CQC report explained · a nursing home
What the CQC found at Cadogan Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention, protective equipment, testing, cleaning, outbreak management and safe visiting. The provider also described measures to manage COVID-19-related staffing pressures.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This area was not assessed in this targeted inspection.
What inspectors found, March 2022
Inspected but not rated; inspectors found strong infection control and visiting arrangements during the COVID-19 pandemic.
This was an announced, targeted inspection on 10 February 2022. Inspectors gave the home 48 hours' notice. They looked mainly at infection prevention and control, visiting arrangements and the effect of COVID-19 staffing pressures.
Inspectors were assured that the home was using protective equipment safely, arranging testing, managing outbreaks and keeping its infection control policy up to date. The home used separate 'bubbles', visiting suites and a visiting pod to reduce infection risks while helping people keep in touch with families.
The inspection did not give an overall quality rating. The Safe area was inspected but not rated. The other four areas were not assessed in this targeted inspection.
Separate infection-control areas
The home divided its units into separate bubbles, with their own staff and communal spaces. This helped reduce the spread of infection and supported zoning during outbreaks.
“Each unit was a 'bubble' with its own staff team, staff room and communal area.” from the report
Family visiting
The home provided visiting suites, a visiting pod and garden visits. It also supported essential care givers and visits at the end of people's lives.
“There was also a visiting pod, accessed from outside and separated by a clear screen.” from the report
Support for family occasions
The home helped people celebrate important occasions with their families, including during lockdowns, using risk assessments and infection-control precautions.
“The service supported people to celebrate significant milestones with their families, even when the home was locked down due to an outbreak of Covid 19.” from the report
Cleaning and staff training
Inspectors found an extensive cleaning schedule, regular checks and ongoing infection-control training for staff.
“There was an extensive cleaning schedule, with regular spot checks and audits.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the home's current overall and five-question CQC ratings, since this inspection was not rated?
- 02How have the home's infection-control and visiting arrangements changed since 10 February 2022?
- 03What plans are in place if COVID-19 or other illness causes staffing pressures?
- 04How are essential care givers and end-of-life visits arranged now?
- 05How does the home check that cleaning, protective equipment and infection-control training remain effective?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not assess the other four key questions and gave no overall rating. This explanation was written from the published report of 3 March 2022 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.
What inspectors found, November 2019
Rated Good overall; inspectors found safe, kind and responsive care, but the home was still rated Requires Improvement for being well-led.
Inspectors visited unannounced on 01 and 03 October 2019. They spoke with people, relatives, staff and a health professional. They reviewed care records, medicines records, recruitment files and management information, and observed care.
People were generally safe and received good care. Staff were described as kind and caring. Medicines, staffing, training, health care, food, activities and complaints arrangements were mostly well managed. The home had made significant improvements since the previous inspection, when its overall rating was Requires Improvement and it was in breach of one regulation.
The main remaining weakness was management oversight. Quality checks had not found some problems with risk records, people's involvement in care plan reviews, and recording end of life wishes. The new manager had started only eight days before the inspection, and improvements were not yet fully established. The home was no longer in breach of regulations, but its well-led rating remained Requires Improvement.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors observed warm interactions, and staff supported privacy, dignity, choice and independence.
“We observed warm interactions between people and staff; people and relatives told us staff were kind and caring.” from the report
Safe medicines support
Medicines were given as prescribed. Storage, ordering, administration and disposal systems were in place, with staff training and regular checks.
“People received their medicines safely, in the way prescribed for them.” from the report
Good activities and stimulation
The home offered activities seven days a week, including individual sessions, dementia-specific activities and opportunities to take part in the wider community.
“The activities programme took place seven days a week.” from the report
Improved management
The home had made significant improvements since the previous inspection. The manager was open about remaining problems and was developing clearer responsibilities and monitoring.
“Overall our findings showed that significant improvements have been made in all aspects of the management of the service” from the report
Support for eating and drinking
Staff and catering workers worked with speech and language professionals to provide attractive, nutritious food for people needing modified diets.
“They worked closely with the SALT (speech and language therapy team) to develop appetising dishes for people who required modified diets due to the risk of choking.” from the report
Risk records were not always consistent
needs fixingSome care guidance and records were incomplete or unclear. Inspectors found uncertainty about current drinking guidance and gaps in repositioning records, although the manager acted immediately.
“There were gaps in recording when another person had been supported to change position.” from the report
People were not always involved in care plans
needs fixingCare plans were detailed and reviewed, but the home did not consistently record people's involvement or give them copies. Relatives said they had not contributed to reviews.
“their involvement was not always documented, and they did not have copies.” from the report
End of life wishes were not always recorded
needs fixingPeople's wishes about end of life care were not consistently or accurately documented. This created a risk that staff might not know or respect those wishes.
“This meant there was a risk people's wishes may not be known and respected by staff.” from the report
Quality checks missed some problems
needs fixingThe quality assurance system had not identified the care plan, end of life and risk-recording issues found during the inspection. Improvements were still not fully established.
“this programme had not recognised people's lack of involvement in developing and reviewing care plans and documenting their end of life wishes.” from the report
- 01How are residents and relatives now involved in developing and reviewing care plans?
- 02Can we see how end of life wishes are recorded, reviewed and shared with staff?
- 03What checks are now used to make sure risk records, such as repositioning records and swallowing guidance, are complete and current?
- 04Who is currently responsible for management oversight, and have the deputy manager posts been filled?
- 05How do you check that improvements found after the last inspection have been maintained?
This was an unannounced planned inspection based on the previous rating and covered all five CQC questions, including the care and premises provided by the home. This explanation was written from the published report of 28 November 2019 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 Cadogan Court
5 rated inspections over 2 years: the service has improved, from Inadequate to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2017Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2017Inadequatestayed InadequateSafe: InadequateResponsive: Requires improvement
- August 2017InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2016
Registered with the Care Quality Commission on 6 July 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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