Cloverdale

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.

At this assessment we assessed 4 of 5 quality statements within the caring key question. The scores of these areas have been combined with scores based on the rating from the last inspection published 28 October 2019, which was outstanding. The overall rating for this key question is now good. We observed a kind and caring culture with staff offering choices to people. This was supported by positive feedback from external professionals who worked with the service. Management encouraged staff to think how they could enrich people’s lives and guidance for staff around people’s communication needs was recorded in their support plans. Staff wellbeing was supported with the ability to express themselves through supervisions and meetings, however staff feedback included increased stress levels, in part from working alone at night. However, the high level of use of agency staff and lack of consistency in management raised concerns around the impact on quality of care. This was in part mitigated by regular agency staff being used and permanent staff knowing people well. In addition to this, the lack of employed drivers at the service, impacted on people’s ability to access the community, which the provider was aware of and taking action to resolve which included working with stakeholders around allocated 1 to 1 hours and arranging public or private transport if required.

We assessed 1 of 7 quality statements in the responsive key question at this assessment. The scores of these areas have been combined with scores based on the rating from the last inspection published 28 October 2019, which was good. The overall rating for this key question remains good. We found the provider had a recruitment plan in place and the provider had worked with external professionals to review people’s care needs where appropriate. However, the lack of employed drivers, impacted on peoples care provision. The provider had recognised this and had a plan in place to recruit appropriate staff members to the team.

We assessed 7 of 8 quality statements within the well-led key question. At our last inspection published 28 October 2019 this key question was rated outstanding. At this assessment the rating has changed to good. During our assessment of this key question, we found systems and processes were in place to identify challenges, areas for improvement and share learning. Also, staff felt listened to and received regular supervisions and were able to raise concerns. However, a lack of visibility of senior leaders, a consistent staff team and gaps identified in some staff’s knowledge were identified as concerns. Leaders had themselves identified these areas of concern and were taking action to improve prior to this assessment.