Cleeve Lodge Care Home

Updated 17 December 2020

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.

This was a targeted inspection looking at the infection control and prevention measures the provider has in place. As part of CQC's response to the coronavirus pandemic we are conducting a review of infection control and prevention measures in care homes.

The service had been identified for use by the Local Authority as a designated care setting in response to the Winter Plan for people discharged from hospital with a positive Covid-19 status. This inspection was to ensure that the service was compliant with infection control and prevention measures.

This inspection took place on 25 November 2020 and was announced.

Updated 17 December 2020

This inspection took place on 28 and 29 March and was unannounced. There were no concerns at the last inspection of February 2016. Cleeve Lodge provides accommodation and personal care for up to 33 people. At the time of our visit there were 27 people living at the service.

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.