West Lodge Care Home

Updated 14 March 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.

Inspection team

Two inspectors commenced this inspection on 27 July 2022 and two inspectors returned to complete the inspection on the 9 August 2022.

Service and service type

West 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 Lodge is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced on the 27 July 2022 and announced on the 9 August 2022.

What we did before the inspection

We reviewed information we 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 requested feedback from Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used all this information to plan our inspection.

During the inspection

We spoke with four members of staff including the clinical lead and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We spoke with three people who use the service about their experience of the care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included five people’s care records and four medicine records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 14 March 2023

About the service

West Lodge is a care home providing accommodation for people who require nursing or personal care in one adapted building. The service provides support to adults over 65 years who may have dementia or physical disabilities. The service can accommodate a maximum of 27 service users. At the time of our inspection there were 18 people using the service.

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

There was a lack of consistency in how the service was managed and led. There were no clear roles and responsibilities for staff who were managing the service.

People were not always protected against avoidable harm. When people’s needs changed, responses were slow in ensuring people had appropriate support. Some care records did not accurately reflect risks to people or how these were managed.

People were not supported to have maximum choice and control of their lives. The systems in place did not always mean people were supported in the least restrictive way and in their best interests.

People had access to health care professionals. The management team were building relationships with local health professionals and where necessary, made referrals for additional advice and support.

Staff were recruited safely, and staffing levels were sufficient to support people's needs. Staff had received training that was appropriate to their role.

Following our feedback, the provider began to address our concerns demonstrating their commitment to improving the standard of care delivered to people.

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 6 August 2021).

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.

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 based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

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

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, consent and good governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.