Cleadon Court

“Since opening the previous management teams had admitted people who experienced complex mental health needs, which were often unrelated to an acquired brain injury. This had led to staff being expected to support people who had needs they were untrained to address. The senior leadership team had recognised this and recently introduced an assessment panel of skilled professionals who were now responsible for making decisions about whether to accept placements.”

“Overall, we found the care and support had not been consistently safe, effective or well led. People’s experiences had been varied, and had depended on staffing, leadership presence and the robustness of systems in place. Professionals and relatives consistently report frequent changes in management, reliance on interim arrangements, and a lack of consistent leadership presence. This has contributed to confusion, poor task ownership, delays in follow‑up and anxiety for people supported and their relatives. While there were areas of positive practice, these were not reliably embedded and did not sufficiently mitigate the identified risks. The provider, new regional manager and management team were taking action to ensure this was addressed, and parts of their action were addressed.”

“Staff turnover had been very high. In the last couple of months a new team had been employed. The new staff team treated people with kindness, dignity and respect, and staff interactions were generally caring. Many staff knew people well and were committed to supporting them. The accommodation model, including self‑contained flats, supported privacy and independence for some people and had reduced incidents. However, person‑centred care was not always underpinned by robust care planning. Records did not consistently reflect people’s current needs, risks, preferences or involvement in decision‑making. Professionals found staff at times had not understood escalation processes or their role.”

“The new staff team had not received comprehensive training around how to use the electronic care record system, and this had led to difficulties finding information such as capacity assessments, ‘best interest’ decisions and deprivation of liberty (DoLS) authorisations. The new regional manager and management team had recognised this and were in the process of ensuring staff produced comprehensive records.”

“There had been shortfalls in safety, particularly in relation to safeguarding, medicines management, staffing oversight, risk management and learning from incidents. Safeguarding systems were in place but had not always been implemented effectively, and staff understanding and escalation of concerns varied. Medicines were not always managed safely, and governance arrangements had not consistently identified or addressed these issues in a timely way. The new management team had put measures in place to make improvements across the service. In the week the new manager had been in post, they had resolved a number of issues.”

“Despite recent instability in management, staff confidence in current leadership is high. Many staff reported feeling well supported by management,…”