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CQC report explained · a nursing home

What the CQC found at Bury Lodge Nursing Home

Goodpublished 6 March 2024, 2 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The latest report, explained

What inspectors found, May 2019

Rated Good; inspectors found safe, kind and personalised care, with some records and supervision needing improvement.

Inspectors visited the home without warning on 16 and 17 April 2019. They spoke with people, relatives, staff and managers. They reviewed care and medicine records, recruitment files, policies, complaints, incidents and quality checks.

People were described as safe, well cared for and treated with kindness and respect. Staff understood people's communication needs and supported their choices, activities, health needs and independence. Inspectors found enough staff, safe medicine systems and good links with health professionals.

The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found a few areas to improve, including some assessment records, formal staff supervision and cleanliness of one damaged chair. The home had also been rated Good at the previous inspection, published in October 2016.

What inspectors praised
  • People felt safe

    People and relatives told inspectors they felt safe. Staff understood safeguarding procedures and knew how to report concerns.

    “People told us they were happy and felt safe living at Bury Lodge Nursing Home.” from the report
  • Personalised activities

    People could take part in activities suited to their interests and abilities. Staff understood that these activities supported wellbeing and quality of life.

    “People had access to a range of activities to meet their individual needs.” from the report
  • Kind and respectful care

    Inspectors saw staff treating people with kindness, dignity and respect. People's preferences and communication needs were taken seriously.

    “We observed people were treated with kindness, respect and care by staff.” from the report
  • Quality monitoring

    The provider used several audits and action plans to identify and track improvements. Records were regularly checked.

    “The provider had robust quality assurance procedures in place to check the safety and effectiveness of the service.” from the report
What inspectors were concerned about
  • Cleanliness and worn furniture

    minor

    Inspectors found dried food on one chair and identified a damaged chair and another that was very worn. The chairs were cleaned or replaced during the inspection, and the manager said regular checks would be made.

    “However, we noticed on one chair there was a lot of dried food between the cushion and the chair arm.” from the report
  • Incomplete assessment paperwork

    needs fixing

    Not all protected characteristics were included in initial needs assessments. Inspectors recommended changing the paperwork, although people's needs were recorded in care plans and met in practice.

    “not all protected characteristics were included in the need's assessments.” from the report
  • Staff supervision

    needs fixing

    Records showed that some staff did not have regular formal supervision. The manager knew about this and had a plan to improve consistency.

    “Records demonstrated that not all staff had the opportunity for regular formal supervision.” from the report
  • Dementia-friendliness

    minor

    Health Watch Hampshire gave the home an average overall rating for dementia friendliness. The home had plans to continue improving this.

    “Bury Lodge Nursing Home was rated with an overall rating of average for dementia friendliness” from the report
Questions to ask them, based on this report
  1. 01What changes were made to the initial assessment paperwork to include gender and sexual orientation?
  2. 02Do all staff now receive regular formal supervision, and how is this recorded?
  3. 03What further work has been done to improve the home's dementia friendliness since the average Health Watch Hampshire rating?
  4. 04How often are chairs and other furniture checked for cleanliness, damage and wear?
  5. 05How are staffing levels adjusted when people's needs change or activities and outings are planned?

This was an unannounced inspection of the overall service, including the premises and care, and inspectors assessed all five CQC questions. This explanation was written from the published report of 21 May 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.

An earlier report, explained

What inspectors found, October 2016

Rated Good in all five areas; inspectors found safe, kind and well-organised care, with some care records needing improvement.

Inspectors made an unannounced visit on 5 September 2016. They observed care, spoke with relatives, staff and health and social care professionals, and checked care plans, medicines records, complaints, accidents, staff files and quality checks.

They found enough staff, safe medicines processes, suitable staff checks and good support for people living with dementia. Staff knew people well, treated them with respect and supported their choices, activities, meals and contact with health professionals.

The overall rating was Good. Each of the five areas was also rated Good. This means the inspectors found the home meeting the required standard at that inspection, although they identified some records and monitoring that needed further work.

What inspectors praised
  • Safe staffing

    Inspectors found enough staff to meet people's needs. Staff worked calmly, answered call bells promptly and supported people without rushing them.

    “There were sufficient staff available to meet the needs of people.” from the report
  • Kind and personal care

    Staff knew people well and adapted their communication and support to each person. Privacy, dignity and independence were respected.

    “People were valued and respected as individuals and were very happy and content in the home.” from the report
  • Food and choice

    People were offered varied, freshly prepared food and alternatives. Special diets and support with eating were provided according to people's needs.

    “People enjoyed a variety of freshly prepared foods of their choice.” from the report
  • Activities

    The home offered music, games, gardening, events and visits from entertainers and animals. Activities were adapted for people who preferred to stay in their rooms.

    “A wide range of activities were provided in the communal areas of the home including music events, games, jigsaws and water painting.” from the report
  • Open management

    Relatives, staff and professionals spoke positively about the management. Staff had regular support, training and opportunities to share learning.

    “Staff felt very well supported in their roles and displayed a good understanding of the person centred values of the service.” from the report
What inspectors were concerned about
  • Some health risks were not fully recorded

    needs fixing

    The risks linked to one person's epilepsy and another person's anticoagulant medicine were not always clearly included in care records. The home was updating these records during the inspection.

    “However, all records did not always reflect these risks.” from the report
  • Care records were sometimes out of date

    needs fixing

    Some care plans and records were inconsistent or did not contain full information about health conditions. The home had identified this through audits and was introducing a new documentation system.

    “Care plans and records were reviewed monthly by registered nurses; however we identified some records contained information which was out of date and were not consistent.” from the report
  • Audit actions lacked dates

    minor

    The home's audits identified areas for improvement, but the action plans did not say when actions should be completed. The audit system was being adapted.

    “Action plans were attached to the audits we saw, however we noted there were no dates of completion of these records.” from the report
  • One recruitment file was incomplete

    minor

    Most recruitment checks were in place, but one long-serving staff member's file contained only one reference instead of two. The manager said this would be reviewed.

    “Two references were sought before people commenced work at the home, however for one person who had worked at the home for a long time, we found their records held only one reference.” from the report
  • Family involvement was not consistent

    minor

    Relatives were generally involved in care planning, but one relative said they had not been involved in planning their loved one's care.

    “although one relative told us they had not been involved in the planning of care for their loved one.” from the report
Questions to ask them, based on this report
  1. 01How do you now record and review risks linked to epilepsy and anticoagulant medicines?
  2. 02What changes were made to care plans and records after the 2016 inspection?
  3. 03Do audit action plans now include clear completion dates and follow-up checks?
  4. 04How are relatives involved in assessing, reviewing and changing a person's care plan?
  5. 05How do you check that all staff recruitment files contain the required references and other checks?

This was an unannounced inspection looking at the overall quality of the home and rating all five key questions. This explanation was written from the published report of 6 October 2016 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.

The story over the years

Every inspection of Bury Lodge Nursing Home

2 rated inspections over 3 years: the service has held its Good rating throughout.

  1. May 2019Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Bury Lodge Nursing Home →

  2. October 2016Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Bury Lodge Nursing Home →

  3. October 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  4. November 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  5. January 2011

    Registered with the Care Quality Commission on 28 January 2011.

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.

Next steps

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Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.

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