The Clavadel

Updated 1 April 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the COVID-19 pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 12 March 2021 and was announced.

Updated 1 April 2021

The Clavadel is a 32 bedded, purpose built short stay care centre for people requiring rehabilitation and convalescence following an operation or illness, such as a stroke. The service provides in-house physiotherapy and hydrotherapy. There is a minimum five-day stay and generally patients will return to their own homes within two weeks or so. However, the service can accommodate longer term stays if needed. At the time of our inspection 28 people were using the service.

This inspection took place on 29 September 2017 and was unannounced.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager helped us during our inspection.

We carried out this inspection because during our inspection in August 2016 we found the registered provider was in breach of three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to recruitment processes, ensuring people’s individual needs were recorded and a lack of quality assurance checks within the service. Following that inspection the registered provider sent us an action plan telling us how they planned to address our concerns. We carried out this inspection to check that action had been taken in line with their action plan and found that it had.

People were cared for by staff who were well trained, professional, polite and friendly. Interactions on the day demonstrated staff respected people, gave them the privacy they wished and enabled and supported them to be as independently as possibly whilst living at the service. People using the service had the capacity to make their own decisions. However, staff were aware of the principals of the Mental Capacity Act in that they were able to tell us there were no restrictions at the service.

People lived in an environment that was well maintained and was safe. Staff carried out appropriate health and safety checks and there was information relating to people in the event of an emergency, such as a fire. People’s rooms were well presented and comfortable. There was a communal lounge area where people could meet with friends and relatives. People could make their own decisions on where they wished to spend their time or eat their meals. People were offered choice in what they ate and staff were aware of people’s individual dietary requirements.

Although the registered provider did not provide specific activities for people, they supported people with making suggestions in relation to how people could spend their time. Such as attending activities in one of the other of the provider’s services. People could come and go as they pleased and the registered manager told us people often went into town to meet friends for lunch, etc.

People were supported to regain their health and mobility. This involved sessions with the in-house physiotherapists and with the use of the hydro pool. The registered provider had good relationships with external health professionals and a doctor from the local GP practice visited the service twice a week. Risks to people had been identified and where accidents and incidents occurred these were reviewed for trends and appropriate action taken.

People were cared for by staff who told us they felt supported and who met with their line manager on a regular basis. We found the registered manager had good management oversight of the service and there was a good working relationship between them and staff. Staff received a good range of training and staff met together regularly as a team to discuss all aspects of the service.

There were a sufficient number of staff available for people. Staff were attentive to people and did not leave them waiting for support. Staff were aware of their role in keeping people safe so they would not be at risk of harm, either by an accident or from abuse. People told us they felt safe. People’s medicines were kept securely and regular audits of medicines were carried out and gaps identified were addressed.

The registered manager and other staff undertook quality assurance audits to ensure the care provided was of a standard people should expect. We found the registered manager had responded to any suggestions that had been made. Recruitment processes had improved to help ensure that there were only suitable staff working at the service.

Regular fire checks and fire drills were carried out to help ensure staff would know what to do in the event of an emergency.

Information was provided to people on all aspects of the service when they first arrived. This included information on how to make a complaint should they need to.

Pre-admission assessments were carried out and these were used to develop care plans (patient records). The records were detailed and included all the information necessary to help ensure people received the responsive care they required. Records were held in each person’s individual room and they told us they were aware that they had a patient record.