CQC report explained · a residential care home
What the CQC found at Cavell Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2021
Rated Good; inspectors found safe, well-managed care, but noted medicine recording gaps and previous medicine shortages.
This was an unannounced focused inspection in August 2021. Inspectors spoke with people, relatives, staff and a health professional. They observed care and reviewed care plans, medicine records, staff files and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, suitable recruitment checks, risk assessments and infection control measures. People said they felt safe, and staff supported people with medicines safely overall.
The home had systems for checking quality, learning from incidents and involving people and relatives. Inspectors saw kind and patient interactions, and found the management team approachable and open to feedback.
Inspectors found some gaps in recording newly delivered medicines and when medicines were opened. These were corrected during the inspection. A relative also reported previous occasions when medicines had run out, and the home had introduced new stock-checking processes.
Enough staff
Inspectors found enough staff to meet people's needs and keep them safe. People also said staff usually answered call bells quickly.
“There were enough staff to support people with their care and support needs.” from the report
Positive relationships
Inspectors observed staff being patient, reassuring and involved with people. The management team knew people's needs and what mattered to them.
“During our visit we observed genuine and positive interaction between people living in the service and staff.” from the report
Open management
The home had daily senior staff meetings, audits and systems for sharing learning. The manager welcomed feedback and used it to plan improvements.
“The registered manager welcomed feedback, whether positive or negative and used suggestions to improve the service.” from the report
Infection control
Inspectors were assured that the home was using protective equipment, testing and visiting arrangements to help prevent and manage infections.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicine records
needs fixingInspectors found gaps in recording newly delivered medicines and when medicines were opened. These were corrected immediately and new processes were put in place.
“During our inspection we identified some gaps in recording of newly delivered medicines and clear information when medicines were opened.” from the report
Previous medicine shortages
needs fixingA relative reported that medicines had run out on some occasions. The home had introduced stock checks and monitoring to identify when supplies were running low.
“A relative told us that there had been occurrences when the service had run out of medicines for their family member.” from the report
Falls
needs fixingThe home had recorded more falls than expected. It had analysed possible causes, bought alert equipment and made referrals to the local falls team.
“There had been a higher than expected number of falls reported for this service.” from the report
Time for one-to-one support
minorSome staff felt more staff would allow more meaningful one-to-one time, although inspectors found current staffing was safe and tasks were completed.
“It was felt that an increase in staff would enable more meaningful time on a one to one basis with people.” from the report
- 01How do you now check that newly delivered medicines are recorded and that opening dates are clear?
- 02What changes have prevented medicines from running out, and how often are medicine stocks checked?
- 03What has happened to the number of falls since the inspection, and how is the alert equipment working?
- 04How many staff are usually on duty for each unit, and how much time is available for one-to-one support?
- 05How will you make sure communication and manual handling training is included in the revised induction programme?
This was a planned focused inspection covering Safe and Well-led only; the previous overall rating was Good and the other key questions were not reassessed. This explanation was written from the published report of 1 September 2021 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, December 2018
Rated Good; inspectors found kind, responsive care and major improvements, but topical medicines were not secured.
This was an unannounced comprehensive inspection on 12 and 13 November 2018. Inspectors reviewed seven people's care records, medicines and other records, and spoke with people, relatives, staff and managers.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines management, suitable training, kind care, activities and improved management oversight.
The report says the home had previously been rated Requires Improvement overall, with Well-led rated Inadequate. Staffing, medicines, care planning, complaints handling and management oversight had improved, but inspectors still found that topical creams were not secured and some records needed more detail.
Improved staffing
Staffing levels had increased and the use of agency staff had reduced. Inspectors saw staff respond promptly to call bells, including when the home was short-staffed on one inspection day.
“There were enough staff to meet people's needs in a timely manner.” from the report
Kind and respectful care
Staff communicated politely, respected privacy and dignity, and adapted their approach to people's communication and sensory needs.
“Throughout our inspection visits, we observed that staff spoke with people in a friendly, jovial but also respectful way.” from the report
Better management oversight
A new manager and additional management support had improved audits, monitoring and action planning. Inspectors saw clear leadership and better staff morale.
“Checks completed on the quality of the service had improved and action was taken to remedy any shortfalls.” from the report
Activities and involvement
People took part in activities that matched their interests and wishes. People and relatives were also involved in decisions about how the home was run.
“People participated in a variety of activities according to their interests and wishes.” from the report
Topical creams not secured
needs fixingCreams for external use were not locked away. The home had not assessed the risk that someone might access them and suffer accidental harm.
“medicines prescribed for external application such as topical creams were not secured.” from the report
Some recording shortfalls
needs fixingAn injury was not clearly explained in the records, and an accident or incident had not initially been reported to the management team. Managers reviewed both matters after inspectors raised them.
“During the course of our inspection, we queried an injury to one person that was not clearly accounted for in their records.” from the report
End-of-life records varied
minorSome people's records did not contain much detail about their final wishes, preferences and advance decisions. The home planned more end-of-life training and further development.
“There was variable practice in the amount of detail that people's care records contained about their last wishes, preferences and advance decisions” from the report
- 01How are topical creams stored now, and how do you assess the risk for each person who may be able to access them?
- 02How do you check that staffing remains sufficient at mornings, mealtimes, weekends and during staff sickness?
- 03How are accidents, injuries and incidents recorded, reviewed and reported to managers?
- 04How do you record each person's end-of-life wishes, preferences and advance decisions?
- 05What quality checks are currently used to make sure the improvements found in 2018 have been maintained?
This was an unannounced comprehensive inspection covering all five key questions, and the report compares the findings with the previous inspection in January 2018. This explanation was written from the published report of 19 December 2018 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 Cavell Court
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- September 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2017Requires improvementstayed Requires improvementSafe: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2015
Registered with the Care Quality Commission on 8 July 2015.
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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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.