Cavendish Residential Care Homes Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment, including infection control and the ways people’s medicines were managed.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and a clear view of potential risk. They did not listen to concerns about safety and did not effectively investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. There was no overarching analysis of themes and trends in incidents, accidents or safeguarding concerns to identify patterns and trends to reduce the risk of reoccurrence. Records showed when incidents happened, such as a fall or episode of choking, action was not always taken to update care plans and risk assessments in response. For example, 1 person had sustained multiple recent falls, but their care plan incorrectly stated they had not had any falls in the past 12 months. Another person had been identified as being at risk in the community as they were not being supported in line with their mobility care plan, but no effective action had been taken, placing them at risk of avoidable harm. We received mixed feedback about whether relatives were always informed of incidents in a timely way. One relative said, “It makes me worry what else happened and I don’t know about it.” The provider took prompt action to update specific care records during the assessment and confirmed all care plans and risk assessments would be fully reviewed.

The provider worked well with healthcare partners, seeking to establish and maintain safe systems of care. Staff coordinated with professionals and sought healthcare advice, making referrals as required. One person’s relative told us, “Staff contact the [district] nurse at the slightest concern.” However, whilst staff worked well with other professionals, we found many care records were lacking in detail or inaccurate. Records were also not always updated following hospital treatment. A relative told us, “Staff have been very attentive to [person] since returning from hospital.” Another relative said, “I know the staff well and they fully understand my relative’s needs.” Whilst familiar staff in the care home knew people well, poor care planning had the potential to impact on people’s safety and continuity of care when people moved between different services, as care and support needs and any risks were not always appropriately recorded.

The provider sought to work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. However, shortfalls in systems and processes meant they did not always have effective oversight of improving people’s lives and protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. This included a lack of analysis in relation to safeguarding matters, and some policies and procedures which were not up to date. We found some allegations of abuse reported to the local authority had not been notified to the CQC by the previous registered manager, despite this being a legal requirement. The provider took action straight away to make the notifications retrospectively and told us they would strengthen this process going forward. The CQC also made an organisational safeguarding referral to the local authority during the inspection, in relation to the safety and quality issues found across the service. Despite this, individual safeguarding measures were generally carried out effectively to raise concerns promptly with the local authority. A staff member said, “I feel confident raising concerns with the current management team. They are approachable and supportive, and they take safeguarding and residents’ wellbeing seriously. I believe that if any concerns were raised, they would act appropriately and report them to the local authority safeguarding team if required.” People told us they felt safe with staff. A person told us, “I definitely feel safe, staff are nice.” Another person said, “I feel safe, definitely.”

The provider did not work well with people to understand and manage risks. Staff did not have the guidance they needed to provide care that was safe, supportive and enabled people to do the things that mattered to them, and instead often relied on their own knowledge of people’s care needs. Whilst risk assessments were in place in some areas using nationally recognised tools, they were not always sufficiently detailed or accurate, and some were missing altogether. This included in key safety areas such as choking, catheter care, falls risks, skin integrity and diabetes. For example, 1 person required the use of a catheter, but there was no risk assessment in place to guide staff on associated risks such as blockages, infections and when to contact a health care professional. Another person had experienced a choking incident requiring staff first aid intervention to clear their airway, but no choking risk assessment had been put in place. The provider acted on this straight away during the inspection process, and supplied evidence to confirm these records had been updated.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Whilst some health and safety checks were completed for premises and equipment, others were out of date or did not show action taken in response to adverse findings, including fire checks. We found some Personal Emergency Evacuation Plans (PEEPs) for use in the event of an emergency such as a fire were inaccurate or did not contain key safety information. For example, 1 person used a flammable emollient cream, but this information was not recorded to show the increased risk to them in a fire. The overview PEEP sheet for people living in the service in the fire grab bag also incorrectly stated 2 people were in hospital, which could cause confusion to emergency services as to who was on the premises. The provider told us they had updated this information and were moving to a fully electronic system so all information would be accessible and up to date going forwards. We were supplied with evidence of additional environmental checks, certification and audits during the assessment process.

The provider made sure there were enough staff deployed. Staff worked together to meet people’s day-to-day support needs. However, under previous management, leaders had not always ensured staff received effective support, supervision and development, such as a robust induction, particularly when taking on a role with more responsibility. This was being addressed by the provider at the time of inspection. Staff received training in a wide range of areas, including completion of the Care Certificate and other nationally recognised qualifications. However, our observations found this did not always translate into consistent person-centred care, as there was evidence of some longstanding institutionalised staff practice. The Nominated Individual was aware of this and supporting changes in this area, and we received feedback this had already led to positive outcomes. A Nominated Individual is a senior leader who acts on behalf of the provider, in this instance the service Regional Manager. A person’s relative said, “Staff are more attentive. I have noticed in the lounge that previously when people used to get out of their chairs they were told to sit down, but now staff get up with them and support them to do what they want to do. Staff are listening more to people’s voices and actions.” We found there were enough staff on duty, and saw they were visible in shared spaces. A person’s relative said, “I think there are sufficient staff. There are usually staff around and they go round checking people. There are always staff in the lounge observing and supporting people.” We found staff were recruited safely, with some minor improvements needed to ensure references were requested from all previous care positions. The provider told us they would act on our feedback.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Whilst there was a dedicated domestic team who ensured cleaning was completed to a good standard inside the main building, our observations showed some areas of the care home needed maintenance work to facilitate this. For example, the laundry room was in an outbuilding in poor environmental condition with cobwebs, mould, thick dust and the surface of walls degraded and crumbling. The provider took action to deep clean this during the inspection and confirmed building works would take place to replaster the walls. However, we also found new equipment such as wheelchairs and mattresses being stored in an outdoor metal shed which was not watertight, alongside items which were dirty or rusty and needed to be disposed of. Some internal walls and doorframes required re-painting, as well as the replacement of fittings such as radiator covers, to ensure they could be kept clean. Staff also provided feedback they felt a dedicated laundry attendant was needed. People were generally satisfied with the cleanliness of the home within the main building. A relative told us, “The home is neat and tidy. There has been some redecoration over the time [person] has been here.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. An electronic Medication Administration Record (MAR) system was used to show the medicines people required and when they had been assisted to take them by staff. However, we found 2 people’s medicines did not have the right number of tablets in stock according to the provider’s own records, indicating they may not have been given as prescribed or errors with the process for carrying medicines over from a previous cycle. We also found personal medication information was not always securely stored with information left on top of the medicines trolley. The provider told us they would strengthen medication auditing processes to address these concerns and provided evidence of this during the assessment. Staff were committed to supporting people expressing distress without the unnecessary use of sedative medication. The deputy manager told us, “A bit of compassion, a cup of tea, a chat. This calms people down more than medication; it’s not warranted.”