CQC report explained · a nursing home
What the CQC found at Annandale Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found detailed risk assessments, safe medicines systems, suitable infection control measures and enough consistent staff.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Outstanding
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found open and supportive leadership, regular quality checks, clear staff responsibilities and ways for people and relatives to give feedback.
What inspectors found, October 2023
Annandale Lodge is rated Good; inspectors found safe care, well-managed medicines and strong leadership.
This was an unannounced inspection on 10 October 2023. Two inspectors and an expert by experience visited the home. They spoke with people, relatives and staff, and reviewed care records, medicines records, recruitment files and management records.
The home was rated Good for Safe and Well-led. Inspectors found that people were protected from avoidable harm, risks were assessed, medicines were managed safely and infection control arrangements were in place. Staffing was consistent, and staff knew people's needs.
People, relatives and staff spoke positively about the care and leadership. The home had systems to check quality, learn from incidents and act on suggestions. The overall Good rating remained unchanged from the previous inspection in 2017.
Risk management
People had detailed risk assessments, which were updated when their needs or risks changed. Staff said these records accurately described how people should be supported.
“People had detailed risk assessments in place which guided staff on how to keep people safe.” from the report
Consistent staffing
Inspectors found enough staff to meet people's needs without rushing. The home did not use agency staff, so people were supported by staff who knew them well.
“The service did not use agency staff, so people were supported by a staff team who knew them well.” from the report
Medicines
Medicines were ordered, stored, given and disposed of safely. The manager carried out regular audits and care plans included information about complex medicines.
“Safe processes were in place for all areas of medicines practice including ordering, administration, storage, and disposal.” from the report
Leadership
People, relatives and staff gave strong positive feedback about management. Staff felt supported and said the manager was approachable.
“We received consistently high praise in relation to the management and leadership of the service.” from the report
Listening to feedback
People and relatives could raise suggestions in meetings. Inspectors saw that a request for armchair exercises was added to the activities programme.
“Monthly meetings were in place for people and relatives, and we saw areas of discussion included activities, staff recruitment and menus.” from the report
Inspectors raised no specific concerns in this report.
- 01How quickly will my relative's risk assessment and care plan be updated if their condition or risks change?
- 02How will you explain and monitor my relative's medicines, especially if they have complex medicines or medicines taken as required?
- 03How do you maintain staffing levels and continuity when regular staff are absent?
- 04What improvements have resulted from recent accident, incident or medicines audits?
- 05How can my relative and our family raise suggestions or concerns, and how will we be told what action was taken?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the Effective, Caring and Responsive ratings were not inspected and carried over from the previous inspection. This explanation was written from the published report of 25 October 2023 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, November 2020
Inspected but not rated; inspectors were assured about the home's infection prevention and control measures.
This was an announced inspection on 03 November 2020. It was part of a CQC thematic review of infection prevention and control in care homes during the coronavirus pandemic.
Inspectors found good practice in visitor checks, communication about changed procedures, personal protective equipment, testing, social distancing, cleaning and infection outbreak arrangements. They were assured that the home was using safe infection prevention and control procedures.
The home was inspected but not rated. This was a focused review of infection prevention and control, not a full assessment of all five areas of care.
Visitor infection controls
The home had an entry process for visitors and regularly told them about changes to procedures intended to keep people safe.
“this included a process all visitors had to complete when entering the building.” from the report
Support for wellbeing
People had access to an activity co-ordinator and allocated one-to-one time with staff.
“people also had allocated one to one time with a staff member.” from the report
PPE checks
A PPE champion was assigned on each shift to check supplies and correct use of PPE.
“The PPE Champion ensured that there was enough PPE in the designated station” from the report
Staff and environment checks
The home used checks to monitor the environment and staff competence in keeping people safe.
“The registered manager had robust checks in place to ensure not only the environment met the requirements to keep people safe” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently check visitors before they enter the home, and how are changes to visitor procedures communicated?
- 02Is there still a PPE champion on every shift, and how do you check that PPE is available and used correctly?
- 03How do you currently arrange testing for residents and staff?
- 04How do you manage new admissions and prevent infection outbreaks?
- 05How will my relative receive activities and one-to-one time with staff?
This was a focused thematic inspection of infection prevention and control; it did not provide ratings for the other areas of care. This explanation was written from the published report of 25 November 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 Annandale Lodge
3 rated inspections over 8 years: the service has held its Good rating throughout.
- October 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not rated
- October 2017Goodstayed GoodSafe: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 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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