CQC report explained · a residential care home
What the CQC found at Alma Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found unsafe medicines handling and weak quality checks, although staffing and day-to-day support had strengths.
This was an unannounced, focused inspection on 13 May 2022. One inspector spoke with people, staff, managers, relatives and a visiting professional. Records about care, medicines, staffing, safety and management were also checked.
The home was not always safe. Some medicines were not recorded correctly, guidance for medicines given when needed was missing, and a loose tablet was found in the medicines trolley. Inspectors also found risks from a window, rubbish and incomplete safety records. The home took immediate action on some of these issues.
The home had enough staff to meet people's needs, followed safer recruitment checks and had staff who understood safeguarding. People and relatives gave positive feedback about the managers and staff. However, quality checks had failed to identify important problems.
The overall rating was Requires Improvement. Safe and well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in calculating the overall rating.
Enough staff
People and relatives said staff were available and responded to needs in good time. Recruitment checks were completed before new staff started.
“People and relatives told us there were enough staff to respond to people's needs in a timely way.” from the report
Safeguarding awareness
Staff understood how to recognise and respond to abuse and discrimination. Managers understood local safeguarding procedures and had responded appropriately to previous concerns.
“Staff understood the need to respond to any concern and had access to relevant contact numbers if they needed to make a referral.” from the report
Positive relationships
People were comfortable in the home and relatives said they felt people were safe. Feedback about the managers and staff was positive.
“People were relaxed in the service and saw the service as their own home.” from the report
Mental capacity practice improved
The home was no longer in breach of the regulation about consent and the Mental Capacity Act. Staff had received further training and restrictions were recorded.
“We found the service was working within the principles of the MCA.” from the report
Medicines were not always safe
seriousSome medicines were not entered in the required register. Guidance for medicines given when needed was missing, and a loose tablet could not be explained.
“Medicines were not always stored or given as prescribed. Therefore, the provider is in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Quality checks missed risks
seriousAudits did not identify the medicines problems or environmental risks. This was a continuing breach of the good governance regulation.
“The provider had failed to assess, monitor and improve the service.” from the report
Incomplete safety records
needs fixingThe night duty rota and fire risk assessments were not fully accurate or up to date. The home also had not notified CQC promptly about a recent safeguarding matter.
“Some records and documents were not complete or accurate.” from the report
Environmental risks
needs fixingA first-floor window restrictor had been removed, and rubbish in the garage and smoking room posed possible risks. The manager said these issues were dealt with after the inspection.
“We found rubbish had accumulated in the garage and smoking room posing a possible fire risk.” from the report
- 01What changes have you made to ensure every medicine is stored, recorded and given as prescribed?
- 02How do staff decide when to give medicines prescribed 'as and when required', and where are the written guidelines?
- 03How do you now check that medicines audits identify errors or missing records?
- 04Have all windows, fire risks and fire risk assessments been checked and updated since the inspection?
- 05What progress has been made on the action plan sent to CQC for the Regulation 12 and Regulation 17 breaches?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 22 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
Alma Lodge Care Home was rated Requires Improvement; inspectors found kind, responsive care but serious medicines, consent and management record problems.
Inspectors visited on 13 and 14 March 2019. The first day was unannounced and the second was announced. They spoke with people, relatives, staff and a visiting professional, and reviewed care plans, staff files, medicines, incident records and audits.
People were treated kindly and staff responded to their individual needs. Staffing levels were sufficient, the home was clean, activities were available and people had choices about meals, daily routines and where to spend their time.
The main problems were medicines not always given at the prescribed time, weak mental capacity assessments, gaps in staff recruitment checks, incomplete care records and poor quality monitoring. The provider breached three care regulations and two notification regulations.
The overall rating stayed at Requires Improvement, as did Safe, Effective and Well-led. Caring and Responsive were rated Good. The provider had improved some issues found at the previous inspection, but Safe and Effective remained Requires Improvement for the second time and Well-led for the fourth time.
Kind and respectful staff
People and relatives described staff positively. Inspectors saw staff speaking calmly, giving people time to respond and protecting their privacy and dignity.
“People were treated with kindness and compassion in their day to day contact with staff.” from the report
Enough staff on duty
Inspectors found staffing levels sufficient and saw call bells answered promptly. People said they felt safe.
“We noticed during our inspection that people's call bells were always answered promptly.” from the report
Personal choices
People could choose when and where to eat, what food to have and whether to join activities. Staff responded to individual communication needs.
“People were able to make their own choices about their social needs.” from the report
Clean environment
The home was clean and communal areas were free from trip hazards during the inspection. Staff used protective clothing and hand sanitisers.
“The home was seen to be clean, tidy and communal areas kept free from trip or other hazards throughout.” from the report
Approachable manager
People, relatives and staff said the manager was supportive and available. Inspectors saw that the manager knew people well and was involved in daily care.
“People were positive about the management of the service.” from the report
Medicines given late
seriousTwo people's time-specific medicines were given late, while records showed the earlier prescribed times. There were also no separate protocols for medicines given when needed.
“Medicines were not consistently given as prescribed.” from the report
Mental capacity decisions
seriousCapacity assessments were completed for everyone rather than only where needed. They were not linked to specific decisions, and a sensor mat restriction had not had the required assessment.
“Staff were not working in line with the principles of the Mental Capacity Act 2005.” from the report
Incomplete care records
needs fixingSome care plans lacked important health and care details, were difficult to read and used language inspectors considered inappropriate. Records also contained conflicting instructions about a sensor mat.
“Care plans lacked detail regarding people's health and social needs.” from the report
Weak audits and feedback
needs fixingAudits often confirmed that documents existed but did not analyse what they found. There were no recorded formal meetings and relatives had not been sent surveys.
“The audit systems were not robust and did not identify the matters we identified during our inspection” from the report
Late or missing notifications
seriousFive deaths were notified together after delays. Two serious falls were not notified to CQC, although relevant professionals and relatives had been contacted.
“Neither had been notified to CQC.” from the report
- 01How are time-specific medicines now given and recorded, and how do you check the actual administration times?
- 02What has been done to investigate whether late medicines were linked to the person's falls?
- 03How do you make mental capacity assessments for each specific decision, including restrictions such as sensor mats?
- 04What dementia and epilepsy training have staff completed since the inspection?
- 05How are care plan audits, staff meetings and feedback from relatives recorded and acted on?
This was a planned inspection covering all five CQC key questions, with an unannounced first day and an announced second day. This explanation was written from the published report of 3 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Alma Lodge Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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