Cavell Park Care Home

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.

This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and their relatives told us that the service took steps to maintain their safety. One person mentioned, “I had a fall at night and the staff have put things in place to make sure that I would be safe in the future.”

Staff knew the systems in place to report incidents, accidents and when things go wrong. They told us they completed an incident report and made their unit manager aware of it. Record showed incidents were investigated and actions taken to ensure learning from them. When issues occurred within the service, they were addressed with staff during handovers team meetings and lessons were shared to improve the service. For example, a clinical supervision was held with staff to review medication practices in the service, reflect on good practice and shared learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. One person told us, “Every month we have a meeting, and we review my care plan and my health conditions, and we agreed what should done to improve. The staff monitor my health as agreed.”

People, their relatives and other professionals were involved in planning people’s care and treatment. We saw records of multi-disciplinary meetings held to discuss safe pathways for people and decisions were made together. Staff knew people well and their individual conditions. They knew when to make referrals to specialist services to support in managing people’s care safely. For example, staff had involved an organisation specialised in supporting people with a specific condition. The organisation visited and provided training to enable and promote the person’s safety and improve their well-being.

As part of the process for new admission into the home, staff completed a body map, and general check of the person’s well-being and made referrals where necessary. Staff also ensured people had appropriate equipment they needed in their rooms as soon they moved into the service to promote their safety.

Professionals we contacted told us staff made referrals to them in a timely manner if they were concerned about people.

People were safeguarded from the risk of abuse and their rights protected. People told us they felt safe in the service. One person said, “I feel very safe and looked after here and the general attitude of the staff is wonderful.” A relative commented, “Yes definitely I feel [relative] is very safe here; the staff are wonderful and make sure they are always safe whether at home or when going out in the community.”

There was a safeguarding policy and procedure in place. Staff had completed training in safeguarding and actions to take to safeguard people in line with the provider’s procedure. Staff knew how to whistle blow and told us they would do so if needed in order to safeguard people. One staff member told us, “I know organisations to contact to raise concerns about the home if the residents are in danger.”

The registered manager understood their responsibilities to safeguard people from abuse. We noted they had taken appropriate actions to address allegations of abuse in the service. They had raised safeguarding alerts to the local safeguarding team, carried out investigations, and notified CQC.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DOLs). Staff had received training on MCA and understood their role and responsibility in promoting the principles of MCA.

People’s rights and freedom were promoted in the home. People had valid DOLs in place or a pending application with the local authority. People could leave the home and return as they wish. The registered manager understood their responsibility to promote people’s right and to notify CQC of any approved DOLs.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and promoted their well-being. There were risk assessments which identified risks associated with people’s physical health and mental health conditions, personal care, skin integrity, mobility, nutrition and moving and handling.

People and their relatives told us they were involved in assessing risks they faced. One person told us, “The staff carried out a risk assessment when I first moved in because of my walking.”

We reviewed risks assessment which detailed the support people required to reduce the risk of pressure sores. They had appropriate equipment such as pressure relieving mattresses and cushions. Where a person had developed a pressure sore, a tissue viability specialist was involved in caring for them. They were supported to reposition regularly and maintain good hygiene and nutrition.

The service had put measures in place to support a person at high risk of falls. They had involved professionals to support staff to manage the risk and provided equipment to minimise the risk of harm to the person.

Risk assessments were reviewed regularly and updated to reflect people’s current situation. Staff understood the measures in place to support people safely and we observed them supporting people safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Records showed health and safety checks were carried out regularly. These included fire safety, electrical installation, gas safety, portable appliance test (PAT), and water management and legionella. The fire risk assessment for the home was up to date and there was no outstanding action.

Care equipment such as moving and handling aids/equipment were serviced and records maintained for them.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We received concerns about staffing levels before our inspection. During our inspection, people, their relatives and staff told us the staffing level was adequate to support safely. One person told us, “I can’t turn around without falling over but it is lovely to know staff are always there to help me.” Another person commented, “Yes, they come very quickly when I call for help. I haven’t had to wait long.”

We observed that there were enough staff around to assist people with their needs in all three units. Staff responded to people’s needs and requests for assistance promptly. Staff were available in communal areas and supported people where needed.
Staff we spoke told us there were enough to support people. One staff member told us, “We are mostly enough. If we are short staffed, they [registered manager] always authorise us to call agency staff to cover.”

Staffing level were determined based on people’s needs and occupancy level. The staffing rota showed the home was covered 24 hours by a team of carers, and a qualified nurse who was mostly based in the nursing unit. We reviewed the call monitoring system to check how long people waited to get a response when they called for help. We noted that most calls were responded to within 5 minutes both during the day and night.

Robust recruitment checks were conducted before applicants could work with people. These included criminal records checks, references, employment history and the right to work in the UK. The provider also checked that nurses employed had the appropriate qualifications and their professional registration was up to date and continued to be valid.

Staff were supported in their roles through effective induction, support, supervision and appraisals.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. One person told us, “My room is cleaned every day, and the staff here are wonderful”. A relative told us, “The home is always fresh and clean and (loved one’s) room is cleaned daily”.

The home was clean throughout, and a good standard of cleanliness and hygiene was promoted. The provider ensured personal protective equipment (PPE) was available, and we saw staff using PPE effectively and safely.

The provider had an infection prevention and control policy that was up to date and covered measures to prevent and manage the outbreak of infections.

Staff had been trained on infection prevention and control, and we saw them following good hygiene practices.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The provider had a medicine management policy and procedure.

People told us they received their medicines as prescribed. One person stated, “I manage my own medication, but the staff will check it with me.” A relative commented, “Absolutely they have been great at organising everything for him.”

People’s medicines were administered and managed safely. Only trained and competent staff were responsible for administering and managing people’s medicines. People had care plans which detailed the support they required from staff with their medicines. Where people had ‘as when required’ medicines, there was a protocol to support the safe management and staff followed this. Medicine administration record charts were maintained.

There were systems for managing controlled drugs (CDs). CDs were locked securely in a cupboard. Two trained staff members administered and signed the CD records and carried out daily checks to ensure records tallied with the stock.
Medicines were stored within safe temperature ranges, in line with the manufacturer’s instructions. Regular checks were made of storage temperature areas to ensure they remained safe.