We carried out a review of the data available to us about Cavell Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Cavell Lodge, you can give feedback on this service.
We found the following examples of good practice.
Visits to the service were managed safely. All visitors had their temperature checked, completed a questionnaire, had a lateral flow test and were given appropriate personal protective equipment [PPE] to wear. Visiting professionals were asked to show evidence of vaccination and this was recorded.
The service was clean and fresh. There were cleaning schedules in place including high touch point cleaning, fogging and deep cleaning.
Staff had received recent training about infection prevention and control, COVID-19 and the correct use of PPE. There were PPE stations throughout the service and staff were observed following good practice such as regular hand washing and wearing masks, gloves and aprons.
People were admitted to the service safely. People’s COVID-19 status was checked before admission and staff understood how to keep people safe using isolation, cohorting and zoning.
Staff and people were part of a regular COVID-19 testing programme. All staff at the service were fully vaccinated against COVID-19.
The service had an up to date COVID-19 policy and contingency plan in place to support people and staff in the event of an outbreak and to manage risks during the pandemic.
From the outset of the pandemic the service had been proactive in their approach to keep people safe.
The registered manager implemented protocols before the government issued advice on restricting visiting to keep people safe. Since visiting has restarted the registered manager had optimised use of outdoor space for this to happen. They have implemented health checks and screening forms for all visitors including professional visitors to complete to mitigate the risks of entry to the service.
The registered manager and staff continued to focus on people's well-being and had tried to keep people's spirits raised throughout. They produced a video of people and staff enjoying themselves set to music for relatives. The registered manager kept relatives informed of all activities and any changes at the service through regular newsletters.
Where people had been at the end of their life, the registered manager took steps to mitigate the risks to others, so their relatives could come into the service to say goodbye to them.
Staff were organised into teams so that they consistently worked together to minimise the risks of cross infection from large staff groups. Initially staff worked and slept onsite in teams. Although this is no longer necessary the service still had this model as part of their contingency planning if needed.
Staff had been provided with the appropriate training and PPE to keep them and people safe. Infection control measures and cleaning regimes were increased and additional hand sanitising stations had been added throughout the service.
Cavell Lodge is a residential care home providing personal care without nursing for up to 34 people some of whom maybe living with dementia. At the time of inspection 31 people were using the service. The service is set over three floors in a residential area.
People’s experience of using this service and what we found
One person said, “The staff are very helpful and kind.”
Care and treatment were planned and delivered in a way that was intended to ensure people's safety and welfare. People were cared for safely by staff who had been recruited and employed after appropriate checks had been completed. There were systems in place to minimise the risk of infection and to learn lessons from accidents and incidents. Medicine was managed safely.
People were cared for and supported by staff who had received the appropriate training.
The registered manager had a good understanding of their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.
People were supported to eat and drink enough to ensure they maintained a balanced diet and referrals to other health professionals were made when required. People had access to other health care professionals such as GPs and district nurses.
Staff cared for people in an empathetic and kind manner. Staff had a good understanding of people’s preferences of care. Staff worked to promote people’s independence through encouraging and supporting people to make informed choices.
People and their relatives were involved in the planning and review of their care. Care plans were reviewed on a regular basis. People were supported to follow their interests and participate in social activities. The registered manager responded to complaints received in a timely manner. People were supported at the end of their life.
The registered manager had systems in place to monitor and provide good care and these were reviewed on a regular basis.
Rating at last inspection: The last rating for this service was Good. (last report published 15 August 2017).
Why we inspected: This was a planned inspection based on the previous rating.
Follow up: We will continue to monitor information and intelligence we receive about the service to ensure good quality is provided to people.
At the last inspection, the service was rated requires improvement in Safe and Well Led domains. At this inspection, we found the service had made improvements and the service was now rated Good in all questions.
The service was safe. The service’s recruitment process ensured that appropriate checks were carried out before staff commenced employment. There were sufficient staff on duty to meet the needs of people and keep them safe from potential harm or abuse. People’s health and wellbeing needs were assessed and reviewed to minimise risk to health. The service had a good management and monitoring structure in place for medication.
The service was effective. People were cared for and supported by staff who had received training to support people to meet their needs. The manager had a good understanding of their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were supported to eat and drink enough as to ensure they maintained a balanced diet and referrals to health and social care services was made when required.
The service was caring. Staff cared for people in an empathetic and kind manner. Staff had a good understanding of people’s preferences of care. Staff always worked hard to promote people’s independence through encouraging and supporting people to make informed decisions.
The service was responsive. People and their relatives were involved in the planning and review of their care. Care plans were reviewed on a regular basis and also when there was a change in care needs. People were supported to follow their interests and participate in social activities. The service responded to complaints received in a timely manner.
The service was well-led. The new manager had initiated the process to register with the Commission having applied for the necessary checks to commence their registration. Staff, people and their relatives spoke very highly of the new manager and how they informed to be very supportive and worked hard to provide an exceptional service since coming into the service. The service had systems in place to monitor and provide good care and these were reviewed on a regular basis. The new manager informed that current systems and processes where being updated and improved. Manager’s registration is yet to be received by the commission however they have started the process.
Cavell Lodge provides care and accommodation for up to 36 older people who may be living with dementia. There were 35 people living in the service on the day of our inspection.
This inspection took place on 19 January 2015.
At our last inspection on 25 June 2014 we had concerns about consent to care and treatment. At this inspection we found that people’s consent had been gained at all stages of their care.
The registered manager had been in post since the service was first registered and is also the nominated individual for the provider organisation. The nominated individual is a person who is employed by the organisation and is responsible for supervising the management of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People said they felt safe. Staff had a good understanding of how to protect people from the risk of abuse; they had been trained and had access to guidance and information to support them with the process. However, we found that the manager had not taken the appropriate action when an allegation of harm had been brought to their attention.
There were systems in place to monitor the quality of the service but they were not always effective. The manager had not sought the views of all of the relevant people and they had not analysed the information that they received from people who used the service and their relatives.
The manager had a good knowledge of the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS.) DoLS are a code of practice to supplement the main Mental Capacity Act 2005. These safeguards protect the rights of adults by ensuring that if there are restrictions on their freedom and liberty these are assessed by appropriately trained professionals.
Risks to people’s health and safety had been assessed and the service had made plans for how they were to be managed. This ensured that people were cared for safely.
The service had good recruitment practices and employed enough staff to meet people’s assessed needs. Staff demonstrated the knowledge and skills needed to carry out their work. They received an induction and then had on-going training and support.
We observed staff caring for people in a kind, caring and respectful way. They ensured that people’s privacy and dignity was maintained at all times. People were able to receive visitors at a time of their choosing. Relatives were made to feel welcome at any time of the day. People participated in a range of activities that met their needs. Complaints had been dealt with informally.
People received their medication as prescribed. There were safe systems in place for receiving, administering and disposing of medicines. People were supported to have sufficient amounts of food and drink to meet their needs.
People’s care needs had been assessed and catered for. The care plans provided staff with sufficient information about how to meet people’s individual needs and preferences and how to care for them safely. The service monitored people’s healthcare needs and sought advice and guidance from healthcare professionals when needed.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to Regulation 11 safeguarding people from abuse. This corresponds to regulation 13 of the Health and Social Care Act 2008 (Regulated Activities)
You can see what action we told the provider to take at the back of the full version of the report.
This is a summary of what we found
Is the service safe?
People told us they felt safe. Safeguarding procedures were robust and staff understood how to safeguard people they cared for. Systems were in place to make sure that managers and staff learnt from events such as accidents, incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.
The home had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We found that before people received any care or treatment they were not asked for their consent in writing. Where people did not have the capacity to consent, the provider did not act in accordance with legal requirements.
People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.
Staff knew about risk management plans and showed us examples where they had followed them. People were not put at unnecessary risk but also had access to choice and remained in control of decisions about their care and lives.
The provider had safe and effective staffing rotas in place. Where staff had been subject to disciplinary action, appropriate procedures had been followed. Policies and procedures were in place to make sure that unsafe working practice was identified and people were protected.
Is the service effective?
People's health and care needs were assessed with them. Specialist dietary, personal care and psychological needs had been identified in care plans where required. People in the main told us that they had been involved in writing them and that they reflected their current needs.
People were protected from the risks of inadequate nutrition and dehydration and people were very complimentary about the food and beverages served.
Is the service caring?
People were treated with respect and dignity by the staff. People were supported by kind and attentive staff. We saw that support workers showed patience and gave encouragement when supporting people.
One person we spoke with told us, 'The staff are very good here and do as much as they can for us. They are kind and hardworking and do their best to meet my needs."
People who used the service and their relatives completed a yearly satisfaction survey. People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.
Is the service responsive?
People knew how to raise a concern or complain if they were unhappy.
The service worked well with other agencies and services to make sure people received care in a 'joined up' way.
People completed a range of activities in and outside the service regularly. The home had its own adapted mini-bus, which helped to keep people involved with their local community.
Is the service well-led?
The service had a quality assurance system. Records seen by us showed that identified shortfalls were addressed promptly. We were therefore assured that the provider had taken steps to continually improve the service.
Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.
One service user and their daughter said they were very happy with the service. They said that the care staff were 'great' and that the rooms were 'lovely'. The daughter said that when their relative had suffered a fall and had fractured their wrist that the staff had sought the correct help straight away and had contacted them to tell them of the incident and kept them informed about how their relative was. We spoke with two other service users who said that they did not want for anything. They said that all staff were very good. When asked what their overall impressions were about Cavell Lodge they said they 'loved it'. We also spoke with another service user and their daughter. The daughter said they lived far away but were very happy that the home maintained good contact with them when they could not visit. They said that their relative had dementia and could be difficult to manage, but that staff were very good with them and that they received good care.
We found that people were well cared for at Cavell Lodge and that their needs were properly assessed and met. We found that the premises were in a very good state of repair and were safe to provide care services. Staff were also properly trained and supported. However, complaints information was not accurate and the provider could not demonstrate learning from complaints.
Changes to assessment and care plan reviews had been made by the provider to ensure people received care and support which met their needs.
Additional systems were in place for the management of infection control.
We saw that staff had been supported to undertake further training to develop their skills and the provider had a system in place for supervising and appraising the work of the registered manager.