- Care home
Cleadon Court
Assessment report published 8 May 2026
Contents
Ratings
Our view of the service
Date of Inspection: 20 March to 13 April 2026. Cleadon Court is a residential care home providing personal care for up to 13 people. The service was developed to provide support to people with acquired brain injuries. At the time of our inspection there were 4 people using the service. The inspection was undertaken in response to ongoing concerns about the quality and safety of care, leadership stability, and governance arrangements.
Cleadon Court opened in July 2024, and this was the first inspection. The registered manager left in July 2025. A new manager was appointed in July 2025 however they withdrew their application after resigning in February 2026 before their registration was completed. On 7th April 2026 a new manager commenced work and was intending to apply to become the registered manager.
Since opening the previous management teams had admitted people who experienced complex mental health needs, which were often unrelated to an acquired brain injury. This had led to staff being expected to support people who had needs they were untrained to address. The senior leadership team had recognised this and recently introduced an assessment panel of skilled professionals who were now responsible for making decisions about whether to accept placements.
Overall, we found the care and support had not been consistently safe, effective or well led. People’s experiences had been varied, and had depended on staffing, leadership presence and the robustness of systems in place. Professionals and relatives consistently report frequent changes in management, reliance on interim arrangements, and a lack of consistent leadership presence. This has contributed to confusion, poor task ownership, delays in follow‑up and anxiety for people supported and their relatives. While there were areas of positive practice, these were not reliably embedded and did not sufficiently mitigate the identified risks. The provider, new regional manager and management team were taking action to ensure this was addressed, and parts of their action were addressed.
Staff turnover had been very high. In the last couple of months a new team had been employed. The new staff team treated people with kindness, dignity and respect, and staff interactions were generally caring. Many staff knew people well and were committed to supporting them. The accommodation model, including self‑contained flats, supported privacy and independence for some people and had reduced incidents. However, person‑centred care was not always underpinned by robust care planning. Records did not consistently reflect people’s current needs, risks, preferences or involvement in decision‑making. Professionals found staff at times had not understood escalation processes or their role.
The new staff team had not received comprehensive training around how to use the electronic care record system, and this had led to difficulties finding information such as capacity assessments, ‘best interest’ decisions and deprivation of liberty (DoLS) authorisations. The new regional manager and management team had recognised this and were in the process of ensuring staff produced comprehensive records.
There had been shortfalls in safety, particularly in relation to safeguarding, medicines management, staffing oversight, risk management and learning from incidents. Safeguarding systems were in place but had not always been implemented effectively, and staff understanding and escalation of concerns varied. Medicines were not always managed safely, and governance arrangements had not consistently identified or addressed these issues in a timely way. The new management team had put measures in place to make improvements across the service. In the week the new manager had been in post, they had resolved a number of issues.
Despite recent instability in management, staff confidence in current leadership is high. Many staff reported feeling well supported by management, including the regional staff. Managers were described as approachable, receptive to staff views, and genuinely invested in staff wellbeing. People spoke about working well together as a team, feeling welcomed, and settling into their roles quickly. Professionals noted the new management team were in the process of stabilising the service.
People's experience of this service
People’s experiences of care at Cleadon Court had been mixed and varied over time. People told us they felt comfortable with staff and were usually treated with kindness, dignity and respect. People told us staff were very caring, kind and supportive. A person said, “I love it here. The staff are like my family, and everyone is so kind and caring.” Relatives found the instability in the staff team had been concerning. A relative said, “My biggest concern with Cleadon Court is the staff turnover. This has resulted in [person] having no idea who is in charge. More recently there has been so many “managers” I can’t keep up. The turnover has resulted in tasks being lost and no one having ownership of tasks.” A visiting professional said, “The service has had a lot of change and inconsistent management structure throughout my time visiting the service.”
People valued the accommodation model, particularly having self‑contained flats. Relatives and professionals told us this supported privacy, independence and personal space and had contributed to a reduction in absconding when compared with previous placements. This had a positive impact on people’s sense of safety and wellbeing. A relative said, “I feel the environment of having your own flat has given [person] the freedom to take themself into their own space.”
Where people had very limited verbal communication, we used a structured observation tool to assess whether they received good care. This approach showed people were listened to and staff consistently interacted positively with them. We observed staff interacting with people in a calm, unhurried and respectful way, and people appeared relaxed and at ease in their presence. Staff often knew people well through day‑to‑day contact and were committed to supporting them.
During our observations and from information from relatives, staff and professionals to understand people’s experiences. These sources indicated that people were generally comfortable in their environment and benefited from positive interactions with staff, but also highlighted the impact that inconsistency in staffing, leadership and care planning had on people’s day‑to‑day experiences.
People were supported to make choices about their day‑to‑day lives, including food. People appeared to enjoy the meals provided, and staff demonstrated good knowledge of people’s preferences and dislikes. A person said, “Staff know what we like and always check we are happy with the choices on offer. The food is pretty good and we are encouraged to make our own meals.” However, some relatives were unsure how involved people were in menu planning and decision‑making, and whether choices were always clearly communicated.
People told us staff listened to them and that there were systems in place to raise concerns or complaints. Relatives said they were usually kept informed, but some felt that while concerns were listened to, actions to resolve them were not always sustained. This led to repeated chasing of issues and uncertainty about whether learning had taken place. A relative said, “Many tasks are outstanding and have been for a while as the person representing Cleadon Court keeps changing. We raised an issue in June with the then manager, they left and we raised the same thing with the next manager, then the next one, and the next one and now ownership of tasks and accountability seems to be with the deputy manager.”