Cleveland House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of legal regulations in relation to good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 75 (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 shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager had been working for the service for a long time. They had an open door policy where people, relatives as well as staff could raise any issues or concerns, they have. People and their relatives said the service was good. A person said, “[Manager] is very kind and very helpful.”

Staff felt the registered manager was doing a good job and they could discuss any issues or make suggestions about the service. Staff had a clear understanding of what was expected of them. They were aware of their responsibilities and who they were accountable to.

The registered manager was aware of when the CQC should be made aware of events and the responsibilities of being a registered manager. We had received notifications from the provider about certain changes, events and incidents that affect their service or the people who use it, as required under our regulations.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

People and their relatives were complementary about the service. A person told us, “The manager is very good.”

Staff told us the registered manager was very supportive and felt confident they would be listened to if they had any concerns. A member of staff told us, “I can talk to the manager if I need any advice or something to discuss.” Staff understood the values of the service and were aware of their roles and responsibilities. They mentioned they worked well as a team.

Staff had access to a range of policies and procedures to guide them in their roles and to ensure people received safe care and support from staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistle blowing policy and procedure in place. Whistleblowing is the term used when a staff passes on information concerning wrongdoing. There was a culture where staff felt safe and confident to raise concerns without fear of reprisal.

Staff were aware of their responsibilities to report concerns and were able to describe the action they would take if they witnessed or suspected any abusive or neglectful practice. A member of staff told us, “If I have any concerns, I will talk to the manager. If they don’t take action, I will go outside and contact either the local authority or CQC.” Staff had received training and were aware on how to escalate any concerns that they might have to external agencies. We also noted this topic was discussed during staff meetings.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager ensured people and staff had an equal opportunity and were not treated differently or discriminated regardless of background and valued individual differences.People and staff had equal opportunity to fulfil their potential. The registered manager encouraged people, relatives and staff to be involved in the day to day running of the service as much as possible. Staff were valued, respected, and included. There were regular meetings held for staff to share their views and experiences and for the registered manager to cascade information about things happening in the service.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

At our last inspection, we found the provider did not have effective systems to assess, monitor and improve the quality and safety of the service. The provider’s quality assurance systems and checks were not always robust, and the systems were not always working effectively. We noted risks associated with people’s care and support had not been fully assessed. People’s medicines were not always managed safely because we found shortfalls around the provider’s arrangements to make sure people received their medicines safely and as prescribed. Medicines were not stored within their recommended temperatures. PRN protocols were not always comprehensive. Health and safety audits and fire safety checks were not being done as per the provider’s policy and procedures.

During this assessment, we found noted improvements had been made around all of the above concerns we identified at our previous inspection.

There were audits carried out to monitor the quality of the service and to identify how the service could be improved. These included areas such as care records, daily records, medicines charts, staff training and risk assessments to ensure they provided care and support to people to the required standard. Where shortfalls were identified, appropriate actions were taken to resolve them.

The management team worked closely with a number of health and social care professionals, and this helped to ensure people’s needs were fully met. People had the contact details of their doctor and other professionals recorded. This helped to ensure staff could also contact them if they had concerns about a person's health.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff monitored people's health and welfare and knew what actions they needed to take if a person became unwell. The management team made referrals to health care professionals where required. They had good links and worked closely with other health and social care professionals. Records showed the registered manager was in regular contact with other health care professionals to ensure people’s needs were met or to seek advice.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager sent satisfaction surveys to people and their representatives to gain their views and feedback about the service. We saw relatives commented positively about the care and support given to their loved one. A relative mentioned that they were very happy with the way their family member’s care and support at Cleveland House. Another relative commented, “My [person] is looked after properly, I am happy with their care.” Any suggestions were taken on board and acted upon.

The provider had processes in place to learn from when things went wrong, and also from examples of good practice. The management team kept themselves up to date with best practice as far as health and social care was concerned. The provider had other services, and the registered managers met on a regular basis to share ideas on how they could improve their services further.