We carried out a review of the data available to us about Cloverdale Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Cloverdale Care Home, you can give feedback on this service.
People’s experience of using this service and what we found
People were happy with the care they received, they felt safe and well looked after. Staff had been recruited safely. There were enough staff on duty who were provided with the appropriate training to enable them to carry out their roles effectively.
The home was clean and tidy and additional cleaning ensured people were safe from the risk of infection. Care plans were up to date, risk assessments were in place and regularly reviewed.
People received their medicines on time and when they needed them. Staff had positive links with healthcare professionals which promoted people's wellbeing.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People and staff spoke highly of the registered manager and their commitment to the service.
A system was in place which was used to monitor the quality and safety of the service. The registered manager carried out regular checks and analysis of incidents to ensure learning from events was shared with staff and actioned appropriately.
People were regularly asked their views on the service provided and action had been taken when suggestions were made.
For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 29 November 2019) and there was a breach of regulation 17. The provider completed an action plan after the inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulation 17.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 14 October 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Good Governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cloverdale Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Cloverdale Care home is a care home in the village of Laceby. It is registered to provide accommodation and personal care to 40 younger and older people, some of whom may be living with dementia. At the time of our inspection, 23 people lived at the service.
People’s experience of using this service and what we found
People were supported with their medicines in a person-centred manner by staff. However, medicine records for prescribed creams were not appropriately completed and did not show if they had been applied as prescribed. Some areas of the service compromised people’s safety and not all areas could be effectively cleaned. Governance systems had failed to identify these shortfalls. The manager responded promptly during the inspection to address the issues.
People were happy with the care provided and told us, “I'm happy here and well looked after” and, “It's next best thing to being at home.” Staff were kind, attentive, respectful and maintained people’s privacy and dignity. People were supported to follow their own routines and at their own pace. Staff promoted people’s independence and respected people’s decisions.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
There was enough staff to meet people’s needs. Recruitment, induction and ongoing training processes ensured only suitable staff were employed and that they had the required skills and knowledge. Staff were supported by the manager who was working to ensure staff received appropriate supervision and appraisal.
People were provided with appropriate support at meal times and had different options to choose from. People were provided with a varied and healthy diet. People were supported to access healthcare services and staff followed professional advice. People’s rooms were personalised, and signs were used to help people find their way around. Activities were available for people and visitors were welcome at any time.
The manager was working to improve the service and sought the views of people and staff. The manager promoted a positive culture and staff were confident in their ability to improve and develop the service.
For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 19 April 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement
We have identified a breach in relation to monitoring and addressing quality shortfalls at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The building is purpose built, with accommodation provided at ground level. All bedrooms are single and thirty-nine have en-suite facilities. Cloverdale Care Home is set in its own grounds and has pleasant views of open countryside. There is ample car parking available.
This inspection took place on 09 March 2017 and was unannounced. The service was last inspected on 18 September 2015 and was found to be compliant with the regulations inspected at that time.
At the time of the inspection 26 people were living at the service.
There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People were cared for by staff who understood they had a duty to report any abuse so people were protected from harm. Staff had received training in how to identify and report abuse, and knew they could contact outside agencies if they wished. Staff, who had been recruited safely, were provided in enough numbers to meet the needs of the people who used the service. The service was kept clean and tidy and all areas were free from offensive odours. People’s medicines were handled safely by staff who had received regular training.
People received a wholesome, well balanced and nutritious diet, their likes and dislikes were catered for and there was a choice of food at all meals times. Staff monitored people’s dietary intake and made referrals to health care professionals when required. People who needed support with making informed decisions were protected by the use of legislation. Meetings were held with all those who had an interest in the person’s welfare to ensure any decisions made on their behalf where in their best interest. Staff had received training which equipped them to meet the needs of the people who used the service.
People were cared for by staff who were kind and caring. Staff understood people’s needs and respected their privacy and dignity. People, who used the service, or those who acted on their behalf, were involved in the formulation of care plans; this ensured people received care which met their needs and was of their choosing. Staff understood the importance of keeping personal information about the people who used the service confidential.
Staff had access to detailed information which described the person and their preferences for care; this ensured the care people received was person centred and met their needs. People had access to a variety of activities both inside and outside of the service. The registered provider had an accessible complaints procedure which was displayed around the service.
Systems were in place which gathered the views of the people who used the service and those who had an interest in their welfare about the quality of the service provided. The registered manager was accessible and approachable. The quality of the service was audited regularly and any short falls were addressed through time limited action plans.
We undertook this unannounced inspection on the 18 & 21September 2015. The last full inspection took place on 27 August 2013 and the registered provider was compliant in all the areas we assessed.
Cloverdale Care Home is registered to provide accommodation and personal care for 40 older people, some of whom may be living with dementia. The home is a purpose built, single storey service situated on the edge of Laceby village and has access to all local facilities. On the day of the inspection there were 24 people using the service.
The service did not have 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 previous registered manager/provider had resigned two weeks before the inspection visit when the new acting manager commenced their role. The acting manager confirmed they would be submitting their application for registration.
We found the quality monitoring system had not been effective in highlighting some areas to improve and action had not been consistently taken in order to address shortfalls. Delays in renewal of the premises were evident however a major refurbishment programme was due to start the following month. The new regional manager had recently completed a full audit of the service and produced an action plan which they were working through. New quality monitoring systems were being introduced.
Efforts had been made to improve the standard of cleaning throughout the service since the new management team had taken over, however not all equipment was found to be clean. The acting manager took action to address this during the inspection.
We found staff ensured they gained consent from people prior to completing care tasks. In the main, staff worked within mental capacity legislation when people were assessed as not having capacity to make their own decisions. However, we found instances when best practice had not been followed; records to support decisions about active resuscitation were not in place to reflect capacity assessments and decision-making. The acting manager told us they would address this straight away.
People told us they felt safe living in the service. We saw staff interacting with people and they did so in a kind, caring and sensitive manner. Staff showed good knowledge of safeguarding procedures and were clear about the actions they would take to protect people.
We saw there was enough skilled and experienced staff on duty to meet people’s needs. We found staff had been recruited using a robust system that made sure they were suitable to work with vulnerable people. They had received a structured induction and essential training at the beginning of their employment. This had been followed by regular refresher training to update their knowledge and skills.
People received a well-balanced diet and were involved in choosing what they ate. The people we spoke with said they were happy with the meals provided. We saw specialist dietary needs had been assessed and catered for.
People’s needs had been assessed before they moved into the home and they had been involved in formulating and updating their care plan. The three care files we checked were individualised and reflected people’s needs and preferences in good detail. Care plans and risk assessments had mostly been reviewed and updated on a regular basis.
People told us in-house social activities were available, as well as occasional trips into the community. They said they also enjoyed going out with relatives.
People told us they had no complaints but would feel comfortable speaking to staff if they had any concerns. We saw the complaints policy was readily available to people who used or visited the service.
There were systems in place to enable people to share their opinion of the service provided and the general facilities at the home.
People’s healthcare needs were met. People told us that they had access to their GP, dentist chiropodist and optician should they need it. The service kept clear records about all healthcare visits and appointments.
People who used the service told us staff supported them well with health and personal care needs and that prompt action was taken to get medical attention when required. Visiting relatives told us they were very satisfied with the service and that staff kept them informed about decisions. We saw that a district nurse had commented in a survey that, 'Staff contact nurses promptly with any concerns' and 'All carers are very friendly and caring and treat people with respect.'
People who used the service told us they received their medication at regular times and when it was required. We found that staff had completed training in the safe handling and administering of medication and that audits of this were carried out, to ensure accurate records were maintained.
We found that records were maintained of regular checks and servicing of equipment, to ensure people's welfare was safety promoted.
People who used the service told us that overall were happy with the service provided and that they were confident appropriate action would be taken, to deal with any concerns should they arise.
People that used the service told us staff were 'helpful and kind.'
People that used the service said that staff supported their health and personal care needs well. People that used the service told us that staff took prompt action to get them medical attention when it was needed.
People that used the service told us that staff spent individual time with them to ensure their health and well being was promoted. We observed staff providing gentle support and assistance to people with personal manicures as part of a pampering session. One person told us that staff took them out in their wheel chair around the local village and that others had recently been out on a visit to Cleethorpes.
People told us they had had 'no concerns' and that staff treated them well. People told us they felt 'safe' living in the home.
People who used the service said that they were "very comfortable" living in the home and that staff were 'good.'
People told us they were 'very satisfied' with the service they received and were confident their views were taken seriously by the manager. People said they had "no complaints" about the home and confirmed they were able to make suggestions to help develop the service.