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We are carrying out a review of quality at Cleaveland Lodge. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 11 November 2020

Cleaveland Lodge is a residential care home providing personal and support for up to 54 people aged 65 and over in one adapted building. At the time of our inspection the service was supporting 51 people.

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

We found continued shortfalls in the oversight and governance of the service. A chaotic culture of leadership scrutiny failed to identify significant shortfalls in the management of the service. These failings placed people using the service at risk of harm, and significant exposure to the risk of harm.

The registered manger resigned in March 2020 but continued to work as part of the management team on a part time basis. A new manager was appointed in April 2020 but had yet to register with the Commission. The provider’s systems for identifying, capturing and managing risks to people’s health, welfare and safety remain ineffective.

Risks to people’s health, welfare and safety had not always been identified with action taken to reduce the risk of harm. Audits did not identify the shortfalls found as part of this inspection and there continued to be no effective quality and safety monitoring in place to drive improvements.

We were not assured the provider was doing all that was practical to ensure Covid-19 outbreaks would be prevented. The service was not consistently following the Government guidance, about how to operate safely during the Covid-19 pandemic, in areas such as the wearing of personal protective equipment (PPE), social distancing and ensure staff were provided with designated areas for putting on and taking off their PPE.

People's medicines were generally managed well, however not everyone prescribed as and when needed medicines, had a protocol in place to guide staff in monitoring their use. Previous inspections identified the need to implement a pain assessment tool for staff to identify and respond to people who lacked capacity to verbally express if in pain. Whilst a monitoring tool had been put in place staff had not been trained in its use and so it remained ineffective.

We recommended further work was needed to consider safeguarding risks and provide procedural guidance for staff where staff who were related or living in the same household worked on the same shift.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was requires improvement [published 7 February 2020].

At our last inspections in July 2019 and January 2020, we found shortfalls in the management of risk to people’s safety. There was continued failure to robustly assess risks relating to the health safety and welfare of people. We found continued breaches of regulation 12 [Safe Care and Treatment] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014 and Regulation 17 [Good governance] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

The inspection was prompted in part due to concerns received about unwitnessed falls and the provider's arrangements for falls management, care and support for people with a catheter and inadequate staffing levels. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of 'Safe', ‘Caring’ and 'Well-Led' only.

You can read the report from our last comprehensive, inspection, by selecting the 'all reports' link for Cleaveland Lodge on our website at


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 insp

Inspection areas



Updated 11 November 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 11 November 2020


Requires improvement

Updated 11 November 2020

The service was not caring.

Details are in our caring findings below.


Requires improvement

Updated 11 November 2020



Updated 11 November 2020

The service was not well-led.

Details are in our well-Led findings below.