CQC report explained · a residential care home
What the CQC found at Bartley Green Lodge Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, risks were assessed, staffing was adequate and medicines were managed safely. Some records were missing emergency guidance, but this was corrected during the inspection.
- Effective?
- Good
- Staff were trained and supported, people enjoyed the food, and healthcare needs were monitored. The home supported people to make choices and followed the Mental Capacity Act.
- Caring?
- Good
- Inspectors saw kind and compassionate interactions. Staff promoted dignity, privacy, independence and people's choices, although one person's dignity was compromised during the inspection and this was addressed immediately.
- Responsive?
- Good
- Care plans included people's needs, preferences and routines. Activities, communication support and links with the community were provided, although people had not formally contributed to planning and reviewing their care plans.
- Well-led?
- Good
- The management team was visible and approachable, and staff morale was positive. Quality systems were in place, but some audits had not identified minor issues found by inspectors.
What inspectors found, August 2019
Bartley Green Lodge Residential Care Home was rated Good; inspectors found safe, kind and personalised care, with some records and planning still needing attention.
This was an unannounced inspection on 6 and 7 August 2019. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They observed care and reviewed care, staff and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, staff were kind, medicines were given safely, and care was tailored to people's needs.
Inspectors found improvements since the previous inspection. The previous overall rating was Requires Improvement, with Safe and Well-led needing improvement. At this inspection, those areas had improved to Good.
The report also identified some minor shortfalls. These included incomplete emergency guidance in some records, limited formal involvement in care plan reviews, and basic end of life planning. The emergency guidance was corrected during the inspection.
People felt safe
People consistently said they felt safe. Staff understood safeguarding procedures, risks were managed and accident reviews were used to improve safety.
“People and their families consistently told us they felt the service was safe.” from the report
Kind and respectful care
Inspectors saw compassionate interactions. Staff supported people's dignity, privacy, independence and everyday choices.
“During our observations, interactions between people and staff were kind and compassionate.” from the report
Personalised support
Care plans recorded people's needs, preferences and routines. Staff knew how to provide care in line with these details.
“This enabled staff to provide person-centred care and support people in line with their preferences.” from the report
Good activities and community links
People could take part in activities suited to their interests, including trips and links with local organisations. Individual support was offered to people who did not want group activities.
“Links had been developed with the wider community, such as the local church and schools.” from the report
Improved leadership
The inspection found better leadership and staff morale than previously. Managers used audits, feedback and partnership working to improve the home.
“The management team had learned from previous inspections and had acted to make things better.” from the report
Residents were not formally involved in care plan reviews
needs fixingCare was reviewed, but people had not formally contributed to planning and reviewing their care plans.
“However, people had not formally contributed to the planning and reviewing of their care plans.” from the report
End of life planning was still developing
minorCare plans had only basic information about end of life wishes. The manager was working to make plans more complete and staff training was still being completed.
“Care plans did contain basic details about people's end of life wishes and preferences.” from the report
Some audits missed minor issues
minorQuality checks had not identified all the minor problems inspectors found. The manager developed the checks during the inspection.
“Some quality checks, such as care plan and environmental audits, had not identified the minor issues we found during our inspection.” from the report
One dignity issue
minorInspectors saw one occasion when a person's dignity was compromised. The manager addressed it immediately.
“We observed one person's dignity being compromised and this was immediately addressed by the registered manager.” from the report
- 01How do you now involve residents and relatives in planning and reviewing care plans?
- 02How do you make sure emergency guidance is complete and available in every relevant care record?
- 03How are residents' end of life wishes discussed, recorded and kept up to date?
- 04What changes were made to care plan and environmental audits after inspectors found that some minor issues had been missed?
- 05How do you check that dignity and privacy are consistently protected during personal care?
This was a planned, unannounced inspection covering all five CQC questions, with the previous Safe and Well-led ratings reviewed because they had required improvement. This explanation was written from the published report of 29 August 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.
What inspectors found, August 2018
Rated Requires Improvement; the home had made major progress after a previous Inadequate rating, but safety and management checks were still not reliable enough.
This was an unannounced, comprehensive inspection on 21 June 2018. Inspectors spoke with people living at the home, relatives, staff and a visiting professional. They observed care and mealtimes, and checked care plans, medicines, recruitment records and quality checks.
The home had improved since its previous inspection in February 2018. Medicines were being given as prescribed, staffing levels had increased, and people received kind, personalised care. Inspectors rated Effective, Caring and Responsive as Good.
Safety and management were still inconsistent. The home did not always learn from accidents, one recruitment file raised concerns, and audits had missed some problems. The overall rating was Requires Improvement, although the home was no longer Inadequate or in special measures.
Medicines
Inspectors checked medicines records for 12 people and found they were complete. Medicines were stored safely and given as prescribed.
“We looked at the Medication Administration Records (MARs) for 12 people and found they had been completed correctly and demonstrated people were receiving their medicines as prescribed.” from the report
Kind care
People and relatives gave positive feedback about staff. Inspectors saw staff being kind, compassionate and respectful.
“Throughout our inspection we observed a lot of positive and caring interactions between people and staff.” from the report
Personalised support
Staff knew people's backgrounds, routines and preferences. Care plans included personal details and activities were varied.
“People received personalised care that was responsive to their needs.” from the report
Improved staffing
Staff numbers had increased after dependency levels were reviewed. People and relatives said waiting times and care had improved.
“At this inspection people and their relatives told us they could see an improvement in staffing levels.” from the report
Recruitment checks
seriousOne reference raised concerns about whether a staff member was suitable to work with vulnerable people. The home had not completed an interim risk assessment.
“However, one reference raised concerns about the staff member's suitability to work with vulnerable people.” from the report
Management audits
needs fixingAudits had improved but still missed important issues, including a missing weight record and incomplete oversight of staff attending fire drills.
“Whilst there had been significant improvements they had not always been effective.” from the report
Accessible information
needs fixingThe home had not fully offered information in formats such as large print, pictorial information or another language. Complaint and speak-up information was also not available in accessible formats.
“The registered provider had not fully offered people the opportunity to receive information in alternative formats such as an alternative language, large print or pictorial format.” from the report
- 01How are accidents and repeated falls reviewed, and what changes have been made to reduce the risk of them happening again?
- 02How do you check that every new staff member is suitable to work with vulnerable people when references raise concerns?
- 03How do you make sure audits identify missing records, including weight monitoring and fire drill attendance?
- 04How will you provide care information, complaint details and speak-up information in formats each person can understand?
- 05How are people's end of life wishes recorded, including their personal, religious, comfort and pain relief preferences?
This was an unannounced comprehensive follow-up inspection covering all five key questions and checking progress since the February 2018 inspection. This explanation was written from the published report of 8 August 2018 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 Bartley Green Lodge Residential Care Home
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- August 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Bartley Green Lodge Residential Care Home →
- August 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Bartley Green Lodge Residential Care Home →
- May 2018Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 29 November 2012.
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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