Cleeve Court Community Resource Centre

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 requires improvement. At this assessment the rating has remained 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.

The service was still in breach of legal regulation in relation to assessing and mitigating risks to people.

This service scored 62 (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 concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place for staff to raise concerns and for them to be addressed by the management team. The management team had an open-door culture which was focussed on learning from mistakes rather than apportioning blame. Examples of learning were shared throughout the inspection including from medicine errors and transitions into the service.

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

Systems were in place to effectively assess people when they moved in even for respite or emergencies. People and their families were involved in these transitions. Learning had taken place following a transition where district nurses had not been informed, to prevent any reoccurrence. One person was having a transition planned to move home including developing as much independence as possible.

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. The provider shared concerns quickly and appropriately.

People told us they felt safe and looked comfortable in every interaction with staff. Staff were able to tell us how to keep people safe and how to recognise potential abuse. Systems were now in place to keep people safe from potential abuse. Management now had oversight.

The provider still did not work well with people to record the management of risks and provide clear guidance. Staff still did not have training or detailed guidance to ensure consistent care was provided to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans still contained inconsistencies or a lack of guidance when there were risks to people. For example, people’s care plans for specific clinical tasks were either missing or lacked details to ensure consistent care in line with best practice. This meant there was a risk of poor, unsafe or inconsistent care and support would be provided. Another person had incorrect information including their diagnosis and health needs in parts of their care plan.

Staff writing the care plans expressed they lacked training to complete them effectively. No harm was identified during the inspection. Staff were able to tell us how they would support people with clinical issues.

The management were fully aware of the issues around the care plans and risk assessments. They urgently put in an action plan to demonstrate how they would resolve the issues. This included mentoring and training for staff completing the care plans. Additionally, we were able to view updated care plans accessing their electronic care plan system.

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 was in a good state of repair. Maintenance issues were managed in a timely way. Systems were in place to manage the environment people lived in. People were kept safe in the event of a fire.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Systems were not effective to ensure staff had received all the training they required. Senior support workers told us they were asked to complete care plan updates without adequate training. This had led to errors and short falls in people’s care plans which could lead to inconsistent care. Records were unclear about which staff had completed all the training required. No people were found harmed. We raised this with the management who immediately took actions to rectify this issue. They organised individual support for senior staff and provided time during work for other staff to complete missing training.

However, people were supported by enough staff to keep them safe and meet their needs. Staff recruitment was completed in a way to keep people safe and in line with legislation.

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.

The home was clean and smelt pleasant throughout the inspection. Staff were aware how to prevent the spread of infections. Cleaners were employed to keep the home clean and tidy.

However, there were occasions when records did not appear to match the cleaning which had occurred. The management immediately put things in place to rectify this.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff knew how to safely administer medicines and people’s individual preferences. Medicines were stored safely. Systems were in place to manage medicines safely. Appropriate action was taken if there was a medicines error.