Cleeve Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to people’s concerns and understood their responsibility to report concerns about safety. Staff told us what they would do if someone had a fall, “I will press the emergency bell, if the manager is there, they will come to assist, I will then record an incident form if I was involved.” Incident forms were reviewed by management and learning documented and shared with staff.

Staff were confident the manager and provider would listen to concerns and act upon these. The provider shared information through daily handovers, staff meetings, communication logs and huddles which are small meetings which provide updates about people and how the day is going. Staff told us, “We have small meetings daily with everyone [all staff]. We are updated about any concerns.”

Relatives felt they were informed about their loved ones. Any changes to people’s care planning and risk management had been promptly recorded, actioned and shared with the wider staff team.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff told us about the process of people moving into the home, “I will be informed by the manager and colleagues” and “When someone comes into the home, a personalised care plan is created, outlining their medical history, medications, dietary needs, mobility support, communication preferences and emotional well-being.”

Staff worked in partnership with other professionals such as GP’s, physiotherapists, dentists and community nurses to support people to promptly access healthcare when required. Professionals we spoke to felt people were well cared for, that the management team and staff completed referral forms appropriately and engaged in visits.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People were protected from abuse and avoidable harm. The provider shared concerns quickly and appropriately. People and their relatives felt the service was safe. Relatives told us, “I absolutely feel my relative is safe at Cleeve Lodge” and “The staff look after [person] very well, and I know [person] is safe with them.”

Staff had received safeguarding training, were aware of people’s needs and knew who to report safeguarding concerns to. One staff member told us, “If I did not want to inform my manager I could inform the safeguarding team.”

Care plans contained details of people allergies, risks, medical conditions and support needs were clearly described. Incidents such as falls were clearly recorded within care plans, including risk factors and guidance for staff. People looked well presented. Staff created a warm friendly atmosphere.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People told us, “I think the staff help me get around safely.” People and their relatives were involved in care planning and reviews of people’s care took place. A relative told us, “Yes, sometimes [involved in reviews]. Really just around [persons] medical needs, we feel that the home is very collaborative.”

Staff were aware of people’s needs and risks and demonstrated a good understanding of how to support people with risks. Staff told us, “As a keyworker, I have to ensure that the resident [person] is okay, do checks on their room and items, if I notice they might need more clothes, I call the family, or if they have a fall I inform the family, every week I give them an update” and “If someone is distressed, I talk to the person, if there are any signs of agitation, we look at the reason why, I sit with the person, and reassure them.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The home had undergone new fire safety equipment to meet standards. Staff had completed the relevant fire training.

The home appeared clean, had recently been redecorated, new seating was in place with different pressure relieving cushions. The conservatory had been reroofed with tiles to improve thermal efficiency and reduce noise from rain, so the conservatory could be comfortably used all year round. The home was appropriate for people with dementia, windows were new and all had window restrictors.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People using the service told us they felt safe with staff, we also heard, “The staff have changed quite a bit although I know most of them now.” Staff felt there were enough regular staff to meet people’s needs training was appropriate and further training available if they required this, “I was new to working in care homes, I received good training online and in person, followed by shadowing” and “I am happy to support more residents, we always have enough staff to take care of all the residents.”

We observed staff to use their skills and knowledge when supporting people living with dementia in a kind and dignified manner. Staff had been recruited safely, and safer recruitment processes had been followed to ensure people were suitable for their roles. Staff received a comprehensive induction when joining the service and ongoing training to support them in their roles. Staff told us they would like to complete further training around dementia, this had been booked by management. Staff received regular supervision and felt supported.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed staff entering the kitchen wore protective aprons, bathrooms and toilets were clean equipped with a thermometer in the bathroom for testing water temperature.

People told us staff wore personal protective equipment (PPE) during personal care. Staff understood the need to wear PPE and how to manage the risk of infection.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff communicated with people when changes happened.

Care plans contained details about how people preferred to take their medicines, and allergies were documented. Best interest documentation was in place for people who received medicines covertly with guidance for staff to follow. The provider supported people, where appropriate, to reduce certain medicines such as antipsychotic medicines to ensure people did not receive excessive and inappropriate use of medicines. Medicines were reviewed by the GP annually.

Medicines were securely stored in a locked trolley with restricted access. Recording of medicines was managed on a digital system. The digital system helped ensure best practice through alerts, enforced workflows and inventory to help the home manage medications efficiently. However, these alerts were not consistently reviewed to ensure people had received their medicines effectively. Stock checks were regularly carried out and audits completed.

Staff felt they had received enough training to support people. One member of staff told us, “I am trained for medication, I had to complete online training and then learnt how to record it into the system, I was signed off visually.”