Cadbury Hall Care Home

Cadbury Hall Care Home is a care home providing accommodation and personal care for up to 34 people. At the time of the inspection, 7 people were living at the home.

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

The provider had failed to identify or act to mitigate the risks to people. We identified through our inspection that the home did not have safe staffing levels on two occasions in January 2023. On these occasions one waking staff was left working alone in the building. This had put the staff member and people at risk. On some occasions one waking night staff worked with a staff member sleeping in. No risk assessment was in place or guidelines as to when the sleep in staff member would be called upon.

Safety monitoring and management checks of the building were taking place. However, we found inconsistencies and improvements were required. Staff had attended a fire safety training session during their induction. However, some staff had not attended a fire drill or there were gaps in them attending one from their initial induction. Some staff did not know what to do in the event of the fire alarm sounding.

Governance systems to monitor the home were not effective. They had not identified the improvements that were required and shortfalls which we identified. The home had had several managers in post since it opened in April 2022 which they had been unable to retain. This had an impact on morale and the staff. The oversight of the provider needed improvement to ensure systems were fully embedded by a stable, consistent staff team and manager. A new manager was recruited in December 2022. They planned to continue to build on staff morale and to drive improvements.

All staff understood their responsibility to keep people safe from harm. Risks to people had been assessed with actions in place to help keep people safe. Checks were carried out on staff before they started work to assess their suitability. Medicines were well managed, and people received their medicines as prescribed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the home supported this practice.

People’s needs were assessed and they were supported to maintain a healthy and balanced diet. People who lived at the home were treated with respect and equality. Care was person centred and staff understood the importance of promoting choice, consent and independence. People’s dignity and privacy were maintained.

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

Rating at last inspection

This service was registered with us on 22 April 2022 and this is the first inspection.

Why we inspected

This was a planned inspection to check whether the provider was meeting legal requirements and regulations, and to provide a rating for the service as directed by the Care Act 2014.

Prior to this inspection we were made aware of some concerns raised about the home. We used this information as intelligence and to help us plan this inspection.

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 and well-led sections of this report. You can see what action we have asked the provider to take at the end of this report. The overall rating for the service is requires improvement. This is based on the findings at this inspection.

Enforcement

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We have identified breaches in relation to ensuring safe levels of staffing, managing risks, and around good governance. This meant that improvements were required to ensure quality monitoring and management and that provider oversight was more effective.

Follow up

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 alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.