CQC report explained · a nursing home
What the CQC found at Cavendish Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that falls risks were not always managed, safeguarding procedures were not always followed, fire information was inaccurate and a hazardous substances trolley was left unattended. Staffing numbers were sufficient, but staff were not always deployed safely.
- Effective?
- Requires improvement
- The home was not always following the Mental Capacity Act or meeting conditions attached to a person's Deprivation of Liberty authorisation. Staff needed further training, and advice about assessing one person's need for one-to-one care was not acted on.
- Caring?
- Requires improvement
- People and their representatives were not sufficiently involved in care planning. Care plans did not always record personal preferences, although staff were observed being kind, sensitive and respectful.
- Responsive?
- Requires improvement
- Care plans did not always reflect people's needs, including pain, medicines and skin care. Communication arrangements were not always used, and written menus were initially unavailable.
- Well-led?
- Inadequate
- The provider's quality systems had not identified or dealt with problems quickly enough. Records were written from memory hours after care was given, and earlier improvements had not been sustained.
What inspectors found, August 2023
Rated Requires Improvement, with an Inadequate well-led rating and serious gaps in risk management, records and care planning.
Inspectors visited without warning on 28 April, 5 May, 11 May and 26 May 2023. They spoke with 17 people, 8 family members and 21 staff. They reviewed care records, medicines records, staff files and management records.
They found risks were not always identified or managed properly. These included falls, fire information, safeguarding, an unattended trolley containing hazardous substances and poor staffing deployment. Care plans and records were not always accurate, complete or based on people's preferences.
The home was rated Requires Improvement overall. Safe, Effective, Caring and Responsive were all rated Requires Improvement. Well-led was rated Inadequate, meaning there were widespread and significant shortfalls in leadership and oversight.
The previous rating was Good, published in July 2021. The report says improvements made after the 2019 inspection had not been sustained. The manager started person-centred reviews and regular residents' and relatives' meetings during this inspection, but CQC said further action was needed.
Kind and respectful staff
People and families spoke positively about the staff. Inspectors saw staff listen to people, act on what they said and knock before entering rooms.
“Nursing and care staff were seen to be kind and caring in their approach.” from the report
Medicines management
Inspectors found medicines were received, stored, given, recorded and disposed of safely. There were some gaps in topical medicine records at the start, which improved during the inspection.
“Medicines were received, stored, administered, recorded, and disposed of safely.” from the report
Food and mealtimes
People's nutritional needs were being met, and staff knew about dietary needs and preferences. People generally spoke positively about the food.
“The nutritional needs of people were being met. Staff were aware of people's dietary needs and preferences.” from the report
Working with health professionals
A visiting doctor said managers and staff worked together with them to meet people's healthcare needs.
“A visiting doctor told us that managers and staff worked collaboratively with them to ensure people's health care needs were met.” from the report
Falls and other safety risks
seriousRisk assessments and care plans did not always reflect the safeguards people needed. One person remained at risk after medical advice about one-to-one care was not acted on and they had further falls.
“Risks to people's health and welfare were not always identified or managed effectively.” from the report
Safeguarding procedures
seriousAn assault causing injury was not reported to the local safeguarding authority or CQC as required. Some staff were also unclear about reporting abuse and whistleblowing protections.
“The provider's 'Adult Safeguarding' policies and procedures were not always put into practice.” from the report
Consent and legal safeguards
seriousThe home was not always following the Mental Capacity Act. Four of five conditions attached to one person's Deprivation of Liberty authorisation were not being met.
“The provider was not always working within the principles of the MCA.” from the report
Care plans and records
seriousCare plans missed important information about people's needs and preferences. Staff were seen writing care records from memory several hours after care had been given.
“Such records cannot be relied upon or considered to be an accurate record of care provided.” from the report
Staff deployment
seriousAlthough there were enough staff overall, 12 vulnerable people were left unsupervised when staff were moved to training. Some nurse call responses also took up to 23 minutes.
“When this staff member assisted one of the people to use the toilet it meant 12 vulnerable people were left unsupervised.” from the report
Involvement and personal choices
needs fixingPeople and families were not sufficiently involved in care planning. Preferences about personal care and clothing were not always recorded or respected.
“People did not always receive the right level of support and care because they and their representatives had not been sufficiently involved in planning and reviewing their care.” from the report
- 01What evidence can you show that falls risks and doctors' advice are now recorded, reviewed and acted on?
- 02How do you make sure staff are deployed safely on each floor when someone attends training or takes a break?
- 03What has changed to ensure safeguarding incidents are reported correctly and staff understand the reporting process?
- 04How are Mental Capacity Act assessments and Deprivation of Liberty conditions now checked and kept up to date?
- 05How are residents and relatives involved in care plan reviews, and how do you record and respect personal preferences?
This began as a focused inspection of Safe, Effective and Well-led, but became a comprehensive inspection covering all five key questions; the previous rating was Good in July 2021. This explanation was written from the published report of 15 August 2023 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, July 2021
Rated Good overall; inspectors found kind, safe care but leadership and systems still needed improvement.
This was an unannounced inspection on 22 and 24 June 2021. Inspectors spoke with people living in the home, relatives, staff and health professionals. They also observed care and checked care, medicine, recruitment and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found improvements in wound care, risk management, medicines, staff training, personalised care and infection control. People were treated with kindness and supported to make choices.
Well-led was rated Requires Improvement. Staff reported pressure on one floor, and inspectors found that some safety checks and care documentation were not fully consistent. The report says the home was no longer breaching regulations, but improvements still needed to become routine practice.
Kind and respectful care
Inspectors saw warm interactions and found that staff knew people well. Relatives said people were treated kindly and supported with dignity.
“We observed warm interactions and genuine affection between staff and people living at Cavendish Court throughout the inspection.” from the report
Safe medicines and risk management
Risks to people's health were assessed and reviewed. Medicines were stored securely and given by suitably trained staff.
“Medicines were managed safely. Records of administration were well maintained, in line with best practice.” from the report
Personalised support
Care plans reflected people's likes, dislikes and communication needs. People were offered choices about meals, activities and daily care.
“Care plans were person centred and reflected people's personal preferences.” from the report
Clean home and infection controls
The home was visibly clean and tidy. Inspectors were assured that measures were in place to prevent and manage infection outbreaks.
“The home was visibly clean and tidy; cleaning schedules were maintained.” from the report
Waiting for help on one floor
needs fixingSome people and staff reported pressure on one floor, including waits for care after using the call bell. The home said it would review staff deployment and replace the call bell system.
“Some people fed back they had to wait for their care needs to be met when they called for assistance.” from the report
Incomplete care information
needs fixingSome records did not fully describe a person's history or an assessed care need. In one case, the records did not clearly say who was responsible for part of the care.
“Documentation to capture information about people's personal history and in one case, a person's assessed need, wasn't always fully completed.” from the report
- 01What changes have been made to staffing on the floor where people reported waiting for help?
- 02Has the existing call bell system been replaced, and can you show how waiting times are now monitored?
- 03How do managers check that areas posing a physical safety risk are secured and kept clear?
- 04How do you make sure each person's care plan fully records their history, assessed needs and who is responsible for each part of their care?
- 05What improvements have been made since the Requires Improvement rating for well-led?
This was an unannounced inspection covering all five CQC key questions, including infection prevention and control; it followed concerns about pressure wounds and infection control. This explanation was written from the published report of 29 July 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.
Every inspection of Cavendish Court
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2021Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 10 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Cheshire East
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 £980 to £1,260 a week. 88 can care for a couple. 10 years' experience on average.
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
“He developed a close affinity with Terence, spending time talking with him before he retired to bed and looking after his needs during the night.”
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.