The Care Quality Commission
  • Care Home
  • Care home

Cavendish Lodge

Overall: Requires improvement read more about inspection ratings

41 Leam Terrace, Leamington Spa, Warwickshire, CV31 1BQ (01926) 427584

Provided and run by:
Rethink Mental Illness

All Inspections

6 December 2022

During an inspection looking at part of the service

About the service

Cavendish Lodge is registered to provide nursing and personal care for up to 8 people who have a diagnosed mental health condition. At the time of our inspection visit there were 8 people living at the home. Care is provided across two floors and a communal lounge and dining area is located on the ground floor.

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

People spoke positively about the support they received from the registered manager and staff to stay well and maintain their independence. However, the provider had experienced difficulties recruiting and retaining staff and staffing numbers were maintained by using temporary staff supplied through an agency. The high use of agency staff had impacted on consistency in following some of the provider’s processes, particularly in relation to safe medicines management.

Staff understood their safeguarding responsibilities and were able to describe the subtle signs that might indicate a person was worried or the subject of abuse. Changes in people’s risks were communicated to staff during handovers between shifts. Staff described an open culture where learning from accidents and incidents was shared within the staff team.

People told us they received care that met their needs and spoke of the positive impact living at Cavendish Lodge had on their well-being. People at Cavendish Lodge were working towards achievable goals in their recovery under the provider’s recovery programme.

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 service supported this practice.

The provider and registered manager took a proactive approach to promoting equality and diversity to ensure the service was inclusive of the needs of people and staff.

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

Rating at the last inspection

The last rating for this service was Requires Improvement (published 30 August 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. This focussed inspection only looked at the key questions of safe, responsive and well-led.

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.

For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating. The overall rating for the service has remained as Requires Improvement. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

8 August 2019

During a routine inspection

About the service

Cavendish Lodge is registered to provide nursing and personal care for up to eight people who have a diagnosed mental health condition. At the time of our inspection visit there were five people living at the home. Care is provided across two floors and a communal lounge and dining area is located on the ground floor.

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

The provider had begun to address the issues from the last inspection, but their own quality assurance process had identified further improvements were still required. Some improvements had only recently been introduced. They needed to be embedded into the culture of the home under the new management team to ensure people’s recovery continued to achieve positive outcomes.

There were enough care staff on duty to keep people safe from risks of harm. However, there continued to be a significant use of agency staff whilst recruitment to fill staff vacancies continued. Staff understood their responsibility to keep people safe from abuse or discrimination. Positive risk taking was considered alongside the provider’s duty of care. People received their medicines as prescribed.

People had access to other health and social care professionals, so their needs could be monitored and met. 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 service supported this practice. Staff respected people's rights to make their own decisions about their lives and care. Where people needed support to make some decisions, staff assisted them or referred them for independent advocacy support.

Staff had completed training and further training sessions were planned to ensure staff's skills and knowledge continued to be refreshed. Staff understood the ethos of the service was to support people’s independence and encourage them to do as much for themselves as possible. People who chose to, were able to come and go freely and their privacy was respected.

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

Rating at last inspection

The last rating for this service was requires improvement (published August 2018) and there was one breach of the regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations, however further improvements are still required.

Why we inspected

This was a planned inspection based on the rating at the last inspection.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

13 July 2018

During a routine inspection

We inspected this service on 13 July 2018. The inspection was unannounced.

Cavendish Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Cavendish Lodge is a mental health nursing home registered to provide personal care, nursing and accommodation for up to eight people. The service is delivered from a large detached house in a residential area and has access to local shops and amenities. Six people lived at the home on the day of our inspection visit.

There was a registered manager in post at 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.

At our last inspection in October 2015 the service was rated as Good. At this inspection we found improvements were required to ensure people received a level of care that was consistently safe and responsive to their individual needs and continued to enable them to meet their identified goals for recovery. The service is now rated as ‘Requires Improvement’.

The provider was heavily reliant on agency and their own bank staff to maintain safe staffing levels in the home. This meant people could not be assured of receiving continuity of care from a consistent staff team who knew them well and the goals they hoped to achieve. The provider’s systems were not supportive of staff when staffing issues occurred at night or at weekends.

Information in care plans and risk assessments was not always detailed enough to ensure staff had the information they required to deliver care that kept people safe at times of anxiety or crisis or to respond to their emotional needs.

Staff received training and support and understood their responsibilities to report any concerns about people’s health or wellbeing. However, some incidents that occurred in the home had not been recorded in line with the provider’s policy and procedures so they could maintain accurate oversight to identify any patterns or trends over the service as a whole.

Staff worked within the principles of the Mental Capacity Act 2005 and supported people to make their own informed decisions and choices.

People were encouraged to make healthy lifestyle choices and maintain a balanced diet. Staff monitored people’s health and referred them to other healthcare professionals for advice and support when a need was identified. Overall, people received their medicines as prescribed.

The environment was homely and the atmosphere was calm and relaxed. People were comfortable with staff and told us staff were approachable and they felt able to speak openly with them. Staff treated people with dignity and respect and encouraged their independence. People were involved in activities when they wanted to be and were able to follow any interests and hobbies they might have.

People and relatives were encouraged to express their views about the service and people felt comfortable sharing any concerns with staff or the management team.

People and staff were positive about the service provided. However, a lack of permanent staff meant it was a challenge for the provider to ensure people continued to receive high standards of care that met their visions and values for the service.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

13 October 2015

During a routine inspection

This inspection took place on Tuesday 13th October 2015 and was unannounced.

Cavendish Lodge is a mental health nursing home, registered to provide personal care, nursing and accommodation for up to eight people over two floors. At the time of our inspection, there were eight people living at the home.

A requirement of the service’s registration is that they have a registered manager.

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. A registered manager was in post.

People told us they felt safe at the home, and that they could raise concerns they had with staff at any time. Staff were trained in safeguarding people, and we saw that they understood what action they should take in order to protect people from abuse, and that they were supported in doing so by access to policies and procedures. Systems were used to minimise risks to people’s safety, and these systems were flexible so that people could build their independence and take appropriate risks if they were able to do so.

People were supported with their medicines by staff who were trained to do so, and had been assessed as competent, and we saw that medicines were given in a timely way and as prescribed. Regular audits of medication took place, which helped to ensure medicines were given effectively. There were enough staff to meet people’s needs, although agency staff were being used whilst a permanent, more consistent staff team was being recruited.

Checks were carried out prior to staff starting work to ensure their suitability to support people who lived in the home. Staff received appropriate training, support and clinical guidance, which helped to give them the skills, knowledge and understanding to meet the needs of people living in the home.

People who were considered to lack capacity to make a particular decision at a particular time had formal capacity assessments in place. Staff had a good understanding of this, and of the need to seek informed consent from people wherever possible, and this was reflected both in records kept and in what people living in the home and their relatives told us.

People told us that staff were respectful and treated them with dignity and respect. They also told us that staff supported them to be as independent as possible and respected their right to privacy. We saw this in interactions between people at the time of our inspection, and this was also reflected in records kept. People told us they could choose what to eat and drink, and that they were supported to prepare their own meals.

People had access to other health professionals whenever necessary, and we saw that the care and support provided in the home was in line with what had been recommended. People’s care records were written in a way which helped staff to deliver personalised care, which focussed on the achievement of goals. People told us they were fully involved in how their care and support was delivered, and were able to decide how they wanted their needs to be met.

People told us they were able to raise any concerns with the registered manager, and that these concerns would be listened to and responded to effectively, and in a timely way. People told us that staff and the management team were responsive and approachable, and we were told about examples where action had been taken as a result. Systems used to monitor the quality of the support provided in the home, and recommended actions were clearly documented. This was achieved through unannounced manager’s visits to check different aspects at each visit.

9 May 2013

During a routine inspection

We spoke with three people who lived at Cavendish Lodge about their experiences of the service. We observed the care that was given to people during our inspection. We also spoke with a range of staff including the registered manager.

People we spoke with told us that the care that was discussed with them matched the care that was provided to them. We saw that regular reviews of people's care and support plans described their progress towards their goals. We saw staff listened to people's input about their care needs and their wishes. We saw people's independence was promoted within their support plans and on the day of our inspection.

We saw that the care plans were person centred and reflected people's individual needs. We saw the members of staff supported people as detailed within their care plans. We saw staff were compassionate and caring when supporting people.

People we spoke with told us that staff were friendly and supported their needs well. We saw staff knew what people's care needs were and how they needed to be supported.

We spoke with two staff members about what they thought abuse was and they showed they had a good awareness of the importance of keeping people safe. They understood their responsibilities for reporting any concerns regarding potential abuse.

We found the service was well led and had systems in place to monitor the quality of service being provided.

31 July 2012

During an inspection looking at part of the service

We visited this service on 31 July 2012. The visit was unannounced so that no one who worked for or used the service knew we were coming.

We carried out this review to check compliance against the concerns we identified during our previous inspection on 20 April 2012.

During our visit we spoke with the deputy manager, staff on duty and some people who were using the service.

People using the service that we spoke with told us that they were provided with information to help them make a complaint or raise concerns about potential abuse. One person commented 'They give us plenty of information.'

People told us that they felt safe in the home and could see that staff responded to complaints or allegations of potential abuse.

One person told us that they liked living in the home and that the staff treated them well, and commented "I feel safe here." when we asked. Another person told us that the staff had provided support when they had raised concerns. 'I have had great support from the staff.'

Staff we spoke with told us that they had learnt a considerable amount in relation to safeguarding since the inspection in April 2012. We saw that processes had been put in place to tighten up the home's procedures in relation to safeguarding. We saw that these included training in safeguarding for all of the staff.

One staff member we spoke with told us that they felt that the team was more vigilant and alert to safeguarding issues. We were also told that the people using the service appeared to be more open and comfortable with approaching staff to raise concerns or issues they were not happy with.

We saw that processes had been put in place to strengthen the record keeping within the home. These included the introduction of personal improvement plans for staff that did not maintain care plans in an accurate and up to date manner. We saw that record keeping had been made a regular agenda item at team meetings and was also discussed during staff supervision sessions.

Care plans we looked at were current with dates for reviews clearly identified and adhered to.

20 April 2012

During a routine inspection

We visited this home on 20 April 2012. We carried out this review to check on the care and welfare of people using this service.

During our visit we spoke with people using the service, the staff on duty and the deputy manager.

Staff we spoke with knew about people's care and support needs and were able to tell us about them.

People using the service that we spoke with told us that they were involved in planning their care and support and felt that their views and opinions were taken into consideration.

We observed positive relationships between people living in the home and the staff on duty, and saw that staff encouraged people to be as independent as possible, whilst maintaining a discreet presence that enabled people to approach them for support if necessary.

Two people gave us permission to look at their care and support plans. We saw that these were well ordered and easy to follow. People had completed their Recovery Star assessments and associated support plans within the previous 12 months, however we saw that staff had not reviewed these in line with the timescales that they had set.

People told us that they were supported with their medical and health care, however in the care and support plans we looked at we noted a lapse in recording in relation to healthcare records.

We spoke with staff on duty about safeguarding procedures. We were told that they had completed training in safeguarding vulnerable adults and were able to talk through the processes to be followed should abuse be suspected. Training records we were provided with confirmed that the staff team had received training in this area.

People we spoke with and records we looked at identified that concerns had been raised with staff in relation to some challenging and potentially abusive behaviours. Responses we saw in relation to concerns raised indicated that the home was viewing such behaviours from the perspective of people's mental health needs, and had not considered the impact of such behaviours on other people living in the home.

We looked at the systems in place for the management of medication. We saw that on the day of our visit systems in place did not place people at unnecessary or potential risk.

We looked at how the service measures the quality of care and support provided. We were told that people had regular one to one meetings with their keyworker or nurse on duty, and felt that they could chat informally with staff when they wished to.

We saw that the service carried out an annual survey to seek the views of the people using it. We saw the results for the survey undertaken in 2011 along with an action plan to address any concerns or dissatisfaction that had been identified.

We saw that the health, safety and welfare of people living, working and visiting the home were monitored by appropriate checks and measures.

Records pertaining to both staff and people living in the home were maintained in good order and were stored securely in locked cabinets.

In the care and support plans we looked at we saw that staff we not adhering to the timescales for reviewing Recovery Star assessments and associated support plans that they themselves had set. We also noted some other lapses in recording. The deputy manager informed us that she was aware of the shortfalls in recording as they had been identified during a recent audit of people's files, and was taking steps to address them accordingly.