Archived: Cavendish House

Cavendish House is a service provided by Cumbria County Council. The service provides short-term respite accommodation for up to six people who have a learning disability and/or a physical disability. Two places available were for emergency admissions. The house is situated near the centre of Workington in a residential area. Accommodation is in single rooms.

The home had a registered manager who had applied to remove her registration but was continuing to be registered for other services for Cumbria County Council. A registered manager is a person who has registered with the Care Quality Commission 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.

Staff had been trained in the protection of vulnerable adults but were not always identifying and reporting potential abuse appropriately. Some people were not being protected from potential or actual abuse and improper treatment.

This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risk assessments relating to the health, safety and welfare of people had not always been completed and did not include plans for managing and mitigating risk.

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The premises were not secure and not suitable for providing short stay and emergency placements. The building and equipment were not being routinely cleaned or maintained to a good level. There were problems with infection control.

This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The deployment of staff and staffing levels at the service did not ensure that people’s needs could be met. People were spending long periods of time with little or no staff interaction. Staff had received training relevant to their roles. However, we found that staff were not always putting this training into practice. Staff supervisions and team meetings were mostly up to date. However, the nominated ‘manager’ had not received supervision for several months. The registered manager who was legally responsible for the service did not supervise staff and was not based in the home.

This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Cumbria County Council had suitable recruitment and disciplinary procedures in place.

Medicines were managed appropriately.

Communication in the service was inconsistent between staff and between shift changes. Staff were not always up to date with the support people needed.

We had evidence of unlawful practices under the Mental Capacity Act 2005 in terms of a failure to obtain lawful consent.

This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Care staff prepared suitable meals and snacks for people but nutritional planning was not always in place. This was a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The environment, both inside and out, needed to be developed and refurbished. There were no plans to upgrade the building available during the inspection.

This was a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the registered provider had not ensured that the premises was fit for purpose and took into account national best practice.

We saw caring and positive interactions from staff who helped people to maintain their privacy and dignity. Staff had an understanding of the needs of people in the service but were not always guided to help people to maintain or improve their independent living skills. We made a recommendation about developing independence and promoting well-being.

Assessment and care planning did not identify all the health and social care needs of people. Care plans were not updated and reviewed after significant or serious events or when needs changed.

This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Activities and entertainments were not been developed to meet people's needs. We saw that people were isolated in the service, particularly in the evenings and at weekends.

This was a breach Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had a registered manager who did not line manage staff and had no control over resources. The service had not had consistent leadership for some time.

The provider had failed to notify the Care Quality Commission of safeguarding matters and other matters of concern. This was a breach of Regulation 18 of the (Registration) Regulations 2009 by Cumbria County Council or the Registered Manager. This was a breach of the provider's condition of registration and this matter is being dealt with outside of the inspection process.

Cumbria County Council’s quality assurance system had failed to identify all of the problematic issues in the home. Some problems had been identified but no action taken. There was a failure of governance and oversight by the provider, Cumbria County Council.

This was a breach Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We served a notice of decision to prevent admission to this service. The Provider complied with this condition and the home now has no one in residence.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.