CQC report explained · a nursing home
What the CQC found at Cavendish Park
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were supported by staff who understood risks to their health and how to keep them safe. Infection prevention arrangements were also found to be suitable, although some medicine fridge temperatures had not been recorded consistently.
- Effective?
- Good
- Staff training and induction were monitored, and staff said they felt confident supporting people. People's dietary, healthcare and consent needs were assessed and supported.
- Caring?
- Good
- People engaged positively with staff and were treated with dignity and respect. They were involved in day-to-day decisions and staff supported their independence.
- Responsive?
- Good
- Care plans reflected people's preferences and were reviewed and updated. People were supported to keep in touch with relatives, follow interests and plan end-of-life care where appropriate.
- Well-led?
- Requires improvement
- Management had changed several times and nursing staff had also turned over. The provider had acted on incidents and was making improvements, but inspectors could not yet be assured that the systems could be sustained.
What inspectors found, April 2021
Cavendish Park was rated Good overall, but inspectors found that management and quality systems required improvement.
This was the first inspection of the newly registered home. Inspectors visited without notice on 18 January 2021. They spoke with staff, observed care, and checked care plans, medicine records, recruitment files and management records.
Inspectors rated the home Good for safety, effectiveness, caring and responsiveness. People were supported by staff who understood their needs, risks and communication methods. Care was reviewed, people were treated with dignity, and families were involved where appropriate.
The home was rated Requires Improvement for being well-led. There had been several changes in managers and clinical leads, as well as turnover in nursing staff. Inspectors also found some medicine fridge temperatures had not been recorded consistently and said they could not yet be assured that systems could be sustained.
The overall rating was Good. This was the home's first inspection, so there was no previous rating to compare with. CQC said it would continue monitoring information and could inspect sooner if concerns arose.
Staff understood people's risks
Staff knew how to support people safely. Risk assessments were completed and updated, and information was shared through daily handovers.
“Staff understood the risks to people's health and how to support people to remain safe.” from the report
Kind and respectful care
People responded warmly to staff. Staff understood the importance of dignity, independence, equality and personal choice.
“People engaged with staff in a positive manner.” from the report
Personalised care
People's preferences and changing needs were recorded in care plans. Staff supported individual interests, communication needs and relationships.
“Care plans we reviewed demonstrated that people's care was reviewed and updated regularly.” from the report
Staff training and support
Staff described the induction as comprehensive and said training helped them support people appropriately. Training was checked to keep it up to date.
“Staff told us they were supported during their induction through a mixture of training and shadowing experienced staff.” from the report
Management was not yet stable
needs fixingThere had been three people carrying out the manager role and two clinical leads since registration. The home did not have a permanent manager in post during the inspection.
“Since the home was registered in August 2019, there had been a number of changes in management.” from the report
Nursing arrangements were not tested
needs fixingThe home was providing residential care while it worked towards having a stable nursing team. Inspectors did not examine systems for nursing care because no nursing care was being provided at the time.
“As no nursing care was being provided at the time of the inspection, systems in place for that activity were not looked at.” from the report
Medicine fridge checks were inconsistent
needs fixingSome fridge temperatures were not recorded consistently. The provider took immediate steps to improve auditing, and inspectors said no harm had occurred.
“However, we noted that there were some occasions when fridge temperatures were not consistently recorded.” from the report
Preventable incidents had occurred
seriousThe provider investigated incidents and made changes, but inspectors noted that some incidents could have been prevented. They were not satisfied that improved systems had yet been shown to last.
“A number of incidents had occurred at the home that whilst not causing long term harm to people could have been prevented.” from the report
- 01Who is now the registered manager, and how long have the manager and clinical lead been in post?
- 02What is the current nursing staffing position, and when will nursing care be provided again?
- 03What changes were made after the incidents mentioned in the report, and how do you check that those changes are still working?
- 04How are medicine fridge temperatures recorded and audited now?
- 05How do you keep families informed about management, staffing and service changes?
This was the first inspection and covered all five CQC questions, but systems for nursing care were not examined because no nursing care was being provided at the time. This explanation was written from the published report of 22 April 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 Park
Each visit the CQC has published, newest first, back to the day the home was registered.
- April 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019
Registered with the Care Quality Commission on 12 August 2019.
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
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What to check when you visit
At least 100 live-in carers within about an hour of Worcestershire
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. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.