Cleeve Court Community Resource Centre

We found 1 breach in regulation around managing risks to people. The service was no longer in breach of the regulation for governance because systems had improved enough.

The provider still did not always work effectively with people to manage risks and provide clear guidance. Care plans contained inconsistencies and lacked details for specific clinical tasks, leading to potential risks to people. Staff lacked training and guidance to ensure consistent and safe care.

The provider did not always ensure there were enough qualified, skilled, and experienced staff. Training and support for staff were inconsistent, leading to potential risks in care delivery. However, there were enough staff to meet people's needs and keep them safe.

The provider did not always have clear responsibilities, roles, or systems of accountability. Actions identified as necessary were not always managed in a timely manner. External and internal audits were conducted, although changes were not always implemented promptly. Following the transfer into the local authority, new systems have been put in place and in some cases slowed down changes and learning.

The provider maintained a proactive and positive culture of safety, characterised by openness and honesty. Staff were encouraged to raise concerns about safety, and these were investigated and addressed promptly.

Lessons learned from safety events were shared and embedded into practice to continually improve safety standards.

The provider collaborated with people and healthcare partners to establish and maintain safe systems of care. This included ensuring continuity of care during transitions between services.

The provider worked with people and healthcare partners to understand what being safe meant to them and how best to achieve it. Staff focused on improving people's lives while protecting their right to live free from abuse and neglect. Concerns were shared quickly and appropriately.

The home was well-maintained, and systems were in place to manage the environment safely. People were kept safe in the event of a fire. The provider assessed and managed the risk of infection effectively. The home was clean, and staff were aware of infection prevention measures. However, there were occasional discrepancies in cleaning records.

People were supported by safe medicine management. The management engaged people and staff in decision-making and promoted diversity and human rights.

The provider had inclusive leaders who understood the context of care delivery and embodied the organisation's culture and values. Leaders demonstrated integrity, openness, and honesty throughout the inspection.

The provider fostered a positive culture where people felt they could speak up and be heard. Staff felt confident raising concerns, although there were occasional lapses in communication up the management chain.

The provider valued diversity and worked towards an inclusive and fair culture. Systems were in place to ensure staff were treated fairly, and there was a focus on equity. Managers were quick to apologise and accept responsibility for errors.