17 October 2023
During a routine inspection
Cleveleys Nursing Home is registered to provide care for up to 32 older people, people living with dementia or physical disabilities. The home is situated close to Cleveleys town centre. There are bedrooms on all 3 floors, and there is a choice of communal lounges and seating areas. There were 24 people living at Cleveleys Nursing Home when we inspected.
People’s experience of using this service and what we found
Records and systems were not in place or robust enough to demonstrate risk was effectively managed. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; as the policies and systems in the service did not support this practice.
Some audits were not consistently applied and did not either identify concerns or drive improvement. Some information was not up to date or correct. We have made recommendations about recruitment, staff deployment and the use of person - centred language.
Observations showed people were happy and relaxed in the company of staff. Feedback about staff, manager and provider was positive. Medicines were stored and administered safely. People were supported safely, and the provider had contingency plans in place in case of emergencies. The home was clean and hygienic, and staff were seen to wear appropriate personal protective equipment (PPE).
The manager and provider were positively engaged in the inspection process and clearly understood their regulatory responsibilities. The manager and staff had been responsive in working with health professionals to improve people’s quality of life.
The service had systems to protect people from the risk of abuse and improper treatment. The service met people’s nutritional needs and worked with them to make sure food provision also reflected their preferences.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update: The last rating for this service was requires improvement (published 07 May 2023) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
At our last inspection we recommended current guidance on the proper and safe management of medicines be followed and communication related to medicines management be improved. At this inspection we found improvements had been made. At our last inspection we recommended the provider ensure schedule 3 information is shown as required, as part of their recruitment process.
The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection, and in part due to concerns received about the management of risk, staffing and good governance. A decision was made for us to inspect and examine those risks.
You can see what action we have asked the provider to take at the end of this full report.
We have found evidence the provider needs to make improvements. Please see the Safe, Effective, Caring and Well-led sections of this full report.
The provider has mitigated the risks and some improvements have been made.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cleveleys Nursing Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to the management of risk, consent and good governance at this inspection.
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 continue to monitor information we receive about the service, which will help inform when we next inspect.