Cavendish Court

Updated 15 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team included 2 inspectors, a Specialist Advisor, a nurse and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Cavendish Court is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Cavendish Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 17 people who used the service and 8 family members about their experience of the care provided. We spoke with 21 members of staff including the registered manager, regional director, 4 members of the provider’s quality team, 2 nurses, 7 care staff, a health care practitioner, an administrative assistant, an activities coordinator, the head housekeeper, a housekeeper and chef.

We reviewed a range of records. This included 11 people’s care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies, procedures and audits, were reviewed. We spoke with a visiting health and social care professional and corresponded with the visiting doctor to gather their views about partnership working and the quality of care provided.

Updated 15 August 2023

About the service

Cavendish Court is a residential care home providing personal and nursing care to 35 people aged 65 and over at the time of the inspection. Some of the people accommodated were living with dementia. The service can support up to 43 people. The accommodation is provided over three floors, each of which has separate adapted facilities.

People’s experience of using this service and what we found

The service was not well-managed at the time of this inspection. We found improvements were needed to ensure people always received safe, effective, and responsive care that met their needs.

Risks to people’s health and welfare were not always identified or managed effectively. We found that one person was at risk because staff were unaware of safeguards that had been put in place to safeguard them from the risk of falls. Another person had remained at risk and had suffered falls because advice provided by their doctor had not been acted upon.

Information to be supplied to the fire service in the event of a fire contained inaccuracies. The housekeeping trolley, which held hazardous substances, was left unattended in the presence of vulnerable people.

Systems to safeguard vulnerable people from abuse where not always followed and two care staff spoken with were unclear on the provider’s safeguarding procedures.

Staff were employed in sufficient numbers but oversight in their management resulted in 12 vulnerable people being left unsupervised for a period.

Staff needed further training on the Mental Capacity Act to ensure people received the right type of support to assist them in their decision-making and the provider was not meeting the conditions upon which a person’s Deprivation of Liberty had been granted.

People and their representatives were not sufficiently involved in the care planning process and care plans were not always person-centred so did not confirm the relevant person’s needs or personal preferences.

The provider’s quality assurances systems had either not identified the improvements needed at this care home or sufficient action had not been taken in a prompt manner to address the improvements which were needed.

Although there were areas for improvement, all the people who lived at the home had something positive to say about the staff and the standard of care provided.

Nursing and care staff were seen to be kind and caring in their approach. They engaged with people sensitively before providing support and care and they listened and acted on what was said to them.

Medicines were managed safely, and a visiting doctor told us that managers and staff worked collaboratively with them to ensure people’s health care needs were met.

People’s nutritional needs were being met and comments about the standard of food were generally positive.

The registered manager worked diligently throughout the course of our inspection and instigated improvements. These included a series of person-centred reviews and monthly residents and relatives’ meetings going forward. This will help to ensure that people are supported to express their views and be involved in decisions about their care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 29 July 2021). At this inspection we found the provider was in breach of regulations. The service is now rated requires improvement.

Why we inspected

We received concerns in relation to the safe and effective care and management. As a result, we commenced a focused inspection to review the key questions of safe, effective, and well-led only. It became clear during the inspection that improvements were also required in the remaining key questions caring and responsive. We therefore broadened the inspection to include all key questions and in doing so completed a comprehensive inspection of the service.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cavendish Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, consent, person centred care and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

We have made recommendations about safe staffing levels and accessible information.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.