CQC report explained · a residential care home
What the CQC found at Amethyst Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some areas needed a deep clean, and waste, laundry and equipment arrangements created infection risks. Staffing was sometimes below safe numbers, although medicines were administered as prescribed and action was taken after the inspection.
- Effective?
- Requires improvement
- People received appropriate food, fluids and healthcare, and staff worked with outside professionals. However, training refreshers, mental capacity reviews, nutrition records and parts of the environment needed improvement.
- Caring?
- Requires improvement
- Inspectors saw kind and respectful interactions, and people had privacy in their bedrooms. But there was little formal feedback, and people were not always involved in reviewing their care plans or setting meaningful goals.
- Responsive?
- Requires improvement
- People had activities, community access and support to keep in touch with family and friends. However, care records and goals were not always accurate, up to date or person-centred, and staffing sometimes cut short outings.
- Well-led?
- Requires improvement
- The home had no registered manager at the inspection, and audits and team meetings were not completed consistently. This meant problems with infection control and care records were not identified quickly enough.
What inspectors found, December 2022
Amethyst Lodge was rated Requires Improvement; inspectors found kind care and some good support, but serious gaps in infection control, records and management.
This was an unannounced comprehensive inspection on 31 October and 7 November 2022. One inspector spoke with people, staff and professionals, observed care, and checked care plans, medicines records, complaints, incidents, rotas and audits.
The home supported four adults with learning disabilities or autistic people. Inspectors saw kind interactions, and people received their medicines, food and healthcare. People also took part in activities and went into the community.
However, the home was not always safe or well managed. Inspectors found cleaning and waste-handling problems, overdue reviews of care and risk records, gaps in staff training, staffing shortages and incomplete quality checks. The home was in breach of three regulations.
All five areas were rated Requires Improvement. The home had the same overall rating as at the previous inspection in March 2020. Caring changed from Good to Requires Improvement.
Kind relationships
Inspectors saw staff interacting kindly and respectfully. The core team knew people well and had positive relationships with them.
“We observed staff interacting with people throughout the day in a kind and respectful manner.” from the report
Medicines
People received prescribed medicines, and medicines records were up to date. Staff had instructions for medicines used when needed.
“People received their medicines as prescribed. Medicine administration records were up to date and well completed.” from the report
Choice and activities
People chose activities, went into the community and maintained contact with family and friends. They could also choose meals and have alternatives.
“People's activity logs showed regular access to the community, and we also observed staff asking people where they would like to go on both days that we visited.” from the report
Healthcare support
Healthcare appointments were arranged when needed, and staff followed professional advice. The home worked with GPs, behaviour specialists and dietitians.
“The service worked well with other agencies, such as GPs, behaviour specialists, and dietitians.” from the report
Infection control
seriousSome areas, including bedrooms, needed deep cleaning. Waste bins, PPE storage, clinical waste and laundry arrangements did not adequately reduce infection risks.
“Clinical waste streams were not in place to ensure waste which may be contaminated was disposed of in line with guidance.” from the report
Staffing and recruitment
seriousStaffing was sometimes below safe numbers and agency staff were used heavily. Recruitment records contained gaps, including an incomplete risk assessment and a missing new DBS check in one case.
“Rotas showed this had not always been possible, and at times the shift ran below safe numbers.” from the report
Care records and involvement
seriousCare plans, risk assessments and goals were not always reviewed or person-centred. People were not always involved in creating or discussing their plans.
“The quality of records made it difficult to track progress for people's set goals, and there was a lack of evidence to show involvement with people.” from the report
Management checks
seriousAudits were missed, and there was no registered manager in post. The manager's time was also spent covering staffing shortages, reducing time for quality checks.
“Audits which monitored the quality and safety of the service had not been completed consistently.” from the report
Training
needs fixingSeveral staff were overdue refresher training in areas including infection control, medicines and the Mental Capacity Act. The system for tracking training was difficult to check.
“Systems used to monitor staff training and competence needed to be improved as it was difficult to ascertain which staff had completed which training” from the report
Outings and environment
needs fixingStaffing and medicines duties sometimes meant people returned early from outings. The home was also plain and needed changes to better support autistic people and people with learning disabilities.
“We have to be back by 4pm to do medicines so this does sometimes cut short people's day's out.” from the report
- 01What has been done to deep clean the home and correct the waste, PPE and laundry arrangements?
- 02How many permanent staff now work at the home, and how often are agency staff used?
- 03How are care plans, risk assessments and mental capacity decisions now reviewed with each person?
- 04What checks show that staff training and refresher training are up to date?
- 05Who is now responsible for the home, and how are audits being completed and acted on?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 22 December 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, March 2020
Rated Requires Improvement; inspectors found kind care and better community access, but records, risk checks and oversight still needed work.
The inspection took place on 12 and 14 February 2020. One inspector and one assistant inspector spoke with people, staff, a relative and professionals. They reviewed care records, medicines records, staff files and management records.
People were treated kindly and supported to make choices, stay independent and use the local community. Staffing had improved since the last inspection, and people were going out more often. Staff knew people well and worked together.
However, some risk assessments, care records and medicines paperwork were inaccurate, incomplete or out of date. Records did not always show that people had helped create their care plans. The home had legal breaches for person-centred care and good governance, and not enough improvement had been made since the previous inspection.
Kind and respectful staff
Inspectors saw respectful and sensitive interactions. People and relatives valued the support, and staff knew people's preferences and needs.
“People were treated with respect and kindness. We observed respectful and sensitive interactions between people using the service and staff.” from the report
More community access
People were going out more regularly than at the previous inspection. Staff also asked people what they wanted to do on the day.
“At this inspection we found improvement; people's activity logs showed regular access to the community, and we also observed staff asking people where they would like to go on the day.” from the report
Stable staff team
Staffing levels had improved and people received support from a consistent team who knew them well.
“There was a stable staff team in place, and people received support from a consistent team of staff they knew.” from the report
Care records were not reliable
seriousSome care and health plans contained different information, and updates were sometimes missing. This could mean staff missed important details about people's needs or risks.
“Care records were not always updated to include relevant information. Information across the care records were not always consistent.” from the report
Risk and medicines paperwork
needs fixingSome risks were not fully assessed or updated. Medicines documentation needed improvement, including records for handwritten entries and arrangements for medicines when people were away from the home.
“Risks had been assessed and those identified were safely managed; however, for some people these were not always accurate, updated, or in place.” from the report
Mental Capacity Act records
needs fixingCapacity assessments did not always cover each decision separately, and some best-interests records were missing. The report recommended that care records be reviewed.
“Where DoLS applications had been made, there were no capacity assessments and associated best interests decisions in relation to this.” from the report
Checks did not find all problems
seriousThe home's monitoring systems had improved but did not identify all the record inconsistencies found by inspectors. More regular care-record audits were needed.
“Governance systems in place had not been wholly effective as they had not identified issues we found during the inspection.” from the report
Limited specialist training
minorStaff had completed many relevant courses, but training about supporting people with learning disabilities and autism was limited. End of life training had also not yet been completed.
“However, we found that staff training in relation to supporting people living with these conditions was limited.” from the report
- 01How have you made sure information in people's support plans and health plans is now consistent and up to date?
- 02How do you record and review risks such as alcohol use, hot surfaces, medicines refusal and community access?
- 03How are capacity assessments and best-interests decisions recorded for each individual decision?
- 04How do you check that medicines records are double-signed and that arrangements for medicines during social leave are safe?
- 05What action has been taken to improve governance checks and specialist training for learning disabilities and autism?
This was a planned inspection of the care home covering all five key questions; inspectors spoke with two people and reviewed two care records and three medication records. This explanation was written from the published report of 17 March 2020 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 Amethyst Lodge
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2019Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2018
Registered with the Care Quality Commission on 5 April 2018.
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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13 live-in carers within about an hour of Norfolk
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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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