We carried out a review of the data available to us about Cleeve Lodge Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Cleeve Lodge Care Home, you can give feedback on this service.
The service had been identified by the Local Authority as a designated care setting. A designated care setting is intended for people who have tested positive for Covid-19 and are being admitted to a care home from hospital.
We found the following examples of good practice.
The provider had identified a self-contained unit within the home to be the designated area. Four bedrooms were available to support hospital discharges. Each room had en-suite facilities.
There was a separate entrance for this unit so access to this area was safe. The designated unit was clean and well-decorated.
The provider had identified dedicated care staff to work in the unit. The staff team would not work anywhere else in the home during the use of this unit. This helped to minimise the risk of cross infection.
Plans had been made for winter when staff sickness, poor weather or an outbreak were most likely to occur. This information was referred to in the homes ‘Business Continuity Plan’ (staff deployment / resilience).
All members of staff had completed a Coronavirus workbook and were up to date with their infection control training. They had received a supervision session specifically relating to Covid-19 infection control which included the donning and doffing of PPE.
The provider had good supplies of appropriate personal protective equipment (PPE) such as gloves, aprons and masks. All staff had training in how and when to wear the PPE correctly. There was a PPE station on the unit so they would be easily accessible by staff.
New equipment had been sourced and purchased to prevent cross contamination. This included moving and handling aids, clinical waste and laundry provision, new cutlery and items to support safe medicine administration.
The provider had up to date infection prevention and control policies and was following national guidance. We were assured that this service met good infection prevention and control guidelines as a designated care setting.
Fire safety had been considered and professional advice had been sought to ensure regulations were being met.
Further information is in the detailed findings below.
We found the following examples of good practice.
• Staff greet visitors at the entrance to the home, and direct them to the nearest handwashing facilities. Visitors are asked, usually in advance, to read and sign the risk assessment, have their temperature checked and complete a health declaration. Clear guidance is provided about what level of PPE is required for a visit. For example, for a contractor who will not access areas used by service users, a facemask only is required. For visitors such as visiting health professionals who will have access to service user areas, change of clothes and footwear, gloves, masks and aprons are required.
• A 'pen pal' scheme was introduced to help reduce social isolation during the pandemic. People living in the home have been delighted with the letters received from people who responded to their requests on social media, for a pen pal. The success of the scheme has been reportedon, in the local news. A member of staff said, "You can just tell it brings joy and excitement and a letter means the world because it's a link to something familiar."
• People’s independence has continued to be promoted. One person goes out into the community, usually independently. They have been been supported by a member of staff, who has shown them the infection prevention and control measures required in public areas such as the local shops. The person has been provided with their own supply of hand gel and disposable masks. The person has also been advised and is aware of the procedure they need to follow when they return to the care home.
• Staff training was carried out in a number of ways. For example, to support staff learning, members of staff were tasked with completing mock simulations. This included the range of infection prevention and control measures they would need to take to keep everyone as safe as possible, if a person was suspected of having COVID-19. The actions they took, including how they communicated to others, were assessed as part of their supervision programme. The staff we spoke with told us they were confident about what they needed to do to keep people safe.
• Cleeve Lodge has developed a Safety Pledge detailing what action is being taken to keep people who use the service, staff and visitors safe. The operations manager commented, 'This helps us to share our values and reassure our service users and the community'.
Further information is in the detailed findings below.
At our last inspection, we rated the service Good. At this inspection, we found evidence continued to support this rating and in addition, we found the service had improved to outstanding in some areas.
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 2008 and associated Regulations about how the service is run.
We were introduced to people throughout our visits and they welcomed us. People were relaxed, comfortable and confident in their home. The feedback we received from people was extremely positive throughout. Those people who used the service expressed great satisfaction and spoke highly of all staff and services provided. One person wrote to the registered manager recently and said, “You have an amazing team of workers that made a difference to my parent’s quality of life”.
Staff involved in this inspection demonstrated a genuine passion for the roles they performed and their individual responsibilities. Visions and plans for the future were understood and shared across the staff team. They embraced new initiatives with the support of the provider, registered manager and colleagues. They continued to look at the needs of people who used the service and ways to improve these so people felt able to make positive changes.
People experienced a lifestyle that met their individual expectations, capacity and preferences. There was a strong sense of empowering people wherever possible and providing facilities where independence would be encouraged and celebrated. People’s health, well-being and safety were paramount.
The registered manager listened to people and staff to ensure there were enough staff on duty to meet people's needs. They demonstrated their responsibilities in recognising changing circumstances within the service and used a risk based approach to help ensure the staffing levels and skill mix was effective.
Staff had the knowledge and skills they needed to carry out their roles effectively. They enjoyed attending training sessions and sharing what they had learnt with colleagues. There was an emphasis on teamwork and unison amongst the staff at all levels. People were supported to enjoy a healthy, nutritious, balanced diet whilst promoting and respecting choice. The ‘residents’ annual surveys consistently reflected how much they enjoyed the quality of food, the variety and the constant access to beverages and snacks through the day.
The registered manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). For people who were assessed as not having capacity, records showed that their advocates or families and healthcare professionals were involved in making decisions.
Staff had an excellent awareness of individuals' needs and treated people in a warm, loving and respectful manner. They were knowledgeable about people's lives before they started using the service. Every effort was made to enhance this knowledge so that their life experiences remained meaningful.
People received appropriate care and support because there were effective systems in place to assess, plan, implement, monitor and evaluate people's needs. People were involved throughout these processes. This ensured their needs were clearly identified and the support they received was meaningful and personalised.
Regular monitoring and reviews meant that referrals had been made to appropriate health and social care professionals and where necessary care and support had been changed to accurately reflect people's needs. People lived meaningful lives and that suited personal interests and hobbies. The service had developed a creative and active community life at the home.
Staff were proud and felt privileged when supporting people during the end of their life. They did this with empathy, love and respected people’s wishes to the very end in order to ensure a peaceful, dignified death. Two relatives wrote expressing their gratitude, “At the end of mum’s life the care she received was great. We couldn’t have had it any better with the love we received” and “ I have no doubt if my father could speak now he would like to say thank you personally in appreciation of all your hard work and time spent with him in his last days his comfort”.
People and relative feedback was a vital part of the quality assurance system either through annual surveys, ‘residents’ meetings, complaints or reviews. People, relatives and staff were listened to and action was taken to make improvements where required. The registered manager monitored and audited the quality of care provided striving to meet the ever changing needs of people living in the home.
This inspection took place on 8 and 12 May 2015 and was unannounced. The previous inspection of Cleeve Lodge Care Home was on 20 September 2013. There were no breaches of the legal requirements at that time. Cleeve Lodge Care Home is registered to provide accommodation and personal care for up to 33 older people (although the provider limited this to 30 by using shared rooms for single occupancy). At the time of the inspection there were 26 people in residence.
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 2008 and associated Regulations about how the service is run.
People were safe. All staff received safeguarding adults training and were knowledgeable about safeguarding issues. When concerns had been raised they had reported events to the local authority and CQC. Their recruitment policy ensured that unsuitable workers were not employed because pre-employment checks were robust.
A range of risk assessments were undertaken for each person and appropriate management plans were in place where needed. The premises were satisfactorily maintained and there were plans in place for refurbishment works. All maintenance checks were regularly undertaken.
The staffing numbers on duty were continually monitored to make sure they were appropriate and that each person’s care and support needs could be met. Staff confirmed that the staffing numbers were appropriate.
Staff completed a programme of mandatory training to enable them to carry out their roles and responsibilities. New staff had an induction training programme and there was a programme of refresher training for staff. Care staff were encouraged to complete nationally recognised qualifications in health and social care.
People were supported to make their own choices and decisions where possible. Where people lacked the capacity to make decisions, assessments were recorded of best interest decisions. We found the home to be meeting the requirements of the Deprivation of Liberty Safeguards.
People were provided with sufficient food and drink. There were measures in place to reduce or eliminate the risk of malnutrition or dehydration. Arrangements were made for people to see their GP and other healthcare professionals as and when they needed to do so. People were administered their medicines as prescribed by their GP.
The staff team had good friendly relationships with the people they were looking after. People were able to participate in a range of different activities.
There was a staffing structure in place and junior staff were supported by senior staff and the registered manager. Daily team meetings and regular staff meetings ensured that all staff were kept up to date with any changes in people’s needs and any events that had occurred or were due to take place.
Care records were kept for each person. These were well written and detailed, which ensured that people would receive the care and support they needed. Accurate records were kept of the care and support provided. People were involved in having a say how they were looked after and were encouraged to raise any concerns they may have.
There was a regular programme of audits in place to check on the quality and safety of the service. The responsibility of these checks were shared between the senior staff. The provider visited the service on a monthly basis and also checked on the quality and safety.
We spoke with people individually during our visit and we observed an arts session in the morning. The artist visited the home weekly and taught people how to paint with watercolours. This gave us the opportunity to get to know about people, the staff and their views.
There was a constant interaction between staff and people in the home; everyone was relaxed, happy and comfortable in each other's company. We were introduced to people throughout the day and they welcomed us to their home. They talked freely with staff in front of us and people were confident and assertive in their surroundings.
People were enjoying time in the lounges, conservatory and spending private time in their rooms. Two people were celebrating birthdays and we saw a cake tier stand with homemade decorated cupcakes that people were going to have with afternoon tea.
We spoke with two relatives who were visiting their relative. They felt that the home had done their "very best" for their relative. They told us 'The admission and settling in period was good and they quickly became accustomed to the staff who are all very kind. The care staff are friendly and show affection. Our relative has grown fond of them all'.
staff and their involvement in making choices about their care. They also told us about the
quality and choice of food and drink available. This was because this inspection was part
of a themed inspection programme to assess whether older people living in care homes
are treated with dignity and respect and whether their nutritional needs are met.
The inspection team was led by a CQC inspector joined by an practising professional.
People were complimentary about the home and the food. One person told us, 'It's a wonderful home, everyone is so kind, I couldn't be treated better anywhere else' and another said, 'Everyone's so kind, you get what you want'plenty of baths!' People told us that there was always a choice of food available.
During the day we spent at Cleeve Lodge we saw a regular flow of visitors coming and going. Relatives told us,' My aunt has picked up a lot (improved in health) since being here, as she was very low in mood previously'.
We found that there were sufficient qualified and experienced staff available to meet people's needs. We observed care and support being delivered in a kind and respectful way.
People told us, 'There is plenty to do here' and, 'Everyone is friendly', 'The staff are marvellous, anything you ask for you get'.
Records of people's needs were up to date and accurate. These records contained information about people's preferences, care, nutritional and health needs.
We found that people are being helped to understand decisions about the care and treatment they are given. When people appear to have reduced mental capacity this is currently assessed informally and referral made to the GP when formal assessment needed.
We found that staff were approachable and people were encouraged and supported to make their views known to the registered manager and staff.
People we spoke with told us they had access to a range of health care professionals including GP, dentist, chiropodist and opticians. Care plans we saw were person centred and contained clear and comprehensive information about individuals and their needs, to guide and enable staff to provide the support and care they needed. Information was current and seen to have been reviewed and updated regularly with the individual person using the service.
We saw people being supported by staff to meet their needs in a caring and person centred manner, which was both timely and effective. We observed staff sitting and listening to people attentively. The responses seen were warm and respectful and showed staff had a good knowledge of the individual's personality, history and preferences. We saw people who use the service enjoying reading their books, or watching television, and three ladies had a manicure during the course of our visit.
We found that people are cared for by a staff team who are properly trained and supervised, to make sure they are competent to meet the varied care needs of people who use the service.
We found that the home is run in an inclusive way and there are systems in place to seek the views of people who use the service.