Background to this inspection
Updated
4 August 2021
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by three inspectors.
Service and service type
Tanglewood Cloverleaf is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before inspection
We reviewed information we had received about the service. We sought feedback from the local authority and Healthwatch, Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with ten people who used the service about their experience of the care provided. We spoke with 13 members of staff including the nominated individual, the regional manager, registered manager, deputy manager, senior care workers, care workers, housekeepers and the kitchen staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. This included eight people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with five relatives and six staff members.
Updated
4 August 2021
About the service
Tanglewood Cloverleaf is a nursing and residential home providing personal and nursing care to 65 people at the time of the inspection. The service can support up to 72 people. The care home is purpose built and accommodates people over three floors.
People’s experience of using this service and what we found
On the day of our visit there were enough staff to support people. However, the feedback from people, staff and the management team was that the service had been short staffed due to sickness and staff leaving. The management team had clear plans in place to manage sickness and had already recruited new staff. They continued to work on recruitment to strengthen the staff team.
People felt safe and there were systems and processes in place to ensure staff were safeguarding people from possible abuse. Risks to people’s safety were assessed and measures in place to reduce those risks. Staff received appropriate training for their role.
People’s medicines were safely managed and there was clear infection prevention practices in place to protect people from possible infections such as COVID-19. Their nutritional and health needs were well managed and the environment they lived in was well maintained.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People and their relatives told us the staff team treated them with care and respect, and their views on their care were listened to. Staff showed a good awareness of supporting people’s privacy and encouraging their independence.
People received person centred care in a way of their choosing. Staff supported people at the end stages of their lives in a caring and empathetic way. Staff had a good knowledge of people’s needs. People were supported to engage in social activities of their choice, and although people told us they had no complaints, there were processes in place to deal with any should they arise.
The service was well-led and the registered manager worked in an open way with people, their relatives, staff and health professionals to provide a good quality of life for people. There were quality monitoring processes in place to monitor practices and maintain good standards of care.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 07/10/2019 and this is the first comprehensive inspection.
Why we inspected
The inspection was prompted in part due to concerns received about staffing. A decision was made for us to inspect and examine those risks. During our inspection we found there had been times when the service had been short staffed. However, the provider had responded to these issues and at the time of our inspection there was sufficient staff in place to support people and the registered manager continued to work to maintain this.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.