CQC report explained · a nursing home
What the CQC found at Barons Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Safe was not inspected during this focused visit. Its previous rating was carried forward.
- Effective?
- Good
- Effective was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- Caring was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- Responsive was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found that management, staff training, audits and feedback systems had improved. The home was no longer in breach of the governance regulation.
What inspectors found, November 2022
Rated Good after improvements; this focused inspection found the home was well-led, with no current breaches.
This was an unannounced, focused inspection on 3 November 2022. One inspector spoke with people living at the home, managers and care workers. They reviewed training records, audits, meeting minutes and other records.
The inspection looked only at whether the home was well-led. Inspectors found improvements in the building, staff training and checks on quality, medicines and safety. People and staff gave positive feedback about the home and its management.
The home was rated Good overall and Good for well-led. The previous rating was Requires Improvement because of problems with governance. The other four ratings were carried forward from the previous inspection rather than checked during this visit.
Improved building
The home had completed extensive refurbishment work. This included new flooring, lighting, fire-resistant doors, handrails and improved access to the garden.
“Extensive refurbishments works had been completed in the home.” from the report
Better quality checks
The provider used regular audits covering health and safety, infection control, care plans, medicines and staff files. Directors also visited monthly.
“The provider completed a number of audits to monitor the quality of service.” from the report
Training monitored
Staff training was up to date, and managers were alerted when training needed renewal. This was followed up in supervision.
“At this inspection, we found staff training was up to date and there were governance processes in place to monitor this on an ongoing basis.” from the report
Positive feedback
People and staff said the home was friendly, caring and well managed. The home also held meetings and gathered feedback from people, relatives and staff.
“People using the service told us they liked living at the home and staff were friendly and caring.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current ratings and recent findings for Safe, Effective, Caring and Responsive, which were not checked at this inspection?
- 02How often are the health and safety, infection control, care plan and medicines audits completed now?
- 03How do you make sure staff training remains up to date when alerts show that training is due to expire?
- 04What progress has been made with the development and learning plan, including the possible electronic care planning system?
- 05How are feedback from residents, relatives and staff acted on and checked?
This was a focused inspection of Well-led only; the other four ratings were carried forward from the previous inspection. This explanation was written from the published report of 18 November 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 2021
Barons Lodge was rated Requires Improvement; inspectors found people safe and positive about their care, but oversight and premises checks were not reliable.
This was an unannounced focused inspection on 9 June 2021. Inspectors looked mainly at Safe and Well-led, and also checked specific concerns about staff training, the premises and the Mental Capacity Act. They spoke with seven people, staff and managers, contacted two relatives, and reviewed care plans, staff files, medicines records, audits and maintenance records.
People and relatives said they felt safe and were happy with the care. Inspectors found enough staff, robust recruitment checks, good risk management, safe medicines support overall and suitable infection control. Staff understood safeguarding and how to support people who might show behaviour that challenged.
The main problems were with management checks and follow-up. Some fire doors, windows, radiators, furniture, lighting and access to the garden needed attention. Training records had gaps, and audits had not always found or resolved problems. The overall rating fell from Good to Requires Improvement, while Safe stayed Good. Well-led fell to Requires Improvement. Effective was inspected but not rated, and Caring and Responsive were not inspected at this visit.
Enough staff
Inspectors found enough staff on duty, with staff responding quickly to requests. The home had not recently used temporary agency staff, supporting continuity.
“There always seems to be plenty of staff around” from the report
Risk and safeguarding
People had regular risk assessments and care plans. Staff understood how to report abuse and support people safely, including people whose behaviour could challenge.
“People were supported to remain as safe as possible through effective risk management procedures.” from the report
Infection control
Inspectors were assured that infection control procedures, including COVID-19 precautions, were being followed. Staff used protective equipment correctly and the premises were hygienically clean.
“We were assured the service was following safe infection prevention and control (IPC) procedures, including those associated with COVID-19.” from the report
People felt safe
People and relatives said they felt safe. Inspectors also found staff knew how to raise safeguarding concerns and that the provider worked with the local authority when concerns arose.
“People told us they felt safe living at the care home.” from the report
Weak governance and follow-up
seriousAudits did not always identify problems or show that known issues had been fixed. This led to a breach of Regulation 17 and placed people at risk of harm, although inspectors found no evidence that anyone had been harmed.
“Systems were either not in place or robust enough to demonstrate safety was effectively managed.” from the report
Fire and premises safety
seriousSeveral fire-resistant doors were held open or had faulty release mechanisms. Inspectors also found a damaged light switch, missing wardrobe doors, a broken chair, an uncovered radiator, windows screwed shut and an uneven route to the garden.
“Several fire resistant doors were inappropriately held open and fitted with faulty fire door release mechanisms.” from the report
Gaps in staff training
needs fixingTraining records showed that some staff had not completed refresher training in safeguarding, the Mental Capacity Act, or fluids and nutrition.
“10 out of 21 had not completed Mental Capacity Act training” from the report
Medicines counting error
needs fixingOne as-needed medicines count did not match the number of tablets present. The provider's medicines audit had not identified the error.
“We saw one example where PRN medicines were counted incorrectly” from the report
- 01What has been done to repair the faulty fire-door release mechanisms and ensure fire doors close properly?
- 02Have the damaged light switch, broken chair, missing wardrobe doors, uncovered radiator and uneven garden access been repaired?
- 03How many staff have now completed the outstanding safeguarding, Mental Capacity Act, and fluids and nutrition training?
- 04How are audits now checked to make sure identified problems are followed up and resolved?
- 05What changes have been made to prevent medicines counting errors, including errors with PRN medicines?
This was a focused inspection of Safe and Well-led, with targeted checks within Effective; Caring and Responsive were not inspected and some previous ratings carried over. This explanation was written from the published report of 25 July 2021 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 Barons Lodge
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementEffective: Inspected but not ratedWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- February 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2013
Registered with the Care Quality Commission on 25 January 2013.
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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