Cleeve Court Community Resource Centre

Updated 2 February 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Cleeve Court Community Resource Centre is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Cleeve Court Community Resource Centre is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post for 1 month and planned to apply to register but at the time of the inspection had not started that process.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 12 people and 5 relatives about their experiences of care and support. We spoke with 8 staff, the manager and the providers head of service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed care records for 15 people, multiple medicines records, incident and accident forms, health and safety records and 4 staff files in relation to recruitment. Following our site visit, we spoke on the telephone to a further 6 members of staff and 2 relatives. We continued to validate evidence found and reviewed complaints, safeguarding, incident management, training data, quality monitoring records and the service improvement plan.

Updated 2 February 2023

About the service

Cleeve Court Community Resource Centre provides accommodation and personal care for up to 45 people. The service provides support to adults over and under 65 years and people with physical disabilities and sensory impairments. At the time of our inspection there were 41 people living at the service.

Accommodation was provided on 2 floors accessed by stairs and lifts. People had their own rooms and there were communal spaces such as lounges and dining areas. The service had a secure enclosed garden.

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

Risks to people’s safety were not always identified so that management plans could be put in place to mitigate risks. Where there were some actions in place to mitigate risks, staff were not recording consistently. This meant the provider could not be assured the correct action had been taken.

People with specific health needs did not have guidance in place for staff to know how to support people. For example, people with diabetes had no management plans in place for this health condition. People who had wounds were receiving treatment from visiting nurses, however, there was no record of this treatment in people’s plans.

Governance systems were not effective in identifying improvements. Audits carried out were not robust and where actions had been identified these were not completed in a timely way. For example, a care plan audit carried out in July 2022 still had actions to be completed in December 2022. The provider commissioned an external consultant to visit the home and carry out a full audit. This audit had also generated actions for improvement. The provider told us they would prioritise actions to complete those linked to risk first.

Incidents and accidents had been recorded, but systems to review them were not robust. Not all incidents had been reviewed by management or reported to the provider. This meant action to prevent reoccurrence had not always taken place and CQC had not been notified.

The provider was open and transparent during this inspection. They were responsive to findings and aware of the improvement needed. They told us they hoped with a new manager in post things would improve. The new manager was organising meet and greet events for people, relatives and staff. Those that had met the manager were positive about their first impressions. The manager was going to register with CQC.

People and relatives told us the service was safe and they were happy with the care provided. All spoke positively about the staff and their caring and kind approach. We observed there were sufficient numbers of staff available to respond to people in a timely way. The service used agency staff to fill gaps in staffing rotas. Staff had been recruited safely and had training to help them carry out their roles. New staff had inductions and there was ongoing support provided through supervisions and team meetings.

People had their medicines as prescribed and only trained staff could administer them. People could see healthcare professionals if they needed to. Staff communicated with local community nurses, GP’s and social workers and shared information with people’s relatives. Staff attended handovers so they could be updated on any new information or changing needs.

The home was clean and smelt fresh. During our inspection there was an outbreak of COVID-19. Staff responded appropriately and followed good infection prevention and control guidelines. Staff were observed wearing suitable personal protective equipment and we found there was plenty of stock. Staff had training on working safely during COVID-19 and guidance was available from local health protection teams.

People could have visits from friends and family members. People and relatives told us the service was homely and had a relaxed atmosphere. People had their own care plans with information about their likes and dislikes. There was also information about their life histories, and we observed staff knew people well. There was a programme of activities on offer for people which included indoor and outdoor activities.

There was no end of life care being provided at the time of inspection. Some people had recorded their end of life wishes and preferences, but others had not. We have made a recommendation about recording end of life care needs.

People told us the food was good and we observed mealtimes were inclusive and relaxed. People had support to eat in a person-centred way. People also had access to drinks throughout the day. People and relatives told us they would complain if needed but had not needed to.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 1 October 2020, this is the first inspection for the service. The last rating for the service under the previous provider was good, published on 27 August 2019.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance at this inspection. We have also made 1 recommendation for end of life care.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.