Cleveleys Nursing Home

Updated 28 December 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

Two inspectors and 1 nurse carried out this inspection.

Service and service type

Cleveleys Nursing Home is a ‘care home’ with nursing care. 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. 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 a registered manager in post, however they were unavailable during this inspection. A new manager started in post during the inspection.

Notice of inspection

This inspection was unannounced on the first day.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, Healthwatch and professionals who work with the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection. 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.

During the inspection

We spoke with 5 people who used the service and four relatives about their experience of the care provided. We spoke with 11 members of staff including the new manager, nurses, care co-ordinator, senior carer, care workers and housekeeping staff. We also spoke with the nominated individual of the service. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 8 people's care records and multiple medication records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. After the inspection we continued to seek clarification from the provider to confirm evidence found. We spoke with professionals who regularly visit the service.

We carried out observations of care to help us understand the experience of people who could not talk with us. We walked around the building to look at the environment to check on the suitability of this.

Updated 28 December 2023

About the service

Cleveleys Nursing Home is registered to provide care for up to 32 older people, people living with dementia or physical disabilities. The home is situated close to Cleveleys town centre. There are bedrooms on all 3 floors, and there is a choice of communal lounges and seating areas. There were 24 people living at Cleveleys Nursing Home when we inspected.

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

Records and systems were not in place or robust enough to demonstrate risk was effectively managed. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; as the policies and systems in the service did not support this practice.

Some audits were not consistently applied and did not either identify concerns or drive improvement. Some information was not up to date or correct. We have made recommendations about recruitment, staff deployment and the use of person - centred language.

Observations showed people were happy and relaxed in the company of staff. Feedback about staff, manager and provider was positive. Medicines were stored and administered safely. People were supported safely, and the provider had contingency plans in place in case of emergencies. The home was clean and hygienic, and staff were seen to wear appropriate personal protective equipment (PPE).

The manager and provider were positively engaged in the inspection process and clearly understood their regulatory responsibilities. The manager and staff had been responsive in working with health professionals to improve people’s quality of life.

The service had systems to protect people from the risk of abuse and improper treatment. The service met people’s nutritional needs and worked with them to make sure food provision also reflected their preferences.

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

Rating at last inspection and update: The last rating for this service was requires improvement (published 07 May 2023) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended current guidance on the proper and safe management of medicines be followed and communication related to medicines management be improved. At this inspection we found improvements had been made. At our last inspection we recommended the provider ensure schedule 3 information is shown as required, as part of their recruitment process.

The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection, and in part due to concerns received about the management of risk, staffing and good governance. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report.

We have found evidence the provider needs to make improvements. Please see the Safe, Effective, Caring and Well-led sections of this full report.

The provider has mitigated the risks and some improvements have been made.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cleveleys Nursing Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the management of risk, consent and good governance at this inspection.

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.