Cavendish Residential Care Homes Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 50 (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 always have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not fully understand the challenges and the needs of people and their communities. The provider was aware of some closed culture indicators, and signs of task-orientated practice. Work was underway to address this, supporting the wider staff team. However, the provider was aware and realistic about the need for time to embed these changes. The culture of the service had also been impacted by recent management challenges and instability, with the registered manager recently resigning from post and other staff also absent from their roles. We received positive feedback from people and from relatives there were already signs of improvement under the new management team, despite this being in its infancy. A relative said, “The home has been up and down. I wasn’t always happy about how things were done or the attitude” but "the home seems to be improving.” Another relative said, “Right now the home is lovely. The changes have made a big difference.” However, there was no overarching service improvement plan in place at the start of inspection, to show the provider’s vision going forwards to address the challenges and shortfalls they had already identified. The provider put this in place during the course of the inspection.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. However, the provider operated with integrity, openness and honesty and took accountability when things had gone wrong. There were a number of significant shortfalls found in the leadership of the service under previous management, and this had not been effectively addressed and remedied by the provider in a timely way. However, at the time of inspection a new manager and a deputy manager had just taken up positions alongside the Nominated Individual, sharing their time with the provider’s 2 sister services. The new manager had proven experience in making improvement works. The provider had also strengthened the management team by hiring a new quality assurance manager. We found the management team were responsive to any issues raised during the inspection and took action straight away to respond to concerns raised. However, the new team were very new in post and therefore had not had time to make the improvement works required, which still needed to be implemented, embedded and sustained.

We received mixed information about whether people felt they could speak up and that their voice would be heard. Staff told us they could raise issues openly with the new management team. A staff member said, “It’s been a bit of a rollercoaster with the recent changes, but the management team has shown so much compassion and support.” A whistleblowing policy and procedure was in place for staff to follow. However, this still recorded the previous management team as key contacts despite them no longer being in post. There had also been a number of recent whistleblowing reports made to the CQC, and also to the provider. This had led to local authority safeguarding team involvement at the service. More time was required to ensure all staff felt able to share their views. The new manager was working to build rapport with the staff team, and relationships of trust.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. However, not all staff felt there was always effective teamwork and inclusion between themselves. Staff received equality and diversity training, and told us they were fairly treated by the new management team. A staff member told us, “All staff are treated equally at the care home, with fairness, respect, and equal opportunities provided to everyone.” Another staff member said, “We don’t work with fear or discrimination, it is a peaceful place to work where all our rights are respected and protected.” However, there were some divides between day and night staff, and new and longstanding staff. The provider was alert to this and the need to ensure a fair culture for all. The new manager told us they had stressed the importance of open dialogue and team working at a recent staff meeting and would continue to support staff as required.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Systems for the governance and oversight of the service were in place but had not been used effectively under previous management. This had created widespread and systemic issues, which the provider had not acted upon. For example, the most recent laundry audit (covering cleanliness and condition), infection prevention and control audit, and medicines audit had all been scored 100% with no actions identified. This did not reflect our inspection findings, and left people at risk of unsafe care. Gaps and inaccuracies in care plans had not been identified, prioritised or addressed through audits or other oversight mechanisms. There was also a lack of analysis of incidents, accidents, and safeguarding concerns, hindering effective oversight of themes and trends. The provider was beginning to address this and supplied evidence of newly completed audits during the inspection. Statutory notifications had also not always been made to the CQC as required under the provider’s legal and regulatory responsibilities, such as where there had been an allegation of abuse or a serious injury. The provider completed these notifications retrospectively.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service worked well with external stakeholders, such as the local authority. The Nominated Individual proactively communicated challenges at the service and welcomed support such as training and other resources provided by the local authority quality and safeguarding teams. We received positive feedback about leaders at the service. For example, a professional told us, “[Deputy manager] is really proactive, and has really good oversight.” The provider had also acted transparently to keep relatives informed of changes to the service. A relative said, “There was a meeting last week with relatives. Everyone agreed that it is much better now.” CQC held multiple meetings with the provider during the inspection and afterwards, to discuss the plans for improvement and to seek assurances from the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The service was committed to improvement, and had aligned resources to complete this work, but was still reactively responding to issues and concerns to ensure regulatory compliance, rather than having a proactive plan to achieve innovative practice. This meant the provider was not currently meeting its own commitments to people as set out in the company Statement of Purpose. This included, ‘Promoting a standard of excellence which embraces fundamental principles of good care practice that is witnessed and evaluated through the practice, conduct and control of quality care in the residential environment.’ Although there were early signs of improvement, the provider still had significant work to do to ensure the safety and quality of the service was improved, lessons learned and changes remained effective going forwards.