West Melton Lodge

Updated 10 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 was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

West Melton 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. West Melton Lodge is a care home without 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 not a registered manager in post. A new manager had been in post for three months and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and 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 3 people who used the service and 7 relatives about their experience of the care provided. We spoke with 6 members of staff including the manager, regional manager, care workers and ancillary staff. We observed staff interacting with people who used the service, to help us understand their experience. We reviewed a range of records. This included 3 people's care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision. We reviewed a variety of records relating to the management of the service.

Updated 10 January 2023

About the service

West Melton Lodge is a residential care home providing personal care to up to 32 people. At the time of our inspection there were 28 people using the service. Some people using the service were living with dementia.

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

Since the last inspection there had been changes in the management team and the service had a new manager and regional manager. New systems and processes had been introduced to monitor the service, however new processes required embedding into practice and sustained to continue to drive improvements. Staff felt supported by the manager and told us they were approachable.

We found some minor discrepancies with the management of medicines. Following our inspection, the manager took action to ensure these concerns were appropriately addressed. We have made a recommendation that all medicines are documented correctly on the medication administration records.

Risks associated with people’s care were identified to keep people safe. However, risk assessments needed to contain more detail. People were safeguarded from the risk of abuse. Accidents and incidents were monitored by the manager and trends and patterns identified to mitigate future risk. The home was predominantly clean and there was a redecoration plan in place to address the décor.

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.

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

Rating at last inspection

The last rating for this service was requires improvement (published 18 May 2022). Although we saw improvements had been made, the service remains rated requires improvement. Over the past 6 years this service has been inspected 10 times and has been rated inadequate on 3 occasions and requires improvement on the remaining. This service has been rated requires improvement for the last 4 consecutive inspections.

Why we inspected

We received concerns in relation to staffing, management of risk and governance. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement.

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.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for West Melton Lodge on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.