Cleaveland Lodge

Updated 24 August 2021

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 Care Act 2014.

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

The inspection was completed by two inspectors.

Service and service type

Cleaveland is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did have a manager registered with the Care Quality Commission.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We did use information the provider sent us and updates they provided. We used all this information to plan our inspection.

During the inspection

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 spoke with six people who used the service about their experience of the care provided. We spoke with five members of staff including the registered manager and care workers. We also spoke with a visiting healthcare professional.

We reviewed a range of records. This included eight people’s care records and medication records. We looked at one staff file in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including training data, meeting minutes and audits and policies.

Updated 24 August 2021

About the service

Cleaveland Lodge provides accommodation and personal care for up to 54 older people, some of whom may be living with dementia. At the time of the inspection 35 people were living in the service.

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

People told us they were happy living at the service and the with the support they received. One person told us, “I have everything I need.”

Since our last inspection the previous registered manager had gone back into post. The provider had worked with the registered manager and local authority quality team to embed improvements at the service.

Care and treatment were planned and delivered in a way that was intended to ensure people's safety and welfare. People were cared for safely by staff who had been recruited and employed after appropriate checks had been completed. Staff had received the appropriate training. There were systems in place to minimise the risk of infection and to learn lessons from accidents and incidents. Medication was dispensed by staff who had received training to do so.

The registered manager had a good understanding of their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People were supported to eat and drink enough to ensure they maintained a balanced diet and referrals to other health professionals were made when required. The environment was well maintained and suitable for people.

People and their relatives and advocates were involved in the planning and review of their care. People were supported to follow their interests and participate in social activities. The registered manager responded to complaints received in a timely manner. People were supported to make plans for the end of their life.

The registered manager had been successful in driving improvements at the service. Systems had been put in place to monitor the service and improve outcomes for people.

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 Inadequate (published 11 November 2020). 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 improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 11 November 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. The overall rating for the service has changed from Inadequate to Good. This is based on the findings at this inspection.

Why we inspected

We undertook this inspection to check the provider had followed their action plan and to confirm they now met legal requirements.

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.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.