CQC report explained · a residential care home
What the CQC found at Cavendish Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, people were protected from abuse, staffing levels were safe and medicines were administered safely. Infection-control arrangements were also found to be suitable.
- Effective?
- Good
- Staff had relevant training and supported people's health, nutrition and communication needs. People had access to healthcare professionals, and consent and best-interest decisions were managed in line with the law.
- Caring?
- Good
- Staff were described and observed as kind, patient and respectful. People were supported to make choices, keep their dignity and maintain their independence.
- Responsive?
- Good
- Care plans reflected people's individual needs, preferences and communication styles. People were supported with activities, relationships, complaints and end-of-life planning.
- Well-led?
- Good
- Managers had improved quality checks, listened to feedback and promoted personalised dementia care. However, some medicines records did not follow policy and care-plan changes had not always been easy to track.
What inspectors found, April 2022
Rated Good; inspectors found kind, safe and personalised dementia care, with some medicines and care-record checks needing attention.
This was an unannounced comprehensive inspection. Inspectors visited on 23 and 24 February 2022, and inspection activity continued until 25 February. They spoke with relatives, staff, managers and a healthcare professional. They observed care and reviewed care, medicines, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable training, personalised care and kind treatment. People were supported with food, healthcare, communication, activities and end-of-life wishes.
The home had previously been rated Requires Improvement in August 2019. Inspectors found that improvements had been made and that the home was no longer in breach of the regulations identified at that inspection. They did find some medicines records had not followed the home's policy, and care-plan changes were not always easy to track.
Kind and patient staff
Relatives and inspectors found staff caring, patient and respectful. Staff understood the distress that dementia can cause and supported people without judging them.
“Staff were kind and patient towards the people they looked after.” from the report
Personalised dementia care
Care was planned around people's choices, interests and histories. Staff used information about likes, dislikes and identity to guide support.
“People's care was planned around their individual needs, choices and preferences.” from the report
Safe staffing and risk management
The home maintained safe staffing numbers despite pandemic-related workforce challenges. Risks such as falls, pressure ulcers, malnutrition and distressed behaviour were assessed and managed.
“Managers had faced workforce challenges during the pandemic but had been able to maintain safe staffing numbers so people's needs were met.” from the report
Support with food and drink
The home provided different types of food and drink for people at risk of choking, weight loss or difficulty using cutlery. People's weights were monitored and concerns were referred for further assessment.
“Particular attention was paid to supporting people to have a positive dining experience which resulted in good outcomes for people.” from the report
Improved leadership
Inspectors found stronger quality checks and a clear commitment from managers to improve dementia care. The overall rating improved from Requires Improvement to Good.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Medicines records
needs fixingSome medicines records had not been completed in line with the home's policy. Managers had already identified this and said they had plans to address it.
“We found some people's medicine records had not been maintained according to the provider's policy.” from the report
Tracking care-plan changes
needs fixingInspectors found it difficult to see when some care-plan changes had been made and who had made them. Managers said after the inspection that they had adjusted the system.
“We found it difficult to always track when an adjustment had been made to a care plan and discussed this with managers during the inspection.” from the report
- 01What checks are now in place to make sure every medicines record follows the home's policy?
- 02How will you show when a care-plan change was made and who made it?
- 03How do you make sure staffing numbers and experience remain safe when there are absences?
- 04How are my relative's food, communication and dementia-care preferences recorded and reviewed?
- 05How will you involve me in planning my relative's end-of-life care and wishes?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control, and checking improvements made since the previous inspection. This explanation was written from the published report of 5 April 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, August 2019
Rated Requires Improvement; inspectors found risks around safeguarding, personalised care and management, although action had started.
This was an unannounced inspection after concerns about care practices and safeguarding had been raised. One inspector visited on 11, 12 and 15 July 2019. They spoke with people, a relative, staff and professionals, observed care and checked care, medicines, recruitment and management records.
The home was not always safe, effective, caring, responsive or well-led. Inspectors found inappropriate restrictive practices, an incident causing harm that had not been reported to the relevant agencies, medicines errors, incomplete recruitment checks and care plans that did not always give clear guidance.
A new manager had begun to stop restrictive practices, review care and medicines, improve staff training and introduce an action plan. However, these changes were new and inspectors could not yet tell whether they would last. The home had been rated Good at the previous inspection, published on 13 October 2017, but all five ratings had fallen to Requires Improvement.
Enough staff
Inspectors found arrangements to provide enough staff with the right skills and experience. Staff said there were enough people on duty, and staff were observed being available to support residents.
“The management staff had ensured there were enough staff in number, skill and experience to meet people's needs.” from the report
Health risk support
Risks such as falls, choking, pressure ulcers and weight loss were assessed, with equipment and healthcare referrals used where needed.
“People had been referred to healthcare professionals and provided with specialised equipment such as pressure reducing mattresses and walking aids.” from the report
Compassionate interactions
Inspectors observed staff offering patient and meaningful support when a person was anxious or distressed.
“We observed caring and compassionate interactions between staff and people which included one member of staff making time to sit with a person to help them through a period of anxiety.” from the report
Activities and relationships
People were supported to keep in touch with family and friends and to take part in group and one-to-one activities.
“Activity coordinators were employed to support people with group and one to one activities which they enjoyed taking part in.” from the report
Safeguarding and restraint
seriousSome restrictive practices were unnecessary or not proportionate, and some had caused harm. A harmful incident had not been reported to the relevant safeguarding agencies.
“Some restrictive practices were in place, which were not necessary or proportionate in managing risks to people.” from the report
Care plans did not guide care clearly
seriousCare plans did not always reflect changing needs, including significant weight loss and distressed behaviour. One person's care was imposed against their wishes and was not the least restrictive option.
“People were put at risk through a lack of clear care planning, which considered people's preferences, specific care needs, and which was amended when people's preferences and needs altered.” from the report
Medicines errors
needs fixingInspectors found a pain relief patch had been changed a day early and that an as-required medicine had sometimes been given routinely. The provider took action and no harm was reported.
“One medicine, prescribed for several people, on an 'as required' basis had been given to some people on a regular basis.” from the report
Weak quality checks
seriousThe provider's audits and monitoring had not identified safeguarding, care planning and practice concerns. Records were also not always easy to retrieve.
“A lack of effective provider quality monitoring processes had failed to identify shortfalls in the quality and safety of the service provided to people.” from the report
Staff induction records
minorThe manager could not find evidence that three staff had completed the expected induction. The provider said new staff would complete induction training in line with the Skills for Care standards.
“For three recruited staff, the new manager could not find any evidence of this.” from the report
- 01What changes have been made to stop unnecessary or disproportionate restraint, and how are you checking that staff follow each person's best-interest decisions?
- 02How are care plans now updated when someone loses weight, becomes distressed or has changing health needs?
- 03What checks are now completed before a new staff member starts work, and how is induction recorded?
- 04How are medicine errors and the use of as-required medicines reviewed and discussed with families and health professionals?
- 05What evidence can you show that the new quality monitoring system is identifying and fixing safeguarding, care planning and medicines concerns?
This inspection was prompted by safeguarding and poor-practice concerns and assessed all five key questions; it was not a routine comprehensive inspection. This explanation was written from the published report of 21 August 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 Cavendish Care Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- April 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
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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Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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