5 December 2023
During an inspection looking at part of the service
People’s experience of the service and what we found:
The registered manager and provider had not put in place effective systems to protect people from risk. Improvements were needed to formal systems throughout the service, particularly in the oversight of risk and people’s safety.
Information relating to people's individual risks was not always recorded or did not provide enough assurance that people were safe.
Systems were in place for accidents and incident recording however lessons were not learned, and improvements were not always made when things went wrong. People were not protected by the prevention and control of infection.
Staff had built positive relationships with people living in the service. However, not all care plans contained enough information to ensure staff knew the persons history and life story to deliver appropriate person-centred care.
The leadership, management and governance arrangements did not provide assurance the service was well-led, that people were safe, and their care and support needs could be met.
People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests.
Staff were recruited in line with requirements and there was a consistent staff team. People had enough food and drink to meet their nutritional needs. The service worked with other organisations to ensure they delivered joined-up care and support and people had access to healthcare services when needed.
There was a homely and relaxed atmosphere between people and staff. People and their relatives told us they were treated with care and kindness. One family member said, “All the staff really care about the residents. There is lots of stimulating activities. Food is very good. It has a lovely warm and homely feel. As a family we are very happy with the level of care [relative] receives at The Lodge.” Another family member said, “My [relative] has been treated with kindness and compassion from the staff.”
Medicines were well managed, and staff received training to help ensure they were sufficiently skilled.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
The last rating for this service was Good when last inspected in March 2019. The report was published 4 April 2019.
Why we inspected
The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk and peoples safety of people. This inspection examined those risks. A decision was made for us to carry out a responsive 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.
Enforcement and Recommendations
At this inspection we have identified breaches in relation to safe care and treatment, need for consent and governance arrangements. Please see the action we have told the provider to take at the end of this report.
Follow up
We have requested 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 continue to monitor information we receive about the service, which will help inform when we next inspect.
You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Lodge on our website at www.cqc.org.uk.