12 July 2023
During a routine inspection
The Lodge is a residential care home providing accommodation and personal care for up to 20 people. At the time of our inspection there were 18 people living in the home.
People's experience of using this service and what we found
Improvements were needed to the governance systems as they failed to bring about the required improvements to the service people received and drive improvements to the overall rating for the service. At the previous three inspections, the service has been rated requires improvement or inadequate.
Risks were not always monitored accurately, and some risks assessments were out of date or missing. These concerns were not systemic across the service, but this placed people at risk of receiving inappropriate care that didn't meet their needs safely. We have made a recommendation about this.
We identified issues of concern with infection prevention and control practices being followed within the kitchen area and the use of PPE. We have made a recommendation about this.
Medicines management had improved, and people had their medicines as prescribed. Staff had received training on administering medicines and their competence was regularly checked.
People and their relatives told us staff were kind and caring towards them and they felt safe living at the service. Staffing levels were good and appropriate to ensure people's needs were met in a safe, timely and consistent way.
Safety checks of the premises and fire safety checks were undertaken and there were plans in place in the event of an emergency evacuation. Staff had completed individual personal emergency evacuation plans for people to support with safe evacuation.
Staff were knowledgeable about people's health needs and the provider worked in partnership with other health professionals as a measure of providing the appropriate level of support.
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 and update
The last rating for this service was requires improvement (published 17 December 2021) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, whilst some improvements have been made, the provider remains in breach of regulation. The service remains rated requires improvement. This service has been rated requires improvement or inadequate for the last three consecutive inspections.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
Enforcement and Recommendations
We have identified a breach in relation to good governance and oversight of the home.
We have made recommendations about the systems in place for monitoring risk, accurate recording of peoples diet and fluids, infection prevention and control measures.
Please see the action we have told the provider to take at the end of this report.
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.