CQC report explained · a residential care home
What the CQC found at Bury Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always given as prescribed, some stock was unavailable and administration records were incomplete. Risk assessments for known risks were also missing or lacked enough detail.
- Effective?
- Requires improvement
- Care assessments did not always reflect people's current needs or best practice. Staff training and inductions were not consistently up to date or completed.
- Caring?
- Good
- Inspectors saw kind and respectful interactions. People were supported with dignity, independence and everyday choices.
- Responsive?
- Requires improvement
- Care plans did not always contain current information about people's preferences and communication needs. Activities took place, but people's views about them were mixed and none were organised at weekends.
- Well-led?
- Requires improvement
- The manager was approachable, but quality checks did not identify important problems with medicines, records and risk assessments. Responsibilities and oversight were not always clear.
What inspectors found, April 2020
Rated Requires Improvement; inspectors found kind care, but medicines, staff training, care records and oversight were not reliable enough.
This was an unannounced inspection on 30 and 31 January 2020. Inspectors spoke with people, relatives, the manager and staff. They observed care and reviewed medicines, care plans, recruitment records, training records and management checks.
People generally said they felt safe and staff were kind, respectful and available. The home was clean, food was good and people were supported to make everyday choices. Inspectors also saw friendly interactions and activities taking place.
However, medicines were not always given as prescribed, some medicines were unavailable and records were incomplete. Risk assessments and care plans did not always give staff enough current information. Staff training was not up to date, including training relevant to people's needs.
The overall rating changed from Good to Requires Improvement. The home breached regulations about safe care and treatment, staffing and good governance. CQC said it would monitor the home and check that the provider took action.
Kind and respectful care
Inspectors observed caring interactions and found that staff knew people's preferences and supported their independence.
“We observed kind and caring interactions between staff and people using the service.” from the report
People felt safe
People told inspectors they felt safe. Staff understood safeguarding procedures and knew what to do if abuse was suspected.
“People commented they were safe living at Bury Lodge "Oh yes, absolutely", and "It's the best thing" (living here).” from the report
Staff availability
Inspectors found enough staff available during the inspection, and people and relatives said staff responded without long delays.
“We saw sufficient numbers of staff were available to meet people's needs.” from the report
Clean environment and food support
The premises were clean, and inspectors saw staff supporting people to eat and drink. Food was described as good quality.
“The premises were clean and free from odour.” from the report
Medicines were not managed safely
seriousSome medicines were not given as prescribed. There were missing signatures, unavailable stock and a medicine record that did not clearly show a changed dose.
“The provider did not have safe systems in place for managing people's medicines.” from the report
Staff training was not up to date
needs fixingSeveral staff needed training updates, including manual handling and infection control. Some staff had not completed their induction or been signed off as competent.
“Staff training was not up to date or designed around the support needs of people who used the service.” from the report
Care records were not consistently current
needs fixingCare plans did not always reflect current health needs, preferences or communication methods. Records about food intake, swallowing needs and nutrition scores were sometimes inaccurate or incomplete.
“Care plans did not always contain detailed information about people's background, likes, dislikes and preferences.” from the report
Quality checks missed problems
seriousAudits had not identified the medicines, record-keeping and risk-assessment problems found by inspectors. The report said improvements were often reactive rather than planned.
“Quality assurance checks were not always effective.” from the report
- 01What has changed to make sure every medicine is available, given as prescribed and signed for on the MAR record?
- 02How do you check that risk assessments for swallowing difficulties, diabetes and other known risks are complete and followed by every staff member?
- 03Which staff training updates have now been completed, and how do you check that new staff are competent before working unsupervised?
- 04How are care plans being updated to reflect people's current health needs, preferences and communication methods?
- 05What new checks make sure problems with medicines, care records, nutrition records and risk assessments are found promptly?
This was an unannounced planned inspection that looked at all five CQC questions, including the care and premises, and compared the findings with the previous Good rating. This explanation was written from the published report of 4 April 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.
What inspectors found, July 2017
Rated Good; inspectors found kind, personalised care, with medicine errors and occasional staffing pressures needing attention.
This was an unannounced inspection on 27 June 2017. One inspector spoke with people living in the home, relatives, staff and a visiting professional. They reviewed care records, medicine records, staff files and management records.
The overall rating was Good. Each of the five areas was also rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were generally safe, well supported and treated with kindness and respect.
There were some issues to watch. The manager had identified medicine errors, including one person not receiving medicine for two days, and was taking action. People, relatives and staff also said staff could feel rushed at times, although staffing hours were above the level calculated as needed.
Kind relationships
Inspectors saw staff treating people with patience, respect and genuine care. People and relatives spoke positively about the staff.
“We saw staff were kind, respectful, very attentive and caring toward people.” from the report
Personalised care
Care plans included people's histories, preferences and routines. Staff used this information to tailor support.
“They were very detailed and personalised.” from the report
Choice and independence
People could choose how to spend their day, where to eat and what activities to join. Staff promoted independence and respected personal choices.
“People were supported to spend their day as they chose.” from the report
Supportive management
Staff described an open and supportive team. The home used meetings, feedback and audits to identify improvements.
“The leadership and management that we saw on the day of the inspection demonstrated an open approach and supporting culture that encouraged good care and team spirit.” from the report
Medicine errors
seriousThe manager had found medicine errors when medicines were received by the home. One person had not received their medicine for two days, and the manager was sending a safeguarding referral and retraining staff where needed.
“The manager told us they were sending a safeguarding referral into the local authority as one person had not had their medicine for two days.” from the report
Busy shifts
needs fixingPeople, relatives and staff said staff sometimes felt rushed or overworked, particularly when people were absent. The manager was reviewing the mix of skills on each shift.
“People, relatives and staff told us at times there were not always sufficient staff to meet people's needs.” from the report
Care record gaps
needs fixingInspectors found two record issues. One person's weight had not been checked when required, and another person's end-of-life plan was incomplete.
“One had not had their weight checked when required and another had an 'end of life' plan which had not been completed in full.” from the report
Emergency key security
minorKeys to people's bedrooms were accessible to visitors. The manager agreed to move them to a more secure area known only to staff.
“Keys to people's bedrooms were also available to emergency staff. These were stored in a drawer in the lobby and could be accessed by visitors.” from the report
- 01What changes were made after the medicine errors, including the person who missed medicine for two days?
- 02How do you make sure there are enough staff with the right skills when someone is off sick or on holiday?
- 03How are people's weights and end-of-life plans checked so that required information is complete and up to date?
- 04Where are bedroom keys now stored, and who can access them?
- 05What personalised activities and food choices are currently available for residents?
This was an unannounced comprehensive inspection covering all five quality areas and the overall rating. This explanation was written from the published report of 28 July 2017 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 Bury Lodge Care Home
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- April 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016
Registered with the Care Quality Commission on 28 April 2016.
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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