We inspected Cleveland House Care Home on 21 and 28 March 2018. Both days of the inspection were unannounced which meant the home did not know we were coming.

Cleveland House is registered to provide personal care and accommodation for up to 45 older people, some of whom live with dementia. The home has three floors accessed by passenger lifts. A lower ground floor and first floor contained single bedrooms and shared toilets and bathing facilities; the ground floor contains single bedrooms, toilet and bathing facilities, plus shared lounges and a dining area. On the first day of our inspection there were 24 people living at Cleveland House and on day two this number was 23. The bedrooms on the lower ground floor were not in use. Outside there is a garden with seating areas.

Cleveland House 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 home did not have a registered manager in post and although a home manager was employed, they were unavailable on both days of our inspection. The regional director for recovery made us aware the home manager was leaving and a new home manager would commence working in the home from mid-April 2018 and they would be expected to register shortly afterwards. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People gave us mixed feedback about staffing levels which had been kept at the same levels since our last inspection. Records of staff response times to nurse call bells showed a number of examples of unexplained lengthy delays and the analysis of these incidents was not thorough.

Examples were identified when some staff did not demonstrate appropriate values to maintain people’s privacy and dignity. People were complimentary about the care provided by staff who were sufficiently skilled. Staff received an appropriate induction and training as part of their development, although supervisions and appraisals were not happening in line with the registered provider’s policy and good practice recognised by the National Institute for Clinical Excellence (NICE).

The management of medicines was not always safe as oxygen cylinders had not been secured since we commented on this in our last inspection and risk assessments for prescribed thickener stored in people’s rooms had not been considered. Topical medicine administration records were not in place for all prescribed creams, gels and ointments in use.

People and their relatives told us people were safe living at Cleveland House Care Home. Recruitment processes were mostly safe, although one staff member had commenced their employment without a last employer reference.

Some examples of unsafe moving and handling transfers were seen which were discussed with the management team. Individual risks to people with one exception had been assessed to reduce the risk of harm.

People’s nutritional and hydration needs were being met as staff had sufficient knowledge and records were in place to support this.

People were supported in accordance with the Mental Capacity Act (2005), although this was not always reflected in their care records. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Applications for Deprivation of Liberty Safeguards had been made appropriately.

Accidents and incidents were recorded, although the analysis of these events required improvement. A new system was in place to support this.

People’s care r

We inspected Cleveland House on 15, 22 and 23 August 2017. The first two inspection days were unannounced. The last day was announced.

Cleveland House is a care home registered to provide residential and nursing care for up to 45 people over 65 years old. It consists of one building and one purpose built extension with three floors accessed by two passenger lifts. The rooms were all single. At the time of our inspection 36 people were living at Cleveland House.

This inspection was brought forward due to concerns raised by the public and stakeholders.

Cleveland House was last inspected on 4 and 10 January 2017. At that time the service was rated requires improvement and had two continuous breaches of regulation relating to safe care and treatment and good governance which had already been identified during our previous two inspections. Following the last inspection, we asked the provider to take action to make improvements to their processes in relation to risk assessments, medicines and auditing. At this inspection we found the service had not made enough improvements and was still in breach.

The home did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a home manager in post but they had not yet registered with CQC.

Although efforts had been made to register a manager and an application had been sent to CQC this was subsequently returned due to incompleteness and a new one had not been submitted. The registered provider had failed to comply with a condition we had applied to their registration requiring them to appoint a registered manager.

Risks associated with people's individual care needs were not always identified or managed appropriately. Medicines were not administered safely at the home and people had been put at risk of harm. During our inspection we raised safeguarding concerns in relation to medication.

Staffing levels were not always sufficient to ensure people received the care they needed. Staff had not always been recruited safely to ensure they were suitable to work at the service. Staff had completed relevant training however, we found examples where staff’s knowledge was not effective in meeting people’s needs. Staff had supervision but not as regularly as stated in the registered provider’s own policies.

People’s mental capacity was not always assessed and best interest decisions were not always completed in line with legislation.

People’s nutritional and hydration needs were not being appropriately met and the registered provider was not managing people’s weight loss safely.

People did not always receive dignified care in accordance with their preferences. The registered provider was not consistently involving people and their relatives in making relevant decisions about their care.

People's personal information was not always stored securely.

People were offered social stimulation on a regular basis through varied and meaningful activities.

There were care plans in place; however, the quality of these care plans fluctuated and some contained contradictory information which put people at risk of inappropriate care.

The registered provider did not have a robust approach to dealing with complaints and people and their relatives could not be reassured their concerns would always be valued and acted upon.

Staff’s morale was low and there were substantial issues with the home’s organisational culture due to lack of strong leadership.

The systems of governance in place and the home manager’s oversight were not robust to implement changes and this was having a negative impact on the overall quality of the service.

The registered provider was in continuing

The inspection of Cleveland House took place on 4 and 10 January 2017. We previously inspected the service on 4 and 11 May 2016, at that time we found the registered provider was not meeting the regulations relating to person centred care, consent, safe care and treatment, nutrition and hydration needs, governance and staffing. We rated them as inadequate and placed the home in special measures. The purpose of this inspection was to see if significant improvements had been made and to review the quality of the service currently being provided for people.

Cleveland House provides support to people with both nursing and residential care needs. The home has a maximum occupancy of 45 people, on the day of our inspection 34 people were resident at the home.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe and staff were aware of their responsibilities in keeping people safe from the risk of harm or abuse. However, where people required staff support due to immobility, not all aspects of their support were robustly assessed. Risk assessments lacked detail regarding equipment and the method staff were to deploy to keep people safe.

Action had been taken to ensure bed rails were used appropriately and the clinical lead nurse was able to tell us about strategies used by staff to reduce people’s falls risk. However, a robust analysis of falls was not in place.

There were systems in place to protect people in the event of a fire. This included fire training for staff and regular checks on the fire detection and methods of escape. Maintenance checks were completed for aspects of the environment and equipment to reduce the risk of harm to people or staff.

A number of pre-employment checks had been completed on potential candidates to reduce the risk of employing staff who may not be suited to supporting vulnerable adults. Some of the evidence to support these checks had had not been filed at the home, but a senior manager emailed outstanding documentation to us after the inspection.

People told us there were enough staff and we saw people’s needs were met by staff in a timely manner but staff lacked time to spend with people other than when they were completing a care related task.

Not all aspects of medicines management were robust. When people were prescribed a cream, this was kept in their bedroom but the records staff were to complete to evidence the cream had been applied as prescribed were not consistently completed. Staffs competency to administer people’s medicines was assessed and checks were made at the ends of each medicine round to reduce the risk of errors.

There was a programme of induction for new staff and this was followed by regular refresher training. A lack of staff knowledge highlighted in our previous report had been addressed through training but these topics were not included in the registered provider’s rolling refresher programme.

Staff told us they received supervision but at the time of the inspection the records did not support this being completed at regular intervals.

All the staff we spoke with expressed an understanding of the Mental Capacity Act 2005 (MCA) and people’s right to make choices and decisions about their daily lives. Peoples care plans contained evidence of capacity assessments and where people were deprived of their liberty, an application to the local authority had been made. This was to ensure a people’s rights were protected.

People were offered a choice of food and drinks and told us the food was good. People were weighed at regular intervals, weight loss was highlighted and action taken to address

We carried out this inspection on 4 and 11 May 2016. The inspection was unannounced.

The service provides accommodation and nursing care for up to 45 people. On the day of our visit there were 41 people living at the home. Accommodation at the home was provided in single bedrooms set over three floors.

There was a registered manager who was no longer managing the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had left the service in February 2016 and the home had been managed on a part time basis by a registered manager from another of the provider’s homes. Subsequent to the inspection we were informed that the provider was reviewing management arrangements to the home in line with our concerns.

Concerns had been raised to us before the inspection about care in relation to people’s pressure relief. Some work had begun to address the need to provide effective pressure care and to treat wounds, such as pressure ulcers and skin tears. However, preventative measures were not robust at the time of the inspection and the repositioning regime for some people was inconsistent.

Practice for moving and handling people was not appropriate at times to ensure people’s safety and staff were not all familiar with the equipment and process needed to assist individual people to move and transfer.

Staff had a clear understanding of the safeguarding procedures to follow should they have concerns about a person’s well being.

The provider did not have robust procedures in place to ensure the requirements of the Mental Capacity Act (2005) legislation was being met in support of people’s rights. Staff knowledge of the mental capacity act was inconsistent.

People reported they enjoyed the food and drink in the home. There were concerns about weight management for some people as the recording and monitoring of this and of food and fluid intake was not consistent.

Staff interaction was kind, caring and patient and people were complimentary about the staff’s approach to their work. Staff showed respect for people’s privacy and dignity when supporting people with their care.

Many people remained in bed, with no clear rationale about the reasons. People did not all wish to remain in bed and expressed some frustration as having to depend upon staff to assist them to be out of bed. Some people were at risk of being socially isolated due to their high dependency needs, although staff made efforts to chat with people when they carried out care tasks..

Care plans were not person-centred, lacked detail and were not up to date or accurate for all people.

People and relatives knew how to complain and the complaints process was managed appropriately.

The home was under new leadership and some improvements to the running of the home and the clinical oversight were being implemented. Staff reported morale was beginning to improve although said this had been poor in recent months, prior to the commencement of the new manager.

Relatives reported improved leadership in the home and they said their views were valued.

Regular audits were carried out by the organisation, although internal audits of quality and practice were not rigorous enough to identify and address the areas of concern highlighted at this inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvement

On the day of our inspection there were 41 people living at the home. We found that the home had undergone a programme of refurbishment since our last inspection and all of the bedroom areas we looked at were newly decorated and had new furniture in place. We saw that people's rooms contained personal items such as photographs and ornaments which made them feel homely.

The manager told us that activities were provided seven days a week with two staff in post to organise and facilitate them. We saw that the home had entertainment booked for the coming months and also an external facilitator of physical exercise to hold sessions within the home. We spoke with two people and the relative of another person who lived at the home. People we spoke with were complementary about the service and the quality of care provided. One person told us the staff are great and very friendly “they all treat me like I’m actually a person”. The person also told us they were happy with the care they received. The relative of one person told us they thought the home provided good care. They also told us they visit their relative six days per week and are always made welcome by the staff.

We spoke to a number of people at this visit they included four people who use the services, two visiting relatives and one health care professional. People living at the home told us they were comfortable and felt safe in their surroundings. They all told us that the staff cared for them well, they were kind and they were able to talk to staff about any concerns or worries.

One visitor told that the staff were busy but overall they were satisfied with the care that their relative received. Staff kept them up to date and informed about their relatives care. The second visitor told us that they found the staff approachable and open to suggestions about their relatives care.

The visiting health care professional was very positive about the care people received at the home; they told us that the staff were knowledgeable about the people who use the services. They had confidence in the staff and they responded in a timely way to their care and treatment requests for people who use the service.

The first day of our inspection of Cleveland House Nursing Home took place on the evening of 26 January 2015 and was unannounced. We also visited during the day on 27 January 2015; this visit was also unannounced. We visited for a third time on 6 February 2015, we telephoned the registered manager the day before this visit to tell them we would be visiting them.

We previously inspected the service on 25 November 2013. The service was not in breach of the Health and Social Care Act regulations at that time.

Cleveland House Nursing Home is registered to provide accommodation and personal care for up to 45 older people. The home is a converted property and provides accommodation and communal areas over three floors. There is also a garden that is accessible for people who live at the home.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The recruitment processes at the home were not robust. We found that one member of staff had not been thoroughly checked before they commenced employment to ensure they were safe to work with vulnerable adults.

The registered manager was aware of their responsibility towards safeguarding vulnerable adults and was also aware of the safeguarding referral process.

We found peoples medicines were managed appropriately. Not all the registered nurses had yet completed role specific training in medicines management and we found one nurse had not had an assessment of their competency reviewed.

Not all the staff we spoke with were not clear about the care and support individuals required and staff were not all aware they could access peoples care plans. This meant people may be at risk of receiving unsafe care and support.

New staff received support when they commenced employment at the service. The registered provider had a system in place to ensure staff received regular training and attended refresher training as required. staff told us they received regular supervision with their manager.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. When we spoke with the registered manager they showed an understanding of how this legislation impacted upon the people they supported. We saw that all staff had received training in this subject, however, a number of staff had not updated this training for over two years.

People were offered a choice for their meals and drinks and were able to choose where they ate their meals. Fresh fruit was available and snacks throughout the day. When some people received their breakfast it was not always hot.

Feedback from people who lived at the home, was that staff were caring. We observed friendly, appropriate interactions between staff and people who lived at the home. Staff were able to tell us how they respected people’s privacy, they said they did this by closing doors and curtains.

We were unable to clearly evidence that the provision of activities for people was person centred and was provided to people on a regular basis. We saw the service had put life history books in people’s room but the three we looked at were all blank.

The registered provider had a system in place to deal with complaints.

We found a number of examples where peoples care and support records were not accurate. This included records of people’s dietary intake and wound care records. This meant we could not evidence these people had received the care and support they required.

The registered provider had a system to monitor and assess the quality of the service people who lived at the home received. The registered manager was aware of the need to ensure staff practice was in line with current good practice guidelines. A nurse we spoke to was confident in speaking to a member of staff in the event they witnessed poor practice.

You can see what action we told the provider to take at the back of the full version of the report.