they were to receive and were involved in making decisions about their care. Visitors were made to feel welcome.



Updated 6 November 2015

The service was responsive. People and those important to them were involved in the planning of their care. People’s care was individualised and reflected their wishes, interests and preferences.

People were encouraged to join in a range of activities both inside and outside of the home. These were provided every day of the week. People who preferred to stay in their rooms were offered one to one activities of their choice.

People and their relatives knew how to make a complaint and were confident they would be listened to and action would be taken to address any concerns.



Updated 6 November 2015

The service was well-led. People and those important to them were asked for their views about the service. Improvements to people’s experience of care resulted from their feedback and analysis of accidents, incidents and complaints.

An open culture was promoted and staff reflected the values of the service to deliver the highest standards of care and to help people live the life they wanted.