Archived: Cavendish Road

As part of this inspection we spoke with four people who used the service, four staff, and the registered manager. We looked at three people's care records. Other records we reviewed included medication records, rotas, meeting minutes, staff recruitment and training records and also quality and monitoring records.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

When we arrived at the service a person using the service had the delegated responsibility of answering the door. They asked to see our identification and asked us to sign in the visitor's book. This demonstrated that the service had taken steps to ensure that the people who used the service were potentially safer and protected from others who did not have the right to access the home.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had been submitted, the service had policies and procedures in place. Staff had been trained in understanding the Mental Capacity Act 2005 (MCA). This enabled them to understand when an application should be made, and how to submit one to the local safeguarding authority.

People told us they felt safe. One person said 'I feel safe here, I have no worries'.

We saw the staff rota which confirmed that the service ensured there were sufficient numbers of staff to meet people's needs. People, who used the service and care staff and told us that there was sufficient numbers of staff to meet people's needs.

We found that the service was operating safe and effective recruitment procedures. Appropriate checks had been carried out to ensure that applicants were of good character. Criminal records checks had been conducted and clearance obtained before staff began working at the service.

We noted that there was photographic identification for people to assist staff with safe medicine administration. Written information was available for staff to guide them on what medicines had been prescribed. However, there was no supporting information such as a personal profile which would describe for staff the reasons for medicines prescribed, contra-indicators and allergies. This meant that staff did not have the written guidance available to safely administer medicines and monitor people's health, safety and welfare.

We found numerical discrepancies whilst auditing the stocks of people's medication. Whilst there was a system in place to account for medicines with regular stock checks we found this to be inaccurate and ineffective. This meant that we could not be assured that people had received their medicines as prescribed.

Is the service effective?

People were treated with respect and dignity by the staff. Staff interactions with people were seen to be kind, supportive and courteous.

People commented, "There is not any staff here that I do not like,"; 'They are all (care staff) alright.'; And; 'It's like home from home.'

Not everyone using the service had a support plan in place. Care records were found to be incomplete. There was a lack of up to date, robust risk assessments in place. Staff we spoke with told us they did not have all the written information they needed and relied on information communicated to them via staff meetings including daily handover meetings. This had the potential to put people at risk of staff not responding to the health, welfare and safety needs of people using the service.

Is the service caring?

People we spoke with told us they were content living at Cavendish Road. One person said, 'It is good here. I feel safe.' Another person told us, 'I have less to worry about here, the staff are all very good.'

Is it responsive?

Observation of a staff handover meeting evidenced staff responding to the health and welfare needs of people, which enabled them to have access to a health professional when needed. Care records also showed us that staff sought support and specialist guidance from health and social care professionals, including a person's designated mental health, care coordinator, clinical psychiatrist, doctor and dentist.

People, using the service, care staff and visitors all told us that they considered staff to be available when they needed them. People also told us that staff always responded to their requests promptly.

People were involved in participating in a range of activities both within the service and also with regular outings within the local community. One person using the service told us they had been supported in the planning of their holidays. We saw that there were many different activities for people who used the service to take part in if they wished to do so.

People told us if they were unhappy about any aspect of the service they had the confidence to approach staff or the manager and that their concerns would be addressed.

The manager held regular meetings with the people using the service to ascertain their views about how the service was managed and to seek their suggestions when organising a plan of activities.

Is the service well led?

Staff we spoke with were positive about the leadership of the service and said that they felt well supported. We saw that staff had been supported with regular one to one supervision meetings where their training and development needs had been discussed and planned.

We saw that the provider operated using a safe and effective staff recruitment system that ensured the protection of the people using the service.

We saw that health and safety checks of the environment had been regularly conducted and records maintained. Although management medication audits had been conducted, our analysis of the stock of medication compared to the records of administration, identified discrepancies. The manager's audit system had failed to identify this.

Relatives told us how happy they were with the care provided to their family members. They told us that the staff knew their relative well.

We observed staff interacting with people in a friendly, respectful and professional manner. They were attentive to people's needs. We saw that staff sought people's agreement before providing any support or assistance.

Staff understood the principle of consent and we saw evidence of this in care plans and observation of staff interactions with people who used the service.

Activities provided by the service were assessed according to the needs of the individual.

On the day of our inspection, the service was clean and tidy. The manager had a budget to implement an ongoing programme of redecoration and refurbishment of the environment.