7 March 2023
During an inspection looking at part of the service
Davigdor Lodge Rest Home is a residential care home providing personal care to up to 25 people. The service provides support to adults, many of whom were living with mental health conditions. At the time of our inspection there were 23 people using the service.
People’s experience of using this service and what we found
People were not always kept safe using the service. Risk assessments were not always completed for known risks to people or were not detailed to guide staff to support people safely. We discussed our concerns with the registered manager during the inspection who acted immediately to investigate the concerns raised and reduce the risk.
Auditing systems were not robust or effective to ensure management had oversight on identifying risk and acting on lessons learnt. The concerns found during this inspection had not been identified through internal quality assurance processes.
People medicines were managed safely and regular audits including competency checks of staff were undertaken. There were enough suitably trained staff to meet people’s needs and keep them safe. Robust recruitment processes were in place to ensure staff employed were safe to work with the people living at Davigdor Lodge.
Staff were caring in their approach towards people. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff demonstrated a good knowledge of the mental capacity act, and it was clear its principles were applied throughout everyday practices. 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.
People, relatives and staff spoke positively about the open culture at the service. They described a registered manager who was approachable and expressed confidence that any concerns raised would be dealt with appropriately.
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 good (published 27 March 2019).
Why we inspected
The inspection was prompted in part due to concerns received about risk management, staffing levels and information not being shared with appropriate external agencies. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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.
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 changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. 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 Davigdor Lodge Rest Home on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to risk management, including fire safety and oversight of quality assurance at this inspection.
Please see the action we have told the provider to take at the end of this report.
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 continue to monitor information we receive about the service, which will help inform when we next inspect.