CQC report explained · a residential care home, run by Achieve Together
Cleveland House
1 Cleveland Road, South Woodford, London, E18 2AN
Rated Good: inspectors found the service performing well and meeting their expectations.
What inspectors found, November 2023
Cleveland House is rated Requires Improvement; inspectors found medicines, risk checks and quality monitoring were not consistently safe or effective.
This was an unannounced focused inspection on 10 and 21 October 2023. Inspectors looked only at Safe and Well-led, including medicines, risks, staffing, safeguarding, infection control and management checks. They spoke with people, staff, relatives and the manager, and reviewed care records and other documents.
The home had enough staff and safe recruitment arrangements. Staff understood safeguarding procedures, worked with other professionals and relatives said they could contact the management team. Infection control arrangements were considered suitable, although some flooring needed deep cleaning or replacement.
Inspectors found important safety problems. Medicines were not always stored or given correctly, some risk assessments and fire safety checks were missing or out of date, and shower fittings created a possible drinking-water contamination risk. The quality monitoring system had not found these issues. The overall rating fell from Good at the previous inspection to Requires Improvement.
Enough staff
Inspectors found enough staff to meet people's needs, and the home did not use agency staff.
“There were enough staff employed to meet the needs of the people using the service.” from the report
Safe recruitment
The provider carried out recruitment checks before staff started work.
“The provider had effective recruitment and selection processes in place.” from the report
Safeguarding awareness
Staff had safeguarding training and could explain how to report concerns. The provider investigated concerns and reported them to the local safeguarding team where appropriate.
“Staff were aware of their responsibilities in relation to safeguarding people.” from the report
Open management
People, relatives and staff said management was approachable and kept them informed. The manager had regular contact with people and relatives.
“The peripatetic manager operated an 'open door' policy.” from the report
Medicines were not always safe
seriousSome medicines were stored above the recommended temperature, and medicines prescribed for use only when needed were sometimes given regularly or without clear guidance.
“People's medicines were not always managed safely because we found shortfalls around the provider's arrangements to make sure people received their medicines safely.” from the report
Risk checks were incomplete
seriousTwo people did not have risk assessments for walking without footwear, and another person's assessment had not been reviewed since March 2021.
“We found that systems were not always in place to effectively assess and manage risks to people while they received a service.” from the report
Building safety checks were overdue
seriousWeekly fire alarm checks and daily and monthly health and safety checks had not been completed as required.
“The provider was failing to ensure people had access to clean drinking water as we found the shower heads in 2 shower rooms could drop below the water level when the showers were in use.” from the report
Quality monitoring missed problems
seriousThe provider's audits had not identified several medicines, risk and premises safety issues found during the inspection.
“The provider had not ensured there was effective governance and quality systems in place to ensure the quality and safety of care was assessed, monitored and improved when needed.” from the report
Some interaction could improve
minorInspectors saw limited interaction between staff and people during lunch, and one person was left sleeping in a dining-room chair without staff attending to their needs.
“During our inspection, we noted the interaction between staff and people could be further improved.” from the report
Safeguarding concerns under investigation
needs fixingSeveral safeguarding concerns had recently been raised about staff. The local safeguarding team and the provider's external investigator were investigating them at the time of the inspection.
“There had been a number of safeguarding concerns raised recently about staff working at the service.” from the report
- 01What has been done to make sure medicines are stored at the correct temperature and given exactly as prescribed?
- 02Have all residents now got up-to-date risk assessments, including people who walk without footwear?
- 03Have the fire alarm, daily health and safety, and monthly health and safety checks been brought up to date?
- 04What action has been taken to deal with the shower fittings and the possible risk to drinking-water safety?
- 05What progress has been made with the safeguarding investigations and the provider's action plan?
This was a focused inspection of Safe and Well-led only; the other question ratings carried over from the previous inspection. This explanation was written from the published report of 16 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Cleveland House
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2022Goodstayed GoodSafe: GoodWell-led: Good
- July 2022Goodstayed GoodSafe: GoodWell-led: Good
- October 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- December 2020
Registered with the Care Quality Commission on 1 December 2020.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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Other services run by Achieve Together Limited
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