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We are carrying out a review of quality at Clovelly House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 4 February 2020

About the service

Clovelly House is a residential care home providing personal care to 17 people aged 65 and over at the time of the inspection. The care home accommodates up to 21 people in one adapted building.

People’s experience of using this service and what we found

People’s health, welfare and safety were placed at risk because the provider did not have effective systems in place to assess, monitor and improve the safety and quality of the service. There was a lack of management oversight of the service and the management team failed to understand the importance of this aspect of their role.

Comprehensive risk assessments were not in place to ensure staff knew how to keep people as safe as possible. Staff did not have the competence or skills to respond appropriately in emergency situations, which put people at risk. There was not an effective system in place to learn lessons from incidents or accidents. Staff numbers and deployment meant that people were not always fully supported in the way they wanted to be and there was a risk that both people and staff were not safe. Medicines were not managed safely.

The provider did not have a satisfactory system in place to ensure that people were protected from abuse and harm. Staff did not have the training or support to carry out their role in line with current good practice guidance and did not always support people to eat and drink enough.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and procedures in the service did not support this practice.

Staff did not always show respect for people or treat them as adults. People were not always given opportunities to make decisions about their care and did not have many choices about the way they led their lives. Staff did not always encourage and support people to maintain their independence.

Care plans had not all been updated or reviewed so staff did not have sufficient guidance to provide each person with the care they wanted. Staff were not always following care plans and records of care were incomplete. The provider had failed to ensure that people would receive the best possible care, in line with their preferences, at the end of their lives as no end of life care planning had been done.

At the start of the inspection there was a serious risk in the event of fire as fire safety arrangements were not robust enough. The provider addressed some of the issues so fire safety had improved by the third day of the inspection.

People told us they felt safe and were happy living at Clovelly House. Relatives were satisfied with the care people received. Activities were organised and people told us they had enough to do. New staff were recruited in line with the regulations and staff were aware of their responsibilities to protect people from the spread of infection.

People spoke highly of the staff and liked the food. People and their relatives knew how to complain but had never needed to. Staff involved other healthcare professionals to support people to maintain their health.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (report published 23 May 2018).

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding including the number of falls and serious injuries; care planning; and a number of other concerns about the safety and effectiveness of the care being provided to people living at the home. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the rep

Inspection areas



Updated 4 February 2020

The service was not safe.

Details are in our safe findings below.



Updated 4 February 2020

The service was not effective.

Details are in our effective findings below.


Requires improvement

Updated 4 February 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 4 February 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 4 February 2020

The service was not well-led.

Details are in our well-led findings below.