Background to this inspection
Updated
27 May 2021
The inspection
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
This inspection was carried out by two inspectors.
Service and service type
Cloverfields 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 did not have a manager registered with the Care Quality Commission. The provider was in the process of recruiting a new manager. The provider is 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 since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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.
During the inspection
We spoke with five people who used the service and three relatives about their experience of the care provided. We spoke with eight members of staff including the quality and compliance team, nurses, care workers and maintenance person. 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 five people’s care records and multiple medication records. We looked at two 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 one further relative and received email feedback from three more. We also liaised with two external professionals in connection to the evidence found.
Updated
27 May 2021
About the service
Cloverfields is a nursing home providing personal and nursing care to 17 people aged 55 and over at the time of the inspection. The service can support up to 35 people. The home is split over three floors and people have access to communal areas and a large garden.
People’s experience of using this service and what we found
Risks to people’s safety were not always considered and governance checks were not robust. Areas with the potential to cause harm were identified, for example, missing bedrail assessments. Accident and incident forms were completed but it was not always clear whether lessons had been learnt or families had been notified.
People were supported by enough staff but felt there were times when more staff were needed. People felt safe and were supported by staff who had been trained in recognising abuse.
Medicine guidance and information was not always complete, and staff felt they were not always given clear instructions for administering people's medicine.
Infection, prevention and control measures were in place but not all of the government guidance was being met. Indoor visits to the home were yet to be facilitated.
The provider was open to the concerns raised and was already taking action to improve the care people received.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 19 November 2019).
Why we inspected
The inspection was prompted in part due to concerns received about the overall governance within the service. A decision was made for us to inspect and examine those risks.
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.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment and the overall governance of the home at this inspection.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.