CQC report explained · a nursing home
What the CQC found at Carlisle Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicines management, suitable risk assessments and good infection control. Staff understood how to recognise and report abuse.
- Effective?
- Good
- People's needs were assessed and care plans were reviewed. Staff supported people's nutrition, healthcare and communication needs, although the wider training programme needed strengthening under Well-led.
- Caring?
- Good
- People and relatives said staff were kind, respectful and attentive. People were involved in decisions and supported to maintain their privacy, independence, relationships and beliefs.
- Responsive?
- Good
- Care was personalised and responded to changing needs and preferences. Activities provided social contact, and complaints were investigated, although the recording of informal dissatisfaction was being refined.
- Well-led?
- Requires improvement
- The manager was visible, caring and had improved several systems. However, quality checks had not identified gaps in essential and refresher training records for all staff.
What inspectors found, April 2019
Carlisle Lodge was rated Good overall, but inspectors found training records and quality checks still needed improvement.
Inspectors visited on 20 and 25 February 2019 without giving notice. They spoke with people, relatives, staff and visiting professionals. They checked care records, medicines, recruitment, training, complaints, accidents and quality audits.
The home was rated Good for Safe, Effective, Caring and Responsive. People were described as safe, comfortable and well cared for. Staff knew people well, respected their choices and worked with health professionals. Food, activities and end of life care were tailored to people's needs.
The home was rated Requires Improvement for Well-led. The manager had improved systems since the previous inspection, including checks on nurses' registration and the Mental Capacity Act. However, training records did not show that all staff had completed essential and refresher training, and quality checks had not found this gap.
The overall Good rating means inspectors found the service met the expected standard in most areas. It does not mean everything was perfect. The regulator said it would continue to monitor information about the home and could inspect sooner if concerns were received.
People felt safe
People told inspectors they felt safe and staff responded to their needs. Risk assessments, emergency plans and equipment checks were in place.
“They look after me, and it's warm and comfortable, I feel very safe here. I press a buzzer and they come.” from the report
Kind and respectful care
Staff knew people well and treated them with dignity. People's privacy, choices, relationships and religious preferences were respected.
“Staff are always polite, professional and genuinely care for their residents.” from the report
Personalised food and care
Meals were adapted to individual preferences and dietary needs. Care plans also included people's personal routines, interests and support needs.
“People eat whatever they want, I do not have a limited budget and can buy whatever people want.” from the report
Good links with professionals
Staff worked with GPs, specialists and other health and social care professionals to support people's health and wellbeing.
“Staff have worked with us to stabilize the correct medicines for this person. They have improved greatly.” from the report
Improvements since the last inspection
The home addressed the earlier problems with Mental Capacity Act processes and checks on nurses' professional registration.
“At this inspection, we found the registered manager had taken steps to address these matters and the Regulation had been met.” from the report
Training records were incomplete
needs fixingThe quality system had not identified that records did not show a rolling programme of essential and refresher training for all staff. This included staff not directly involved in care.
“The training records did not confirm staff received a rolling programme of essential training along with appropriate refresher courses.” from the report
Informal complaints needed clearer recording
minorThe manager was improving the complaints process so that smaller expressions of dissatisfaction were recorded more clearly. This would make it easier to identify patterns and actions taken.
“The registered manager was refining the procedure to ensure dissatisfactions expressed were captured within the complaint documentation.” from the report
- 01Which essential and refresher training courses have all staff now completed, including staff who do not provide direct care?
- 02How do you check that training records remain complete and up to date?
- 03How are informal complaints or expressions of dissatisfaction recorded, reviewed and used to improve the service?
- 04What systems are now used to check nurses' professional registration and other legal requirements?
- 05How are people's changing health, dietary and communication needs reviewed and reflected in their care plans?
This was an unannounced follow-up inspection covering all five CQC questions and the overall rating, after the previous inspection found two legal breaches. This explanation was written from the published report of 3 April 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, March 2018
Rated Requires Improvement; inspectors found kind, safe and person-centred care, but consent, nurse registration and quality checks needed fixing.
The inspection was unannounced and took place on 15 February 2018. Two inspectors and an expert by experience reviewed records, care plans, medicines, staff files and quality checks. They spoke with people living in the home, relatives and staff.
The home was rated Good for Safe, Caring and Responsive. Inspectors found enough staff, safe recruitment, safe medicines systems, kind staff, individual care and a range of activities. People were supported with food, drink and healthcare, and visitors were welcome.
The home was rated Requires Improvement for Effective and Well-led. Mental capacity and liberty safeguards were not being applied consistently. The system for checking nurse registration had failed, and quality checks had missed important problems. Two legal regulations were breached.
Kind and respectful care
Inspectors saw warm, patient interactions. Staff knew people well and respected their privacy, choices and routines.
“Staff knew people well and treated them with kindness, understanding and patience.” from the report
People felt safe
People and relatives said they felt safe. Staff understood safeguarding, risk management and how to respond to concerns.
“People and their relatives said they felt safe and well cared for by staff that had a very good understanding of their needs and preferences.” from the report
Enough suitable staff
Staffing levels were consistent and people received calm, unhurried support. Recruitment checks were completed to assess whether staff were suitable.
“There were sufficient numbers of staff deployed to meet the needs of people.” from the report
Individual care and activities
Care plans included people's histories, preferences, cultural needs and interests. People had a choice of activities and one-to-one support.
“Care plans contained information about each person, their family history, individual personality, preferences and interests.” from the report
Food and healthcare
People were supported to eat and drink enough, with choices suited to their needs and beliefs. Healthcare appointments and support were arranged when needed.
“People were effectively supported to eat and drink enough to meet their needs.” from the report
Consent and liberty safeguards
seriousThe home did not consistently assess whether people could consent to their care, living arrangements or restrictions such as bed rails. Its checks did not reliably identify when a Deprivation of Liberty Safeguards application might be needed.
“Robust systems were not in place to identify when a person may be subject to an unlawful deprivation of liberty.” from the report
Nurse registration check failed
seriousThe registration of the registered manager, who was also working as the nurse on duty, had lapsed. The home arranged cover for nursing shifts while re-registration was completed.
“During the inspection, it was found that their registration had lapsed.” from the report
Quality checks missed problems
needs fixingAudits had not identified the problems with mental capacity, liberty safeguards or nurse registration. A water safety assessment also identified tanks that did not meet recommendations, without a clear action timetable.
“However, these systems had not identified all the areas for improvement we found.” from the report
Medicine recording errors
needs fixingA change to the medicines system had led to many errors. The February 2018 audit found nine errors, including incorrect stock calculations and missing signatures, although the number was reducing.
“A monthly medicine audit was completed and the audit dated February 2018 found only nine errors.” from the report
Activities needed expansion
minorThe provider recognised that activities should be available every day and that more activities were needed for people living with dementia. It was recruiting a second activity coordinator.
“We've recognised that we need activities to be available seven days a week and more activities are required to support people living with dementia.” from the report
- 01What has been done since the inspection to assess capacity for specific decisions, including the use of bed rails?
- 02Have Deprivation of Liberty Safeguards applications been made where needed, and how are these now reviewed?
- 03How do you check that every registered nurse has current Nursing and Midwifery Council registration?
- 04What changes were made to the medicines system, and how are stock levels, signatures and errors now checked?
- 05What action was taken about the water tanks identified as not meeting Health and Safety Executive recommendations?
This was an unannounced inspection covering all five key questions, with records, care plans, medicines, staff files, the premises and people's experiences reviewed. This explanation was written from the published report of 9 March 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 Carlisle Lodge
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- April 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016
Registered with the Care Quality Commission on 3 October 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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