Cloverdale

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 7 out of 8 quality statements within the safe key question. Safe- this means we looked for evidence people were protected from avoidable harm. At our last inspection published 28 October 2019, this key question was rated good. At this assessment the rating remains good. During our assessment we found the provider had completed investigations where required into safety events and learning implemented to improve care to people. We found some gaps in record keeping which the manager was working with staff around embedding a learning culture. In addition, there were safe systems in place to support people when moving into Cloverdale or accessing other services. Risks to people were well managed and staff were observed to support people safely and appropriately. We found some support guidelines required updating, however the provider was aware, and work had begun. The homes environment was safe and suitable for the people living there. Safe systems were generally in place to manage people’s medicines. The provider said they would review processes around competency assessments for agency staff. Safeguarding incidents were investigated, and learning implemented where appropriate, however not all staff were confident in their knowledge and concerns around lack of stability in management and high use of agency staff were identified, in addition not all staff recruitment records were being completed.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they felt safe in the care of staff and were kept updated on any safety events and the steps taken to avoid similar incidents. For example, following a safety incident investigation, information was shared with the person and their relatives to ensure everyone understood what had happened and how this would be prevented in the future.

During the assessment, we reviewed 11 staff surveys which had been completed. All staff said they felt they had the required skills to keep people safe. In addition to this, staff told us following certain events, there were individual and group review sessions to discuss what had happened and how similar occurrences could be prevented. Staff feedback also included a lack of visibility from senior leadership. In response to this feedback, senior leaders said they would look at ways to ensure they are more visible to staff and able to support them.

Incidents, accidents and safeguarding events were recorded by staff and investigated independently where required. For example, following a safety event, an investigation was completed by a person independent from Cloverdale, relevant concerns were identified and analysed, with lessons learned being acted upon and shared with staff. As a result, disciplinary action was planned, and ongoing actions added to the service improvement plan and work in progress around embedding a learning culture within the service.

One person told us they felt safe when receiving support from or transitioning between services. Another person said they were kept informed of appointments and felt supported by staff to attend them, for example, people and their relatives told us staff supported them when they needed to visit a GP, with a staff member driving them to the appointment in the home’s transport or supporting them to attend the appointment using public transport.

The provider worked well with other health and social care professionals. Staff were clear when to share and where to record this information following GP visits. Referrals were made to health and social care professionals when people’s needs changed. Leaders told us staff were encouraged to identify and escalate concerns and processes to capture information after appointments had been made more robust.

External health and social care professionals were positive about their involvement in the service and felt staff and providers worked well with them to optimise people’s care. For example, one external professional told us “Staff know people well and treat them with kindness, there’s open and transparent communication with the home.”

There were systems in place to ensure people were assessed before they started using the service, followed with a care plan, hospital and communication passports based on their individual needs. Staff were aware of systems in place to facilitate consistent care was provided to people. This included a handover with a communication book, which allowed information to be available to incoming care staff.

People and relatives raised no concerns about safety and told us they were involved in safeguarding and care planning meetings. One person told us “I’m safe here, it’s my house.” Relatives told us action was taken when concerns were raised, however, we found for one person learning following an incident had not occurred which led to further distress.

Staff completed safeguarding training; however, 2 staff were not up to date with this training and not all staff we spoke to were confident in their safeguarding knowledge. Further training had been completed by staff following recent incidents, for example on reporting responsibilities, however we saw body maps completed without the required incident form. This was bought to the attention of the manager who took immediate action.

We did not observe anything of concern during our site visit. The care and support people received was safe. We observed people were mostly relaxed with staff and we saw no evidence people were at risk or fearful of the staff team.

Safeguarding concerns had been identified, reported and investigated with appropriate actions being taken where concerns with the culture of the service were identified. There was concern raised about the process of inducting new managers to the service which led to a lack of stability in management and identified how changes of manager could impact on the safety of people. This was discussed with the provider who said they would review the induction process in place and support offered to new managers and make changes where necessary. The provider had relevant policies and procedures in place and told us staff were required to read them and sign to confirm they had done so. The provider’s commitment to safeguarding was also set out in their statement of purpose.

People and relatives told us overall, risks were well managed, and relatives were made aware of people’s known risks. One person described to us their mobility equipment and understood when and how they needed to use it and another relative told us risks around personal hygiene were well managed. People also told us staff supported them with any risks, for example people were supported to help in the kitchen safely. This included ensuring safe numbers of people and good hygiene practices were supported. People’s care plans were personalised for each person. In addition, the provider’s behaviour support team had contributed to people’s behaviour support plans appropriately.

Leaders and staff were aware of what caused people distress, which for one person, had changed since they were admitted to the service. The reason for change had been considered, action had been taken, there was guidance in place for staff to follow and the provider’s behaviour support team were also involved. The outcomes of any changes would continue to be reviewed for effectiveness. Staff told us about techniques used to support people if they were distressed, they understood people’s right to make choices and how they supported people to take positive risks. Staff reported through a survey, all 11 staff felt incidents were reported appropriately, they received debriefs appropriately to reflect on incidents, allow learning and better outcomes and safe care for people.

Staff were available to offer support to people. We observed staff understood how to support people safely and appropriately. Staff confirmed they were informed about changes to people’s support guidelines.

Some people’s support guidelines required updating as they had not been reviewed for a considerable time. The provider was aware, and work had begun, but not yet been completed. People’s support guidelines described how risks to them were to be managed and included how people expressed themselves and communicated their needs. In addition, staff told us they had the required skills to provide people with safe care and felt supported to do this.

People’s relatives told us the environment was safe and one person’s relative said adaptations were made to the environment following an incident which supported ongoing care to be safe. In addition, people’s relatives told us people who needed to have a downstairs room due to mobility needs, were in the appropriate rooms.

Staff we spoke to told us they felt the environment was safe for the people who lived there, and agency staff received an induction when employment commenced.

We observed the environment was safe for people who lived at the service. This included window restrictors and finger guards on doors being in place.

Systems were in place to maintain a safe environment. This included utility safety checks and legionella checks which were completed as required. In addition, required actions from a recent fire safety report, had been completed.

People and their relatives told us they were happy with the staff in post at the time of assessment. Staff knew and understood people and their health and wellbeing needs. Staff were able to describe protocols for people and their role within the provision of care. For example, people’s bandages were changed by appropriate external professionals because staff knew the limitations of their role. People had keyworkers working with them who helped them set goals to achieve and to complete a decision-making profile to show how people were supported to make decisions.

Leaders told us there was a high use of agency staff due to current staffing levels at night, however regular agency staff were employed and there was an ongoing recruitment plan to reduce this need. Leaders told us staff had access to on call assistance if required. Some concerns were identified around lack of stability in management, consistency of staff employed and the impact this had on staff and the people they supported. The service had 2 managers in the previous 6 months, in view of this, the provider was reviewing the induction for new managers and were in the process of recruiting a new manager.

We observed, during the day, there was a senior staff member on duty and sufficient staff during the day to meet people’s needs. We observed positive interactions between staff and people with a focus on their individual preferences. These interactions included staff promoting people’s choice and validating people’s efforts.

We reviewed staff recruitment records and found not all contained the required information. We raised this with the provider who was already aware, and action was being taken to obtain the required information. We also reviewed staff rota's and found on occasion, staff had worked two shifts in succession, this was addressed by the provider at the time it occurred. We reviewed staff training records and found not all staff had completed a specialist training course, we discussed this with the provider who was already aware and told us the training had already been arranged. In the interim, we viewed detailed guidance in place for staff to follow. In addition, epilepsy was covered in staff’s induction, however not all staff had refreshed this knowledge. We discussed this with the provider who acted and arranged the relevant training.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they received their medicines from staff and relatives told us they felt this was done safely. One person told us “staff help me with my medication,” and were able to describe some of the prescribed medicines they received. Also, one person’s relative told us staff followed protocols with the administration of prescribed medicines.

Staff surveys were completed in 2023. 11 surveys were reviewed, and all 11 staff said medicines were administered safely. Staff also told us they had access to relevant guidance and confirmed they received additional training in the event of a medicines error and when we spoke to staff, they understood how to give medicines safely. The provider told us a staff member was allocated to support with medicines on each shift. We reviewed training records and saw all staff had completed medicines training and received a competency assessment, however agency staff who worked at the service did not have a competency assessment completed before administering medicines. There was no indication people had received inappropriate care and there were no adverse events from this.

Processes were in place to identify and review any medicines errors and themes. People at the service had medication plans, reviews and PRN (as required) protocols were in place. Also, people’s medicines were stored safely in line with good practice guidance, and staff had access to relevant policies and guidance documents. Evidence was seen of staff receiving competency assessments relating to safe medicines administration. In addition, regular audits of medicines were completed with action taken in response to any identified themes or patterns. Also, evidence was seen the provider was applying STOMP principles to reduce overmedication of people with psychotropic medicines.