Cavendish Homecare Ltd improved from Requires Improvement to Good across all inspected key questions, having remediated prior breaches of Regulations 17, 18, and 19. Minor recommendations remain regarding medicines recording and MCA documentation, but no regulatory breaches were found at this inspection.
Concerns (3)
minor
Medication management
: “We identified several issues with the recording of medicines. The registered manager told us this would be addressed.”
minorRecord keeping: “The provider was strengthening their recording systems around the MCA, to ensure it was clear how staff were following the requirements of the MCA.”
minorComplaints handling: “We spoke with the registered manager about recording any concerns and actions taken centrally, so any themes or trends could be more easily identified.”
Strengths
· Effective recruitment checks in place following previous breach of Regulation 19, with provider no longer in breach
· Sufficient staffing levels maintained; provider reduced coverage areas to ensure consistent, reliable care
· People felt safe; safeguarding system in place with concerns reported to appropriate agencies
· Staff well-supported and trained following previous breach of Regulation 18; ongoing face-to-face training organised
· Person-centred care planning with six-monthly reviews; care plans reflected individual preferences
Quality-Statement breakdown (21)
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood