Clayburn Lodge

Updated 10 November 2018

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 comprehensive inspection took place on 11 September 2018 and was unannounced. The inspection was carried out by one inspector.

Prior to our inspection, we reviewed the information the registered provider had sent us in the ‘Provider Information Return’ (PIR). The PIR is information we require registered providers to send us, at least annually, 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, such as statutory notifications. Notifications are the events happening in the service that the provider is required to tell us about. We used the intelligence we held about the service to plan what areas we were going to focus on during our inspection.

During the inspection we engaged with five people who lived at the service and observed staff interactions with people. We also spoke with two care staff, the deputy manager , clinical lead, the quality assurance manager and the registered manager. We looked at a range of records which related to people's individual care and of the running of the home. This included two people's care and support records, three staff recruitment files, training and supervision information, arrangements for medicines, policies and procedures and information on how the safety and quality of the service was being monitored. Following our inspection, we received feedback about the service from five health care professionals.

Updated 10 November 2018

This comprehensive unannounced inspection was carried out on 11 September 2018.

Clayburn Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to support up to six people with complex and enduring mental health needs. On the day of our inspection, six people were living at the service.

At our last inspection on 5 January 2016, we rated the service as ‘good’ in all domains. At this inspection, we found the service had improved to ‘outstanding’ in two domains and therefore had improved to an overall rating of outstanding.

The service required, and did have, a registered manager, who was also the owner of the business. 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 service was extremely responsive to people’s individual needs which had a positive impact on their wellbeing, enabling them to lead meaningful and fulfilled lives. People were involved in the development and review of their care plans which were regularly reviewed. Care plans were exceptionally person centred, holistic and recovery focussed and clearly reflected people's individual needs. People and health care professionals were extremely complimentary about the service. People repeatedly told us the care and support they received from staff resulted in positive outcomes for them which had a significant impact on their well-being and recovery. Staff were fully committed to improving the lives of people living at the service and worked with people to achieve their goals and aspirations.

Staff recognised the importance of preventing social isolation and how this could be detrimental to people’s recovery and supported people to engage in meaningful activities and pursue their hobbies and interests. People were supported to maintain relationships with friends and families. Where necessary, this included working with people and families to rebuild their relationships and supporting families to gain a better understanding of their family member’s diagnosis and how their illness impacted on their day to day lives.

The registered manager provided outstanding leadership and had developed a strong and visible person centred culture which was open and inclusive, empowering people to lead fulfilling lives. They demonstrated an on-going commitment to developing an exceptionally skilled and motivated staff team, ensuring people received an excellent standard of care which promoted their recovery. Staff fully embraced the service’s vision and beliefs , felt valued and supported and enjoyed working at the service.

Quality assurance processes were robust. The registered manager expected high standards and attention to detail; this was reflected in the comprehensive systems and processes in place for checking the quality of the service and driving continuous improvement. The service was continuously learning and improving to ensure its sustainability. Management were able to demonstrate how they measured and analysed the care and support provided to people, and how this ensured the service was operating safely, continually improving to meet people’s needs and having a positive impact on people living at the service. Feedback from people, relatives, staff and external stakeholders was encouraged and valued. This was done in a number of ways such as daily interactions with people, through meetings and satisfaction surveys.

People living at the service felt safe and were empowered, as much as they were able, to take responsibility for their own safety. Individual risks to people were appropriately assessed, monitored and effectively managed. The provider’s recruitment processes were robust and ensured that unsuitable workers could not be employed at the service. People were supported by skilled and trained staff. There were enough staff to help keep people safe, meet their needs and protect them from harm and abuse. There were safe systems in place to manage people’s medicines.

Positive relationships had been formed between staff and people living at the service. Staff knew people well and were kind and sensitive to their needs, ensuring people’s privacy and dignity was respected at all times. People told us they were extremely happy with the care they received from staff.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

The service had forged strong links with the community and was working in conjunction with people living at the service and staff to raise awareness and tackle the stigma around mental illness.

Further information is in the detailed findings below.