Background to this inspection
Updated
22 April 2021
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 Care Act 2014.
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
There were three inspectors in the inspection team.
Service and service type
Cavendish Park is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission at the time of the inspection. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided. The registered provider had recruited a new manager who was due to commence work shortly after the inspection.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgments in this report.
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.
During the inspection-
We spoke with twelve members of staff including the assistant manager, clinical lead, senior care workers, care workers and the activities co-ordinator. 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 reviewed a range of records. This included five people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We reviewed the information sent into us by the provider.
Updated
22 April 2021
About the service
Cavendish Park is a nursing home providing personal and nursing care to 26 people aged 65 and over at the time of the inspection. The service can support up to 67 people.
People’s experience of using this service and what we found
People were supported by staff who understood how to keep them safe and understood the risks to their health. The registered provider had recruitment systems that reviewed the background of potential staff to assure themselves of the suitability of potential staff. Through their own checks, the registered provider became aware of a number of issues and the registered provider had improved systems for staff support with medicines.
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 supported this practice.
People were involved in planning their care. Staff training was monitored to ensure staff training was up to date. Staff were supported with guidance from senior staff on how best to support people.
People liked the staff supporting them. Staff understood the importance of supporting individuals to maintain their dignity, independence and understood how to promote their human rights.
People’s care was updated and reviewed regularly. People were supported to maintain relationships important to them and staff understood how best to communicate with them. The registered provider had a complaints process in place to review and act upon any complaints they received. People were I
involved in planning their end of life care where appropriate.
A number of changes had occurred in the management team of the home. At the time of the inspection there was no permanent manager in post and a clinical lead had just joined the home. A new manager had been appointed and was due to join the organisation on 01 February 2021. The home was operating at below fifty percent of maximum registered occupancy, with the registered provider focusing on residential care until they had a stable nursing team in place. We could not yet be assured that systems in the home could be sustained.
Staff enjoyed working at the home and felt it was a good place to work. The registered provider was working with the local authority and Clinical Commissioning Group to develop the home.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 12/08/2019 and this is the first inspection.
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.
The inspection was prompted in part due to concerns received about medicines, infection control, and staffing. A decision was made for us to inspect and examine those risks.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.