What the CQC found at Cadbury Hall Care Home

People were treated with dignity and staff understood their individual needs. Staff offered comfort and checked on people when they were unwell.

“The staff were calm, focused and attentive to people's emotions and needs.” from the report

Care plans recorded people's choices, preferences, life histories and interests. People could choose where to spend time and when to receive personal care.

“People's care was personalised.” from the report

Medicines records were accurate and detailed. Medicines were stored safely and the system was regularly checked.

“Medicine administration records (MARs) were accurate and detailed when people's medicines were administered or refused.” from the report

The home offered activities linked to people's interests and encouraged community involvement. Staff also supported people who preferred to spend time in their rooms.

“People enjoyed a programme of activities and a weekly calendar was on display.” from the report

People had a range of food and drink choices, and staff monitored intake and followed up concerns. People spoke positively about the meals.

“People had access to plenty of food and drink choices throughout the day.” from the report

On two nights, one waking staff member was left working alone. On another occasion, the planned sleeping-in staff member left without the manager being told, and there was no clear guidance on when sleeping-in staff should be woken.

“The provider had failed to safely monitor and manage risks within the home.” from the report

Some staff had not attended a fire drill soon after starting work and four staff did not know about the evacuation plan. Fire drill records also lacked important detail.

“Four staff that we spoke with were not aware of the evacuation plan despite having fire safety training during their induction.” from the report

Quality systems had not found obvious problems with staffing and safety. Rotas and signing-in sheets did not match and were not a reliable record of shifts worked.

“Systems for monitoring the quality of the service and ensuring people and staff were kept safe were not always robust and had not identified obvious short falls in practice.” from the report

Several managers had left since the home opened. Staff said this had unsettled them and affected morale, although the new manager was working to improve this.

“The provider had not been able to retain a stable manager.” from the report

One person's capacity information did not match their emergency care form and had to be corrected. The manager was also working on a separate record for people's end-of-life wishes.

“However, the person's care plan stated they did have capacity.” from the report