CQC report explained · a nursing home
What the CQC found at Bentley Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Rated Good overall; inspectors found kind, improved care, but the Safe rating was Requires Improvement because some safety checks and records were not yet fully reliable.
This was an unannounced focused inspection on 27 and 28 April 2021. Inspectors spoke with four people, nine relatives and ten staff. They reviewed care and medicines records, staff files and management information.
The home had improved since the previous inspection. People and relatives described staff as kind, gentle and caring. Inspectors found enough staff, safer medicines processes, better care planning and stronger management oversight.
Safety was still rated Requires Improvement. Fire risk assessment actions were not yet fully completed. Some recruitment checks, cream records, medicine trolley temperature checks and PPE use needed improvement. Caring and Well-led were rated Good. The overall rating changed from Requires Improvement to Good.
Kind and respectful care
Inspectors saw staff treating people with patience, kindness and compassion. Staff spent time talking with people and supported their privacy and independence.
“People were observed to be happy and calm in the company of staff.” from the report
Enough staff
Staffing levels were based on people's needs. Inspectors saw a calm atmosphere, with call bells answered promptly and care provided without rushing.
“There were sufficient staff rostered to keep people safe and to meet their needs, in an unrushed manner.” from the report
Improved management
The manager had introduced stronger audits, clearer accountability and regular meetings about risks and actions. Staff and relatives reported better communication and leadership.
“Quality assurance arrangements were consistent and effective at driving improvements within the service.” from the report
Improved care planning
Care plans were being moved to a new electronic system and were more focused on people's needs and preferences. Staff were encouraged to add their knowledge of each person.
“People's care plans were more centred on their needs and preferences about their care and how these should be achieved for them.” from the report
Fire safety work unfinished
needs fixingA new fire risk assessment identified several actions. An action plan was in place, but the recommended work was not fully completed at the inspection.
“It will take further time to fully complete these planned works.” from the report
Some safety records needed correction
needs fixingOne person's risk assessment did not match their current risks. Some topical cream records were not signed, and two medicine trolleys did not have their temperatures checked.
“One person's risk assessment did not accurately reflect their current risks.” from the report
Recruitment checks were incomplete
needs fixingSome staff recruited during the COVID-19 outbreak did not initially have all the required pre-employment checks. The manager completed the checks and introduced measures to prevent a repeat.
“We found records for staff recruited during the home's COVID-19 outbreak lacked some pre-employment checks.” from the report
Occasional PPE concerns
needs fixingInspectors were only partially assured that PPE was always used correctly. They saw isolated occasions when staff did not use it effectively, and the manager addressed this immediately.
“We did observe isolated occasions when individual staff did not use their PPE effectively.” from the report
- 01What work from the new fire risk assessment has now been completed, and what is still outstanding?
- 02How do you check that every new staff member has completed all required recruitment checks before starting?
- 03How do you audit topical cream records and medicine trolley temperatures?
- 04What checks are now in place to make sure staff use PPE correctly on every shift?
- 05How will you make sure every care plan and risk assessment on the new electronic system reflects the person's current needs?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 29 May 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.
What inspectors found, January 2021
Bentley Lodge Care Home was rated Requires Improvement, with Safe rated Inadequate and serious concerns about infection control, staffing, medicines and risk management.
This was an unannounced focused inspection on 26 November 2020. Inspectors looked at Safe and Well-led, then added Caring after finding further concerns. They spoke with seven people, ten relatives and 12 staff, and reviewed care, medicines, staff and management records.
Inspectors found people’s physical needs were usually met and many people liked the staff. However, infection control was not safe enough. Equipment and the building were not always properly maintained. Medicines records were incomplete, staffing levels were not sufficient, and some people faced unnecessary restrictions on movement.
People’s emotional needs, independence and relationships were not supported well enough. Management oversight and quality checks were not effective. The overall rating fell from Good at the previous inspection, published in December 2017, to Requires Improvement. The report says the manager started taking action after the visit, but CQC planned to return and monitor progress.
Kind staff
People and relatives generally said staff were polite and kind, and people’s physical needs were met.
“People and their relatives told us overall, their physical needs were met, and they liked the staff who were kind.” from the report
Safeguarding knowledge
Staff had completed safeguarding training and understood how to recognise and report possible abuse.
“Records showed staff were up to date with their safeguarding training and those spoken with demonstrated an understanding of the signs of abuse and how to report any concerns.” from the report
Medicine training
Staff who gave medicines had received training and had their competence checked.
“All staff administering medicines had their competency to do so assessed.” from the report
Community links
The home kept links with a chaplain and community volunteers during the pandemic.
“There was evidence the service had contact with the local Chaplain, who provided a weekly letter which was shared with people who had previously attended the home's church service.” from the report
Infection control
seriousVisitors were not always screened, social distancing was not consistent, PPE was not always used correctly, testing was incomplete and some areas and equipment were not clean.
“Processes, systems and staff practices to protect people from the risk of acquiring an infection were not adequate.” from the report
Unsafe equipment and premises
seriousSome mattresses and call bells did not work, shower rooms needed repair, and risks linked to fire and Legionella had not been properly managed.
“The failure to ensure the environment and equipment provided for people were safe and properly maintained and the failure to mitigate identified risks was a breach of regulation 12” from the report
Too few staff
seriousCall bells rang repeatedly and the home could not show that people’s needs were being used accurately to set staffing levels. Staff were also covering laundry, phones and management duties.
“There were not sufficient numbers of suitable staff rostered to keep people safe and meet their needs.” from the report
Medicines records
seriousThe times for some time-specific medicines were not recorded. Liquid medicines were not always dated, and some cream records were unsigned.
“People's medicines were not managed safely. Some people were on time-specific medication, for conditions such as Parkinson's disease.” from the report
Restrictions and wellbeing
seriousSome people in the discharge-to-assess beds stayed in their rooms after 14 days and may not have consented to these restrictions. People also had too little social contact, activity and rehabilitation.
“People accommodated in the 'discharge to assess' beds had been subjected to unnecessary restrictions on their movement once their 14 day self-isolation period had ended.” from the report
Weak oversight
seriousAudits did not reliably identify problems, and improvement plans did not clearly say who was responsible or when actions should be completed.
“Quality assurance arrangements were not consistent or effective at driving improvements in the service.” from the report
- 01What has changed in infection control, including visitor screening, PPE use, social distancing, testing and cleaning?
- 02How do you now calculate staffing levels from each person’s actual needs, and how quickly are call bells answered?
- 03How are time-specific medicines recorded and checked, especially medicines for Parkinson’s disease?
- 04How do you make sure people can leave their rooms, maintain independence and receive activities or rehabilitation?
- 05What actions have been completed after the two warning notices, and what evidence can you show that they are working?
This was a focused inspection of Safe and Well-led, with Caring added during the visit; Effective and Responsive were not inspected and earlier ratings were carried over. This explanation was written from the published report of 27 January 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 Bentley Lodge Care Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2021Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2021Requires improvementdown from GoodSafe: InadequateCaring: Requires improvementWell-led: Requires improvement
- December 2017GoodSafe: GoodCaring: GoodWell-led: Good
- June 2017
Registered with the Care Quality Commission on 16 June 2017.
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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