We carried out a review of the data available to us about Cavendish House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Cavendish House, you can give feedback on this service.
The service provides care and support to people with high support needs, learning disabilities, autism and mental health conditions. There were six people living in the service at the time of the inspection.
We found the following examples of good practice:
The management team led by example and worked as part of the team to combat Covid 19. There had been no outbreak of Covid 19 in the service.
The service had not taken any new people into the service during lockdown as they had no vacancies. This meant people were kept safe from any additional exposure.
There was enough PPE for staff to use and this was worn appropriately. Distinct and separate space had been allocated for changing PPE to prevent cross contamination.
Face masks had been given to staff members households in order to remind them of the risk of cross infection from home to work and to be vigilant.
People were fully involved in discussions about Covid 19 and its effects, prevention, spread and control. This included one person undertaking learning about food hygiene, food preparation and infection control using the same training as care staff for their own personal development.
There was information in easy read and pictures readily available around the service as a reminder of the control of infection.
People were supported to see their families outside of the service in open spaces to reduce the risk of infection. People were supported to observe social distancing whilst meeting with their families.
Detailed risk assessments had been carried out for people who used the service and staff. This ensured that everyone's characteristics such as age, sex, ethnicity and circumstances were considered to ensure risks to the spread of infection were minimised for those most vulnerable.
Clear policies, procedures and contingency plans were in place. Effective monitoring provided good management oversight of the day to day running of the service and their preparedness should there be a second wave of the virus.
Further information is in the detailed findings below.
The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.
On the day of our comprehensive, announced inspection on 21 September 2018, there were six people living in the service. We gave notice of this inspection to make sure that people who used the service and staff would be available to see us.
At our previous inspection of 11 November 2015, this service was rated good overall. We found the evidence from this inspection of 21 September 2018, continued to support the rating of good overall. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
People continued to receive a safe service. There were systems in place designed to reduce the risks of abuse and avoidable harm. Where incidents had happened, the service learned from these and used the learning to drive improvement. Risks to people continued to be managed well. People were supported with their medicines in a safe way. Staff were available to support people and the systems to recruit staff safely were robust. There were infection control procedures in place which reduced the risks of cross contamination.
People continued to receive an effective service. People were supported by staff who were trained and supported to meet their needs. People had access to health professionals when needed. Staff worked with other professionals involved in people’s care. People’s nutritional needs were assessed and met. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The environment was well maintained and suitable for the people using the service.
People continued to receive a caring service. People shared positive relationships with staff. People’s privacy, independence and dignity was respected. People were listened to in relation to their choices, and they and their relatives, where appropriate, were involved in their care planning.
People continued to receive a responsive service. There were systems in place to assess, plan and meet people’s individual needs and preferences. People’s had access to social activities to reduce the risks of isolation and boredom. There was a complaints procedure in place and people’s complaints were addressed.
People continued to receive a service which was well-led. The registered manager had a programme of audits which demonstrated that they assessed and monitored the service provided. Where shortfalls were identified actions were taken to improve. People were asked for their views about the service and these were valued and listened to. As a result the service continued to improve.
The inspection took place on 11 November 2015 and was unannounced. Cavendish House provides accommodation and personal care and support for up to six people who live with a learning disability or autistic spectrum disorder. The service does not provide nursing care. At the time of our inspection there were four people who lived in the service.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.
People were safe because staff understood their responsibilities in managing risk and identifying abuse. People received safe care that met their assessed needs. There were enough staff who had been recruited safely and who had the skills and knowledge to provide care and support in ways that people preferred. The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely.
The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. The Act, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals. No-one at the home was subject to the Deprivation of Liberty Safeguards (DoLS). Staff had been trained and had a good understanding of the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
Staff had developed positive, respectful relationships with people and were kind and caring in their approach. People were given choices in their daily routines and their privacy and dignity was respected. People were supported and empowered to be as independent as possible in all aspects of their lives.
Staff knew people well and were trained, skilled and competent in meeting people’s needs. Staff were supported and supervised in their roles. People were involved in the planning and reviewing of their care and support.
People’s health needs were managed appropriately with input from relevant health care professionals. Staff supported people to have sufficient food and drink that met their individual needs. People were treated with kindness and respect by staff who knew them well.
People were supported to maintain relationships with friends and family so that they were not socially isolated. There was an open culture and staff were supported to provide care that was centred on the individual.
The provider had systems in place to check the quality of the service and take the views and concerns of people and their relatives into account to make improvements to the service.
A visiting healthcare professional said, 'This is a good set up, with a good ethos and a nice, committed staff group. It's well run here and always feels calm.' People were able to make choices about all aspects of their lives, and were supported to be as independent as possible. Staff worked with people towards a more independent future. Care records gave staff good guidance on how each person wanted to be supported.
Staff had received training in how to protect vulnerable people and demonstrated they knew the procedures for reporting any concerns. Staff were recruited well, with all the required information being obtained by the provider before each member of staff started work.
People and their relatives were given a service user guide so that they had information about the service, including how to make a complaint if they wanted to. However, people told us there was nothing to complain about.