We undertook this unannounced inspection on the 18 & 21September 2015. The last full inspection took place on 27 August 2013 and the registered provider was compliant in all the areas we assessed.
Cloverdale Care Home is registered to provide accommodation and personal care for 40 older people, some of whom may be living with dementia. The home is a purpose built, single storey service situated on the edge of Laceby village and has access to all local facilities. On the day of the inspection there were 24 people using the service.
The service did not have 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. The previous registered manager/provider had resigned two weeks before the inspection visit when the new acting manager commenced their role. The acting manager confirmed they would be submitting their application for registration.
We found the quality monitoring system had not been effective in highlighting some areas to improve and action had not been consistently taken in order to address shortfalls. Delays in renewal of the premises were evident however a major refurbishment programme was due to start the following month. The new regional manager had recently completed a full audit of the service and produced an action plan which they were working through. New quality monitoring systems were being introduced.
Efforts had been made to improve the standard of cleaning throughout the service since the new management team had taken over, however not all equipment was found to be clean. The acting manager took action to address this during the inspection.
We found staff ensured they gained consent from people prior to completing care tasks. In the main, staff worked within mental capacity legislation when people were assessed as not having capacity to make their own decisions. However, we found instances when best practice had not been followed; records to support decisions about active resuscitation were not in place to reflect capacity assessments and decision-making. The acting manager told us they would address this straight away.
People told us they felt safe living in the service. We saw staff interacting with people and they did so in a kind, caring and sensitive manner. Staff showed good knowledge of safeguarding procedures and were clear about the actions they would take to protect people.
We saw there was enough skilled and experienced staff on duty to meet people’s needs. We found staff had been recruited using a robust system that made sure they were suitable to work with vulnerable people. They had received a structured induction and essential training at the beginning of their employment. This had been followed by regular refresher training to update their knowledge and skills.
People received a well-balanced diet and were involved in choosing what they ate. The people we spoke with said they were happy with the meals provided. We saw specialist dietary needs had been assessed and catered for.
People’s needs had been assessed before they moved into the home and they had been involved in formulating and updating their care plan. The three care files we checked were individualised and reflected people’s needs and preferences in good detail. Care plans and risk assessments had mostly been reviewed and updated on a regular basis.
People told us in-house social activities were available, as well as occasional trips into the community. They said they also enjoyed going out with relatives.
People told us they had no complaints but would feel comfortable speaking to staff if they had any concerns. We saw the complaints policy was readily available to people who used or visited the service.
There were systems in place to enable people to share their opinion of the service provided and the general facilities at the home.
People’s healthcare needs were met. People told us that they had access to their GP, dentist chiropodist and optician should they need it. The service kept clear records about all healthcare visits and appointments.