Cavendish Care Home

Updated 5 April 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors and an Expert by Experience carried out this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Cavendish Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Cavendish Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 23 February 2022 and ended on 25 February 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with eight relatives to gain their feedback on the service provided. We spoke with two care staff (one a senior care leader), two housekeepers (one also a social activity co-ordinator), the registered manager and the nominated individual.

The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed six people’s care records including a selection of records relating to medicines administration. We reviewed the recruitment records of two staff including staff training records. We reviewed records relating to the management of the service; quality monitoring audits, action plans and a selection of policies and procedures.

After the inspection

We sought and received feedback from a healthcare professional.

Updated 5 April 2022

About the service

Cavendish Care Home is a residential care home registered to provide, accommodation for persons who require nursing or personal care, to a maximum of 24 people. The service is a specialist dementia care home. At the time of our inspection there were 22 people using the service.

People are accommodated in one adapted building which has a large conservatory extension and enclosed back and front garden.

People’s experience of using this service and what we found

Risks to people were assessed and action taken to reduce or mitigate these. This included risks associated with the Coronavirus. People were protected from abuse. There were enough staff in number and experience to meet people’s needs. People’s medicines were managed safely.

People’s care was delivered in a personalised way, recognising and respecting people’s individual choices, preferences and protected characteristics. Staff were trained and supported to deliver care in line with best practice guidance and the law.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service also supported this practice.

Particular attention was paid to supporting people to have a positive dining experience which resulted in good outcomes for people. People’s specific nutritional and dietary needs were met.

People had access to healthcare professionals, which included emergency health support and mental health specialists as needed. Support was provided to maintain and improve people’s mental wellbeing. There were arrangements in place to support people's end of life care and wishes.

Staff were kind and patient towards the people they looked after. Staff understood how to support people with the challenges that living with dementia could bring. A relative said, “We cannot fault the care which mum gets; they understand her.”

People were supported to express their views and to feel part of the care home’s community. Staff treated people with dignity and respected their right to privacy. People were supported to maintain daily skills which supported their ability to remain as independent as possible.

People’s representatives were kept informed of any changes to their relatives’ care or needs. A relative said, “We are informed of any changes in mum’s health or medication and any other situations which may affect her.”

Managers promoted a culture which enabled people, their representatives and staff to feel comfortable in giving feedback, raising a concern or where needed, to make a complaint.

Managers had a clear vision for the service and effectively communicated this, along with their expectations, to the staff who shared their commitment to supporting people to live well with dementia. A relative said, “There has been a huge change and difference since the new manager [started]. For the better.”

There were robust quality monitoring systems and processes in place to ensure outcomes for people remained positive and that the service remained compliant with necessary regulations.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 21 August 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 11, 12 and 15 July 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve, safeguarding service users from abuse and improper treatment, person - centred care and good governance.

We undertook this comprehensive inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contained those requirements and also the Key Questions Effective and Caring which required improvement.

The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.