Updated 23 March 2023
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 Health and Social Care Act 2008.
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 site visit was completed by an inspector, a specialist advisor who was a nurse and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Cleves Place is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Cleves Place is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
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. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 16 people who lived at Cleves Place to seek their reviews of their care and support. Not everyone who used the service were able to tell us about their experience of receiving the service, so observations of care and support were also made. We spoke with 2 people’s relatives and received written feedback from a further 6 relatives. We spoke with 12 staff members. These included the deputy manager, registered manager, the regional director, trained nurses, care and maintenance staff. Following our site visit, we received feedback via email from a further 14 staff.
A selection of records were also viewed, and these included the care plans and associated records for 7 people who used the service. The medicines records for multiple people were also assessed. The governance records viewed included policies and procedures, staff recruitment records, training information, quality monitoring audits and maintenance records.