• Care Home
  • Care home

Cadbury Hall Care Home

Overall: Good read more about inspection ratings

High Street, Yatton, Bristol, BS49 4DW (01934) 833073

Provided and run by:
Barchester Healthcare Homes Limited

All Inspections

During an assessment under our new approach

Cadbury Hall is a residential care home for older people, some of whom are living with dementia. The assessment commenced on 21 November 2023 and was completed by 3 January 2024. The assessment included a site visit to the service on 23 November 2023. We looked at 14 quality statements; Safeguarding, Involving people to manage risks, Safe environments, Safe and effective staffing, Medicines optimisation, Independence choice and control, Equity in experiences and outcomes, Shared direction and culture, Capable, compassionate and inclusive leaders, Freedom to speak up, Workforce equality, diversity and inclusion, Governance, management and sustainability, Partnerships and communities and Learning, improvement and innovation. We found that since our last inspection of the service, improvements had been made and breaches of regulation had been addressed. There were sufficient numbers of staff to meet people's needs and ensure they were safe. Fire safety in the home had improved. Feedback from people and their relatives was positive in relation to how safe they felt and how they were treated by staff. However, we did receive some mixed feedback about waiting times for staff to attend when people used their alarm call. People and their families told us they were included and involved in decisions about their care and support. People received support to access other health professionals when required and to take part in activities they enjoyed. The service was well led and the views of people and staff were included in planning for the future and identifying areas for improvement. Equality and diversity was considered in the planning of activities and strong links were being forged with the community.

18 January 2023

During a routine inspection

The inspection

Cadbury Hall Care Home is a care home providing accommodation and personal care for up to 34 people. At the time of the inspection, 7 people were living at the home.

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

The provider had failed to identify or act to mitigate the risks to people. We identified through our inspection that the home did not have safe staffing levels on two occasions in January 2023. On these occasions one waking staff was left working alone in the building. This had put the staff member and people at risk. On some occasions one waking night staff worked with a staff member sleeping in. No risk assessment was in place or guidelines as to when the sleep in staff member would be called upon.

Safety monitoring and management checks of the building were taking place. However, we found inconsistencies and improvements were required. Staff had attended a fire safety training session during their induction. However, some staff had not attended a fire drill or there were gaps in them attending one from their initial induction. Some staff did not know what to do in the event of the fire alarm sounding.

Governance systems to monitor the home were not effective. They had not identified the improvements that were required and shortfalls which we identified. The home had had several managers in post since it opened in April 2022 which they had been unable to retain. This had an impact on morale and the staff. The oversight of the provider needed improvement to ensure systems were fully embedded by a stable, consistent staff team and manager. A new manager was recruited in December 2022. They planned to continue to build on staff morale and to drive improvements.

All staff understood their responsibility to keep people safe from harm. Risks to people had been assessed with actions in place to help keep people safe. Checks were carried out on staff before they started work to assess their suitability. Medicines were well managed, and people received their medicines as prescribed.

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 home supported this practice.

People’s needs were assessed and they were supported to maintain a healthy and balanced diet. People who lived at the home were treated with respect and equality. Care was person centred and staff understood the importance of promoting choice, consent and independence. People’s dignity and privacy were maintained.

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

Rating at last inspection

This service was registered with us on 22 April 2022 and this is the first inspection.

Why we inspected

This was a planned inspection to check whether the provider was meeting legal requirements and regulations, and to provide a rating for the service as directed by the Care Act 2014.

Prior to this inspection we were made aware of some concerns raised about the home. We used this information as intelligence and to help us plan this inspection.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this report. You can see what action we have asked the provider to take at the end of this report. The overall rating for the service is requires improvement. This is based on the findings at this inspection.

Enforcement

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We have identified breaches in relation to ensuring safe levels of staffing, managing risks, and around good governance. This meant that improvements were required to ensure quality monitoring and management and that provider oversight was more effective.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.