- Care home
Cleeve Court Community Resource Centre
Assessment report published 26 November 2025
Contents
Ratings
Our view of the service
Assessment activity started on 17 July 2025 and finished 2 October 2025. This was a responsive focused inspection to follow up concerns in safe and well led plus checking on previous concerns.
We found 1 breach in regulation around managing risks to people. The service was no longer in breach of the regulation for governance because systems had improved enough.
The provider still did not always work effectively with people to manage risks and provide clear guidance. Care plans contained inconsistencies and lacked details for specific clinical tasks, leading to potential risks to people. Staff lacked training and guidance to ensure consistent and safe care.
The provider did not always ensure there were enough qualified, skilled, and experienced staff. Training and support for staff were inconsistent, leading to potential risks in care delivery. However, there were enough staff to meet people's needs and keep them safe.
The provider did not always have clear responsibilities, roles, or systems of accountability. Actions identified as necessary were not always managed in a timely manner. External and internal audits were conducted, although changes were not always implemented promptly. Following the transfer into the local authority, new systems have been put in place and in some cases slowed down changes and learning.
The provider maintained a proactive and positive culture of safety, characterised by openness and honesty. Staff were encouraged to raise concerns about safety, and these were investigated and addressed promptly.
Lessons learned from safety events were shared and embedded into practice to continually improve safety standards.
The provider collaborated with people and healthcare partners to establish and maintain safe systems of care. This included ensuring continuity of care during transitions between services.
The provider worked with people and healthcare partners to understand what being safe meant to them and how best to achieve it. Staff focused on improving people's lives while protecting their right to live free from abuse and neglect. Concerns were shared quickly and appropriately.
The home was well-maintained, and systems were in place to manage the environment safely. People were kept safe in the event of a fire. The provider assessed and managed the risk of infection effectively. The home was clean, and staff were aware of infection prevention measures. However, there were occasional discrepancies in cleaning records.
People were supported by safe medicine management. The management engaged people and staff in decision-making and promoted diversity and human rights.
The provider had inclusive leaders who understood the context of care delivery and embodied the organisation's culture and values. Leaders demonstrated integrity, openness, and honesty throughout the inspection.
The provider fostered a positive culture where people felt they could speak up and be heard. Staff felt confident raising concerns, although there were occasional lapses in communication up the management chain.
The provider valued diversity and worked towards an inclusive and fair culture. Systems were in place to ensure staff were treated fairly, and there was a focus on equity. Managers were quick to apologise and accept responsibility for errors.
People's experience of this service
People and relatives told us they felt safe and said, “It is very safe… because of the way it is run,” “I feel safe and comfortable,” and “I feel safe.” Staff carried out regular fire drills, and people confirmed they understood what to do. Staff maintained visibility and checked frequently on people who could not use a call bell. We observed staff respond to a movement alarm in under a minute. Relatives were positive about how staff managed incidents, including changing medication to reduce a person pacing in distress. Housekeeping staff kept the home clean and supported safe routines.
People told us staffing levels met their needs and praised staff skills. Comments included, “There is plenty, I think. If they are short staffed they get the agency in” and, “[Staff] are lovely. Spoil me, bring cups of tea and come and have a little chat. I give them 10 out of 10.” Staff delivered attentive care and adjusted mealtime arrangements when 1 person fell asleep at lunch. They administered medicines on time and respected preferences to give tablets 1 at a time. Night checks were person centred. Staff stopped middle of the night checks for 1 person because it kept waking them.
People and relatives described the service as well organised. The management held regular handovers and stayed visible and approachable. Relatives reported involvement in care planning, including arranging additional support hours. The management acted promptly to concerns. For example, adjusted a room temperature promptly for 1 person. People and relatives told us staff treated everyone fairly and with dignity. A relative suggested communication could be improved although explained it may be said to another family member.
People experienced a positive, learning culture that was compassionate. For example, we observed warm, respectful interactions, with humour and appropriate touch throughout the inspection. Staff sat with people who did not speak to offer company and reassurance. Activity staff provided personalised options, used memory boxes and tactile objects, and placed orientating visuals to promote engagement. When people with higher levels of capacity expressed boredom, an activity coordinator offered a puzzle and conversation immediately. Staff anticipated needs, identified fizzy drinks as a trigger for 1 person’s epilepsy, and reduced episodes by adjusting drinks. These examples show a positive, learning culture and compassionate, person centred care.