Cavell Park Care Home

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.

This is the first assessment for this newly registered service. This key question has been rated Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew the visions and ethos of the service. The provider focused on providing high standard of care in a beautiful and peaceful environment. One staff member said, “The home is beautiful and feels like a luxury home. The care we provide here is warm and person-centred. The team work together. I would put someone I love here. It is a lovely place to work.” The registered manager promoted a culture where the team work together to deliver care and support to people in a way that achieved positive outcomes for them.

The registered manager and provider used various systems and processes to share the organisation’s values. These included regular team meetings, supervisions, appraisals and handovers. Staff told us the registered manager shared updates within the home and organisation. Staff confirmed that a culture of openness was promoted in the service. We saw records of safeguarding allegations, complaints and incidents and accidents. Complaints had been investigated and addressed as required. Actions were taken to address areas that required improvement.
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was visible and clear leadership in the service. Each unit had a team leader who provided day to day support and guidance to staff. Staff knew who to go to if they needed support to meet people’s needs. The unit leaders we spoke to told us the registered manager was approachable and supportive. One staff member told us, “[Registered manager] is always here if we need support. I can go into her office anytime and she would listen and support me. She finds time to come to the unit to check on the residents.” The registered manager and team leaders held meetings daily where they discussed any issues in the service openly and agreed actions to rectify them.

The registered manager understood their regulatory requirements in line with their registration. They told us they were supported by the senior management team in the organisation. They had notified CQC of incidents in line with the requirements of their registration.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident to voice their concerns about the service to the registered manager, senior management within the organisation and to external authorities if needed. One staff member commented, “If I am not happy about something, and I am not getting the feedback, I would whistle blow to protect everybody. I’m not scared to do this.”

The provider had a policy and procedure which supported staff to speak up about the organisation. The registered manager told us they operated an open-door policy, and they always welcomed staff and visitors, and encouraged them to raise their concerns. They also told us they walked around the home every day, and they chatted with staff giving them opportunities to speak up.

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.

There was a mix of staff within the home, and they told us they felt valued and supported in their roles. One staff member told us about their experience working in the home. They told us how the registered manager had supported them to develop and build their confidence. Another staff member told us they had the opportunity to progress in the job.

The registered manager told us they made adjustments to accommodate staff needs and took account of their personal circumstances to support them in their roles. For example, providing training in different formats for staff depending on their abilities and needs, and providing coaching sessions to help staff improve performance. One staff told us, “When I needed a small operation, management was very supportive. They helped me get back to work slowly, made sure I wasn’t lifting anything heavy, and kept checking I was ok.”

The provider had different schemes to reward, motivate and support staff. For example, celebrating their achievements, milestones and special occasions. One staff mentioned, “On Fridays, a trolley comes round with goodies for the staff like pastries and cakes.”

Staff knew about the procedure to follow if they needed to raise any grievance about their work.

The provider had clear responsibilities, roles, systems of accountability and good governance in place. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were systems and processes in place to monitor the quality of the service delivered. The registered manager reviewed audits and quality checks which included health and safety, medicines audits, care records, call bell audit, staff training and supervision audits, pressure sores monitoring, falls monitoring, fluid and food chart record audits.

The reports from these audits were discussed with the members of the management team. Action plans were produced to address areas of concern. For example, the staffing level was increased in a unit following the audit of call bells that improved response times.

The quality of the service was also discussed and shared with people, their relatives and staff during meetings. Their views on how to improve the service were sought and considered. One person told us, “They are very good at making sure everything is good and well organised.” A staff member commented, “The quality of the service is very good here. I can, without any doubt, put my mum or someone I love here.”

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 closely with local service commissioners, the NHS Clinical Commissioning Group, health and social care professionals to improve the service delivered to people. Members of the commissioning team we contacted told us they were working with the service to continuously improve and meet people’s needs.

The service also liaised with organisations such as Dementia support, Parkinson society, Stroke support and Progressive Supranuclear Palsy Association (PSPA) to provide training and information to staff to enable them to provide effective support to people with those conditions. One partner we contacted told us, “We view Cavell Park as a very proactive care home and easy to work with collaboratively.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering quality of experience, outcomes and quality of life for people. They actively contributed to safe, effective practice and research.

The service ensured they continued to learn and improve the service. We noted that they had implemented lessons learnt from complaints, safeguarding, accidents and incidents. The registered manager told us they analysed the data from the call monitoring system, and they used it to evaluate staffing levels and adjusted staffing levels accordingly. The registered manager told us they were carrying out on-going recruitment to fill staff vacancies in the service. They were looking at the best ways to attract good and qualified staff to work in the service.

They had improved on their communication and engagement with people and their relatives. The registered manager was regularly monitoring care delivered and they involved other organisations and specialist services to support staff through training to meet people’s specific needs.

The registered manager is a member of various networks and professionals’ bodies such as Skills for Care we they shared information, learning and updates about the care sector.