10 October 2023
During an inspection looking at part of the service
About the service
Cleveland House is a care home registered to accommodate and support up to 11 people with mental health needs, learning disabilities and/or autism. At the time of the inspection, 9 people were using the service.
People’s experience of using this service and what we found
Right support
Staff, people and relatives told us that the service was good and that they could speak with the peripatetic manager as and when they wanted. There were sufficient staff to meet people’s needs and recruitment processes were safe. The provider had a system in place to record and monitor accidents and incidents. They worked closely with other professionals and had regular contact with them to ensure people’s needs were met fully.
Right care
Risk assessments were not always completed fully meaning staff did not always have the correct information on how to deliver safe care. People’s medicines were not always managed safely. 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 supported this practice.
Right culture
There were quality assurance and governance systems in place to drive continuous improvement; however, the systems were not always working effectively because the provider had not identified some health and safety issues. Staff had received training of what constituted abuse and how to report any concerns to keep people safe. Staff and relatives commented positively about the changes being made by the new peripatetic manager.
For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 3 November 2022).
Why we inspected
The inspection was prompted in part due to concerns received about how people were safeguarded at the service. A decision was made for us to inspect and examine those risks.
This was a focused inspection, and the report only covers our findings in relation to the key questions Safe and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
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:
We have identified breaches of regulations in relation to safe care and treatment and quality assurance at this inspection.
The overall rating for this service has now changed from good to requires improvement.
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.