Cavendish Lodge

Updated 12 January 2023

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

The inspection team consisted of two inspectors.

Service and service type

Cavendish Lodge 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 Lodge is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We also sought feedback from healthcare professionals who work with the service.

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 spoke with 5 members of staff including the registered manager, the regional operations manager, a support worker, an agency support worker and a newly recruited nurse. We also spoke with 6 people who lived at Cavendish Lodge. We looked at 2 people's care plans and a selection of medicine records. We also looked at a range of records relating to the management of the service including 1 staff recruitment file, maintenance of the building and premises, staff meetings, audits and quality assurance checks.

Updated 12 January 2023

About the service

Cavendish Lodge is registered to provide nursing and personal care for up to 8 people who have a diagnosed mental health condition. At the time of our inspection visit there were 8 people living at the home. Care is provided across two floors and a communal lounge and dining area is located on the ground floor.

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

People spoke positively about the support they received from the registered manager and staff to stay well and maintain their independence. However, the provider had experienced difficulties recruiting and retaining staff and staffing numbers were maintained by using temporary staff supplied through an agency. The high use of agency staff had impacted on consistency in following some of the provider’s processes, particularly in relation to safe medicines management.

Staff understood their safeguarding responsibilities and were able to describe the subtle signs that might indicate a person was worried or the subject of abuse. Changes in people’s risks were communicated to staff during handovers between shifts. Staff described an open culture where learning from accidents and incidents was shared within the staff team.

People told us they received care that met their needs and spoke of the positive impact living at Cavendish Lodge had on their well-being. People at Cavendish Lodge were working towards achievable goals in their recovery under the provider’s recovery programme.

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.

The provider and registered manager took a proactive approach to promoting equality and diversity to ensure the service was inclusive of the needs of people and staff.

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

Rating at the last inspection

The last rating for this service was Requires Improvement (published 30 August 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. This focussed inspection only looked at the key questions of safe, responsive and well-led.

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 COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating. The overall rating for the service has remained as Requires Improvement. 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 Cavendish Lodge 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.