Cleadon Court

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. This was the first inspection for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Albeit the provider generally operated a proactive and positive culture of safety, based on openness and honesty. The instability in the staff team had led to this not always translating into practice. Professionals and relatives report that high turnover and use of agency staff impact continuity of care, staff knowledge of individuals, and consistent implementation of care plans and therapy programmes. Staff listened to concerns about safety and investigated and reported safety events. Systems were in place to report incidents and concerns, but learning from these was not always clearly identified recorded or embedded into practice.

Staff had not always worked well with people and healthcare partners to establish and maintain safe systems of care. They had not always managed or monitored people’s safety. Previous management teams had accepted placements at the service for people with needs, which staff did not of the skills, training or experience to met. This had led to placements needing to be terminated. Staff made sure they provided all the information they had when people moved between different services. A staff member said, “I retired in January 2024. Before I left, I was asked by senior managers to remain on a part-time basis to support a person who was to transition from my service to Cleadon Court as they felt this would help them settle in. I agreed because I had formed a good relationship with [person] and that it would ensure a smooth transition for them.”

Staff had not always worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider had put measures in place to reduce the reoccurrence of this. The new staff team concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had training and a good understanding of what to do to make sure people were protected from harm or abuse. Deprivation of Liberty Safeguards (DoLS) authorisations were sought when needed and any conditions imposed by them were followed. However, staff were sometimes unable to find them on the electronic care record system.

Staff 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. Risk assessments were in place and assisted staff identify how to mitigate risks. However, at times, the potential for distressed behaviours had not been fully assessed and there was limited information on what people’s behaviour may look like or the triggers. The new management team were taking steps to make improvements.

The provider detected and controlled potential risks in the care environment. The provider had a rolling programme of refurbishment. People were supported to be as independent as possible within the environment. Environmental risks were assessed and addressed. They made sure equipment, facilities and technology supported the delivery of safe care and worked with external professionals to review people’s aids. The staff team knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment people needed.

The high staff turnover had led to inconsistencies in the care provided. The provider had been working to stabilise the staffing and employed a new team. These staff worked together well to provide safe care that met people’s individual needs. People confirmed there were always enough staff on duty. Recruitment practices were meeting requirements. The provider promoted a learning culture and staff had received mandatory and condition specific training. However, they constant change meant this training was not always embedded into their practice. The new manager was in the process of determining where these gaps were and recognised the team needed in-depth training around how to use the electronic care record system. A staff member said, “Training is very high on the agenda at Voyage Care and I believe it is a very important aspect of the job we do. There is a lot of E-learning which I feel isn't always as effective as face-to-face learning.”

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. Staff followed the required infection control guidelines.

Systems to support safe medicines management were in place but were not consistently followed. The new management team were taking action to ensure staff understood how to safely manage medicine. The team leader now acted as champion and was taking steps to train up enough staff to act as second when signing for controlled medicines. They had rectified issues around the late delivery of medicine and was looking at how to streamline the ordering system. They were in the process of ordering a new controlled drug book, as the one in place did not provide space for staff to record the count, which meant staff could not readily establish how much medicine should be on site. Staff worked closely with the GP and pharmacist to make sure medicines were managed appropriately.