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CQC report explained · a nursing home

What the CQC found at Cavendish Lodge

Requires improvementpublished 12 January 2023, 3 years ago

Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Requires improvement
Inspectors found weaknesses in medicines records and stock checks, and some risk plans lacked detail. People were otherwise supported by staff who understood safeguarding, and premises safety checks were in place.
Effective?
Good
This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
Caring?
Good
This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
Responsive?
Good
People's needs, preferences and recovery goals were recorded and supported. People were encouraged to go out, maintain relationships and take part in activities.
Well-led?
Requires improvement
The manager and provider had quality checks, but these did not reliably identify or prevent medicines recording failures. High use of agency staff affected how consistently procedures were followed.
The latest report, explained

What inspectors found, January 2023

Rated Requires Improvement; inspectors found kind, person-centred support, but medicines management and service oversight were not reliable.

This was an unannounced focused inspection on 6 December 2022. Two inspectors spoke with people and staff, checked care plans and medicines records, and reviewed records about recruitment, maintenance, incidents and quality checks.

People said they felt safe and received support that helped them stay well and independent. The home supported people to go out, keep relationships, follow interests and work towards recovery goals. Responsive care was rated Good.

Inspectors found problems with medicines records and checks. One person had missed medicine on two occasions. Staffing relied heavily on agency workers, which affected consistency. Safe and Well-led were rated Requires Improvement. The overall rating stayed Requires Improvement, as it had been at the previous inspection and for the last three inspections.

What inspectors praised
  • Support for independence

    People described care that improved their wellbeing and helped them work towards recovery goals. They were supported to make choices and live with few restrictions.

    “People told us they received care that met their needs and spoke of the positive impact living at Cavendish Lodge had on their well-being.” from the report
  • Responsive care

    Care plans reflected people's needs and preferences. People could go out, maintain family and friendship links, and pursue hobbies and activities.

    “People were supported to engage in activities and hobbies of interest to them and maintain their links with families and friends.” from the report
  • Safeguarding

    People said they felt safe. Staff understood signs of possible abuse and knew how to report concerns.

    “People were kept safe from avoidable harm because staff understood how to protect them from abuse.” from the report
  • Accessible support

    Staff adapted information for people's communication needs and arranged advocacy where needed.

    “Where a need was identified, staff arranged for advocacy services to ensure people's voices were heard.” from the report
  • Open management

    People and staff said the manager listened and responded to requests. Staff said they could raise concerns and discuss training needs.

    “People and staff told us the registered manager was always available, took time to listen to them and was responsive to any requests.” from the report
What inspectors were concerned about
  • Medicines records

    serious

    The home could not always show that medicines were given as prescribed. Stock balances were incomplete and handwritten entries were not always checked properly.

    “We could not be assured people received their medicines as prescribed because the systems to support safe medicines practices were ineffective.” from the report
  • Missed medicine checks

    serious

    The required daily check of medicine administration records had not been completed on the weekend before the inspection. One person consequently missed medicine on two occasions.

    “This meant one person had not received their medicine on two separate occasions.” from the report
  • Reliance on agency staff

    needs fixing

    Only two permanent care staff were employed at the inspection. The high use of temporary agency staff affected consistency in following some procedures.

    “The provider had experienced difficulties recruiting and retaining staff and as a result, staffing numbers were maintained by using temporary staff supplied through an agency.” from the report
  • Risk plan detail

    needs fixing

    Some risk management plans did not give enough detail to ensure staff would respond consistently when a particular risk arose.

    “We found some risk management plans would benefit from more detailed information to ensure staff responded consistently if a particular risk presented itself.” from the report
  • Worn areas and bins

    minor

    Some parts of the home were worn and difficult to clean. The provider also needed to ensure all waste bins had foot-pedal lids.

    “However, some areas of the home were worn and therefore difficult to clean and the provider needed to ensure all waste bins had lids operated by a foot pedal.” from the report
Questions to ask them, based on this report
  1. 01What has changed to make sure medicine stock balances are recorded accurately at each medicines cycle?
  2. 02How do you now make sure daily medicine record checks are completed, including at weekends?
  3. 03What action has been taken after one person missed medicine on two occasions?
  4. 04How many permanent care staff are currently employed, and how are agency staff trained and checked?
  5. 05Have the risk management plans, worn areas and waste bins been updated since the inspection?

This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 12 January 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.

An earlier report, explained

What inspectors found, August 2019

Cavendish Lodge was rated Requires Improvement; care was safe, effective and kind, but personalised support and management needed further work.

Inspectors made an unannounced visit on 8 August 2019. They spoke with two people and five staff, and reviewed care records, medicines records and management documents.

The home was rated Good for Safe, Effective and Caring. People had enough staff to keep them safe, received their medicines as prescribed, had access to health professionals, and were treated with kindness, dignity and respect.

The home was rated Requires Improvement for Responsive and Well-led. Inspectors found that new approaches to supporting recovery, care planning and management had only recently started and were not yet consistent. There was also continued high use of agency staff because of vacancies.

The overall rating stayed at Requires Improvement. The home had improved since the previous inspection and was no longer in breach of regulations, but inspectors said further improvements needed to become established.

What inspectors praised
  • Safe medicines

    Medicines were stored, administered and recorded in line with the home's procedures. Staff were trained and assessed as competent.

    “People had their prescribed medicines available to them when they needed them.” from the report
  • Health support

    The home worked with community mental health and social care professionals to support people's physical and mental health.

    “People had access to other health and social care professionals, so their needs could be monitored and met.” from the report
  • Kind and respectful care

    People gave positive feedback about staff. Inspectors saw staff communicating with people in a kind and respectful way.

    “The interactions we saw between people and staff were limited. However, those we did see demonstrated staff engaged positively with people and were kind and respectful towards them.” from the report
  • Promoting independence

    Staff encouraged people to do as much as possible for themselves and supported people to make their own choices.

    “Staff understood the ethos of the service was to support people's independence and encourage them to do as much for themselves as possible.” from the report
What inspectors were concerned about
  • Recovery support was not consistent

    needs fixing

    The recovery-focused approach had produced some positive outcomes, but it was not yet reflected consistently in staff practice. More detail was also needed in care plans about emotional support during anxiety.

    “This positive approach needed to become embedded within staff's practice to ensure people's recovery continued to achieve positive outcomes.” from the report
  • Keyworker system was not fully effective

    needs fixing

    The keyworker arrangement could not become fully effective until more permanent staff were employed. This may affect the consistency of people's relationships and support.

    “The registered manager acknowledged the keyworker scheme would not become fully effective until they had more permanent staff in post.” from the report
  • Staff vacancies and supervision

    needs fixing

    There were only three permanent care staff, with continued high use of agency staff. Staff supervision meetings had not been happening as regularly as planned.

    “Although there were only three permanent care staff contracted to the home, the provider ensured bank and agency staff were clear about their responsibilities.” from the report
Questions to ask them, based on this report
  1. 01How many permanent care staff are now in post, and how often is agency staff used?
  2. 02How do you make sure care plans explain how to support each person when they become anxious?
  3. 03How is the recovery approach now reflected in everyday staff practice?
  4. 04How does the keyworker system work now, and who would be the permanent keyworker for my relative?
  5. 05How often do staff receive supervision and refresher training?

This was a planned, unannounced inspection covering all five CQC questions and the overall quality and safety of care and the premises. This explanation was written from the published report of 30 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.

The story over the years

Every inspection of Cavendish Lodge

4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.

  1. January 2023Requires improvementcurrent ratingstayed Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Cavendish Lodge →

  2. August 2019Requires improvementstayed Requires improvement
    Safe: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read what inspectors found at Cavendish Lodge →

  3. August 2018Requires improvementdown from Good
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  4. December 2015Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. June 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. August 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. May 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. December 2010

    Registered with the Care Quality Commission on 1 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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