Cleveland House Care Home

Cleveland House Care Home is a nursing home providing personal and nursing care to 27 people aged 65 and over at the time of the inspection. The service can support up to 45 people.

Cleveland House Care Home has three floors accessed by passenger lift with single rooms, shared toilet and bathing facilities on each floor. Outside there is a garden with seating areas.

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

Infection Prevention and Control (IPC) measures were not consistent in the service. Some senior members of staff were not wearing personal protective equipment correctly. One senior member of staff wore clothes which increased the risk of infection transmission. Staff were not consistently socially distancing.

Audits were regularly completed but these did not consistently identify issues that needed addressing.

Care plans and records were reviewed regularly. Care plans were person centred and clear in detailing what support the person required. People had not consistently been involved in the creation of their care plans and consent was not always sought.

People felt safe living at the home. People seemed relaxed and comfortable and staff knew people’s preferences. Staff treated people with dignity and respect and staff had good interactions with people.

People and their relatives spoke positively about the staff, service and the care people received.

Staff members had been recruited safely and there were enough staff to meet the needs of people using the service.

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.

Staff were able to demonstrate how they were meeting the underpinning principles of Right Support, Right Care, Right Culture guidance. People were treated with dignity and respect; people’s choices and preferences were sought, and staff prioritised the happiness of the people using the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 28 June 2019).

Why we inspected

We received concerns in relation to infection prevention and control following a recent COVID-19 outbreak at the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to required improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to regulation 17 (good governance) and regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

Cleveland House Care Home provides personal and nursing care for up to 45 older people. At the time of our inspection there were 38 people living at the service.

The care home has three floors accessed by passenger lifts. A lower ground floor and first floor contains single bedrooms, shared toilets and bathing facilities; the ground floor contains single bedrooms, toilet and bathing facilities, plus shared lounges and a dining area. Outside there is a garden with seating areas.

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

People felt safe living at the home. Risks were well managed. Medicines were managed safely. Staff helped people to stay healthy and people had access to a range of health care professionals.

Staff received the training and support they needed to carry out their roles effectively. Staff members had been safely recruited and there were enough staff to provide people with the person-centred support they needed.

The home was clean and maintained.

People were involved in decisions about their care and support. The provider was working within the principles of the MCA.

Staff interacted with people in a kind and respectful manner. People seemed relaxed and comfortable in the company of staff. Staff and managers knew people really well and showed an understanding for the people who lived at the home.

Care records were person-centred and were reviewed regularly. They gave sufficient information to staff to guide them on the care and support people needed.

There was a range of activities on offer, both in the home and in the community to help prevent people becoming socially isolated and to keep people active.

Everyone was very positive about the registered manager and the way the service was organised and run.

Audits of the service, company policies and procedures and staff practice all helped to evidence how the service was meeting the regulations. The quality assurance records that we saw demonstrated how the registered manager maintained good oversight of the service.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 18 June 2018) and there were three breaches of regulation. The provider completed an action plan after the last 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 regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Cleveland House is registered to provide personal care and accommodation for up to 45 older people, some of whom live with dementia. The home has three floors accessed by passenger lifts. A lower ground floor and first floor contained single bedrooms and shared toilets and bathing facilities; the ground floor contains single bedrooms, toilet and bathing facilities, plus shared lounges and a dining area. On the first day of our inspection there were 24 people living at Cleveland House and on day two this number was 23. The bedrooms on the lower ground floor were not in use. Outside there is a garden with seating areas.

Cleveland House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home did not have a registered manager in post and although a home manager was employed, they were unavailable on both days of our inspection. The regional director for recovery made us aware the home manager was leaving and a new home manager would commence working in the home from mid-April 2018 and they would be expected to register shortly afterwards. 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.

People gave us mixed feedback about staffing levels which had been kept at the same levels since our last inspection. Records of staff response times to nurse call bells showed a number of examples of unexplained lengthy delays and the analysis of these incidents was not thorough.

Examples were identified when some staff did not demonstrate appropriate values to maintain people’s privacy and dignity. People were complimentary about the care provided by staff who were sufficiently skilled. Staff received an appropriate induction and training as part of their development, although supervisions and appraisals were not happening in line with the registered provider’s policy and good practice recognised by the National Institute for Clinical Excellence (NICE).

The management of medicines was not always safe as oxygen cylinders had not been secured since we commented on this in our last inspection and risk assessments for prescribed thickener stored in people’s rooms had not been considered. Topical medicine administration records were not in place for all prescribed creams, gels and ointments in use.

People and their relatives told us people were safe living at Cleveland House Care Home. Recruitment processes were mostly safe, although one staff member had commenced their employment without a last employer reference.

Some examples of unsafe moving and handling transfers were seen which were discussed with the management team. Individual risks to people with one exception had been assessed to reduce the risk of harm.

People’s nutritional and hydration needs were being met as staff had sufficient knowledge and records were in place to support this.

People were supported in accordance with the Mental Capacity Act (2005), although this was not always reflected in their care records. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Applications for Deprivation of Liberty Safeguards had been made appropriately.

Accidents and incidents were recorded, although the analysis of these events required improvement. A new system was in place to support this.

People’s care records were person-centred, although some issues remained with record-keeping and consistency. Some improvements had been made with recording end of life care wishes, although these lacked detail. Care records showed staff supported people to access healthcare services from a range of professionals.

Activities were taking place during our inspection, although people told us they were unsure when and where activities were taking place. The incoming home manager wanted to use the gardens more effectively.

Relatives and staff were complimentary about the home manager in post at the time of our inspection, although it was noted they lacked a visible presence in the home.

Meetings with people, relatives and staff were taking place. Some audits were not fully effective as they were missing actions and dates. New quality management initiatives had been introduced to improve performance since our last inspection.

We recommend the registered provider reviews the mealtime experience to remove avoidable delays in people receiving their meals and also to develop links with services in the local community.

We found three breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the end of this report.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Cleveland House is a care home registered to provide residential and nursing care for up to 45 people over 65 years old. It consists of one building and one purpose built extension with three floors accessed by two passenger lifts. The rooms were all single. At the time of our inspection 36 people were living at Cleveland House.

This inspection was brought forward due to concerns raised by the public and stakeholders.

Cleveland House was last inspected on 4 and 10 January 2017. At that time the service was rated requires improvement and had two continuous breaches of regulation relating to safe care and treatment and good governance which had already been identified during our previous two inspections. Following the last inspection, we asked the provider to take action to make improvements to their processes in relation to risk assessments, medicines and auditing. At this inspection we found the service had not made enough improvements and was still in breach.

The home did not have a registered manager in place. 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 2008 and associated Regulations about how the service is run. There was a home manager in post but they had not yet registered with CQC.

Although efforts had been made to register a manager and an application had been sent to CQC this was subsequently returned due to incompleteness and a new one had not been submitted. The registered provider had failed to comply with a condition we had applied to their registration requiring them to appoint a registered manager.

Risks associated with people's individual care needs were not always identified or managed appropriately. Medicines were not administered safely at the home and people had been put at risk of harm. During our inspection we raised safeguarding concerns in relation to medication.

Staffing levels were not always sufficient to ensure people received the care they needed. Staff had not always been recruited safely to ensure they were suitable to work at the service. Staff had completed relevant training however, we found examples where staff’s knowledge was not effective in meeting people’s needs. Staff had supervision but not as regularly as stated in the registered provider’s own policies.

People’s mental capacity was not always assessed and best interest decisions were not always completed in line with legislation.

People’s nutritional and hydration needs were not being appropriately met and the registered provider was not managing people’s weight loss safely.

People did not always receive dignified care in accordance with their preferences. The registered provider was not consistently involving people and their relatives in making relevant decisions about their care.

People's personal information was not always stored securely.

People were offered social stimulation on a regular basis through varied and meaningful activities.

There were care plans in place; however, the quality of these care plans fluctuated and some contained contradictory information which put people at risk of inappropriate care.

The registered provider did not have a robust approach to dealing with complaints and people and their relatives could not be reassured their concerns would always be valued and acted upon.

Staff’s morale was low and there were substantial issues with the home’s organisational culture due to lack of strong leadership.

The systems of governance in place and the home manager’s oversight were not robust to implement changes and this was having a negative impact on the overall quality of the service.

The registered provider was in continuing breach of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to vary or cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling or varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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

Cleveland House provides support to people with both nursing and residential care needs. The home has a maximum occupancy of 45 people, on the day of our inspection 34 people were resident at the home.

The service did not have a registered manager in place. 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 2008 and associated Regulations about how the service is run.

People told us they felt safe and staff were aware of their responsibilities in keeping people safe from the risk of harm or abuse. However, where people required staff support due to immobility, not all aspects of their support were robustly assessed. Risk assessments lacked detail regarding equipment and the method staff were to deploy to keep people safe.

Action had been taken to ensure bed rails were used appropriately and the clinical lead nurse was able to tell us about strategies used by staff to reduce people’s falls risk. However, a robust analysis of falls was not in place.

There were systems in place to protect people in the event of a fire. This included fire training for staff and regular checks on the fire detection and methods of escape. Maintenance checks were completed for aspects of the environment and equipment to reduce the risk of harm to people or staff.

A number of pre-employment checks had been completed on potential candidates to reduce the risk of employing staff who may not be suited to supporting vulnerable adults. Some of the evidence to support these checks had had not been filed at the home, but a senior manager emailed outstanding documentation to us after the inspection.

People told us there were enough staff and we saw people’s needs were met by staff in a timely manner but staff lacked time to spend with people other than when they were completing a care related task.

Not all aspects of medicines management were robust. When people were prescribed a cream, this was kept in their bedroom but the records staff were to complete to evidence the cream had been applied as prescribed were not consistently completed. Staffs competency to administer people’s medicines was assessed and checks were made at the ends of each medicine round to reduce the risk of errors.

There was a programme of induction for new staff and this was followed by regular refresher training. A lack of staff knowledge highlighted in our previous report had been addressed through training but these topics were not included in the registered provider’s rolling refresher programme.

Staff told us they received supervision but at the time of the inspection the records did not support this being completed at regular intervals.

All the staff we spoke with expressed an understanding of the Mental Capacity Act 2005 (MCA) and people’s right to make choices and decisions about their daily lives. Peoples care plans contained evidence of capacity assessments and where people were deprived of their liberty, an application to the local authority had been made. This was to ensure a people’s rights were protected.

People were offered a choice of food and drinks and told us the food was good. People were weighed at regular intervals, weight loss was highlighted and action taken to address this.

Staff were caring and kind, they spoke with people in a caring and inclusive manner. People told us staff respected their privacy and dignity. People were not nursed in bed unless they wished to remain in bed or there was a clinical reason for that decision if they lacked the capacity to decide for themselves. There were plans in place to improve the care planning documentation in regard to people’s wishes as they entered the final stages of their lives.

The home had a new activities coordinator and they were introducing a programme which included one to one and group activities. For example, singalongs, crafts, gardening, chair exercises and group discussions as well as external entertainers coming to the home.

Information within people’s care plans was recorded consistently throughout their care plan. Records were person centred and recorded people’s likes and preferences, staff also recorded the care they provided to people on a daily basis throughout their shift.

Where people had raised a complaint, we saw this had been investigated and a response had been sent to them. The registered provider had a system in place to ensure, where people were unhappy with the outcome to their complaint, this was escalated to a more senior person to review.

We received positive feedback about improvements at the home. We saw evidence action had been taken by the registered provider to improve the quality and safety of the service people received. A number of audits had been undertaken to assess and monitor the quality of the service but it was not always evident actions had been addressed. During our inspection we found evidence of some improvement, however as evidenced within the main body of the report, there remains a number of areas where there is a need for further work to ensure the safety and well-being of the people who live at Cleveland House.

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

The service provides accommodation and nursing care for up to 45 people. On the day of our visit there were 41 people living at the home. Accommodation at the home was provided in single bedrooms set over three floors.

There was a registered manager who was no longer managing the service. 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 had left the service in February 2016 and the home had been managed on a part time basis by a registered manager from another of the provider’s homes. Subsequent to the inspection we were informed that the provider was reviewing management arrangements to the home in line with our concerns.

Concerns had been raised to us before the inspection about care in relation to people’s pressure relief. Some work had begun to address the need to provide effective pressure care and to treat wounds, such as pressure ulcers and skin tears. However, preventative measures were not robust at the time of the inspection and the repositioning regime for some people was inconsistent.

Practice for moving and handling people was not appropriate at times to ensure people’s safety and staff were not all familiar with the equipment and process needed to assist individual people to move and transfer.

Staff had a clear understanding of the safeguarding procedures to follow should they have concerns about a person’s well being.

The provider did not have robust procedures in place to ensure the requirements of the Mental Capacity Act (2005) legislation was being met in support of people’s rights. Staff knowledge of the mental capacity act was inconsistent.

People reported they enjoyed the food and drink in the home. There were concerns about weight management for some people as the recording and monitoring of this and of food and fluid intake was not consistent.

Staff interaction was kind, caring and patient and people were complimentary about the staff’s approach to their work. Staff showed respect for people’s privacy and dignity when supporting people with their care.

Many people remained in bed, with no clear rationale about the reasons. People did not all wish to remain in bed and expressed some frustration as having to depend upon staff to assist them to be out of bed. Some people were at risk of being socially isolated due to their high dependency needs, although staff made efforts to chat with people when they carried out care tasks..

Care plans were not person-centred, lacked detail and were not up to date or accurate for all people.

People and relatives knew how to complain and the complaints process was managed appropriately.

The home was under new leadership and some improvements to the running of the home and the clinical oversight were being implemented. Staff reported morale was beginning to improve although said this had been poor in recent months, prior to the commencement of the new manager.

Relatives reported improved leadership in the home and they said their views were valued.

Regular audits were carried out by the organisation, although internal audits of quality and practice were not rigorous enough to identify and address the areas of concern highlighted at this inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures”

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

The manager told us that activities were provided seven days a week with two staff in post to organise and facilitate them. We saw that the home had entertainment booked for the coming months and also an external facilitator of physical exercise to hold sessions within the home. We spoke with two people and the relative of another person who lived at the home. People we spoke with were complementary about the service and the quality of care provided. One person told us the staff are great and very friendly 'they all treat me like I'm actually a person'. The person also told us they were happy with the care they received. The relative of one person told us they thought the home provided good care. They also told us they visit their relative six days per week and are always made welcome by the staff.