CQC report explained · a residential care home
What the CQC found at Cepen Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improved risk plans, safe medicines management, suitable infection control and enough staff overall. They raised concerns about intermittent evening supervision in the dementia household and missing checks that medicine patches remained in place.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- Inspectors found that quality checks were embedded, improvement actions were followed up and the management team was approachable and responsive to feedback.
What inspectors found, December 2023
Cepen Lodge is rated Good; inspectors found safe, kind care, but evening supervision and checks on medicine patches needed attention.
This was an unannounced focused inspection in response to concerns about staffing and their effect on care. Inspectors visited over three days, spoke with people, relatives, staff and healthcare professionals, and reviewed care, medicines, recruitment and quality records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff overall, improved risk assessments, safe medicines management, good infection control and regular checks on quality and safety. People and relatives described people as safe and staff as kind and caring.
There were two areas for improvement. People living in the dementia household had intermittent supervision when staffing reduced to night levels in the evening. There was also no recorded check between applications to confirm that medicine patches stayed in place.
The overall rating improved from Requires Improvement to Good. However, this was a focused inspection of Safe and Well-led only. The ratings for the other three questions were carried forward from the previous inspection.
Improved risk planning
Risk assessments were reviewed monthly and updated when people's needs changed. Staff had detailed guidance for risks such as falls, skin problems and pressure ulcers.
“Risk management plans were available to give staff guidance on how to support people safely.” from the report
Kind relationships
People and relatives said staff were kind and caring. Inspectors also saw warm interactions and staff who knew people well.
“We observed during our inspection warm interactions between people and staff, and it was clear staff knew people very well.” from the report
Stronger management checks
The home had regular quality checks by managers and other staff. Actions for improvement were recorded, shared and followed up.
“At this inspection we found systems were embedded and quality monitoring was regularly taking place.” from the report
Improved medicines management
Inspectors found that people received medicines as prescribed. Staff had medicines training and their competence was checked.
“At this inspection, this had improved, and people had their medicines as prescribed.” from the report
Evening supervision
needs fixingWhen staffing reduced to night levels at 8pm, people in the dementia household were sometimes left with intermittent supervision. Inspectors recommended reviewing evening staffing through observations and feedback from people.
“This meant people had intermittent staff supervision in the dementia household.” from the report
Medicine patch checks
needs fixingThe home recorded when patches were applied and changed, but did not record checks between applications to confirm they were still in place. The manager introduced a checking procedure, which inspectors recommended monitoring.
“We found there was no documented monitoring that the patches remained in place.” from the report
- 01What staffing arrangements are now in place in the dementia household after 8pm?
- 02How do you observe evening care and gather people's feedback when deciding staffing levels?
- 03How often are medicine patches checked between applications, and where is this recorded?
- 04What ratings for Effective, Caring and Responsive were carried forward from the previous inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 7 December 2023 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 2022
Overall rating Requires Improvement; inspectors found medicine safety and management records needed improvement, although new systems had begun.
This was an unannounced focused inspection on 25 November and 1 December 2021. Inspectors looked only at Safe and Well-led because concerns had been raised about medicines, staffing and support plans. They spoke with people, relatives, staff and professionals, and checked care, medicine, recruitment and management records.
People said they felt safe and were happy with the support they received. Inspectors found environmental safety, infection control, recruitment and emergency arrangements were generally managed. However, medicines were not always stored or recorded safely, and some required-medicine information was missing.
The home had been without a manager for several months. Some earlier risk reviews, care records, incident records and quality checks could not be found or had not been completed. A new manager and deputy manager had introduced improvements, but these systems had not been in place long enough to show they were sustained.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Infection control
Inspectors were assured about the home's infection prevention arrangements, including protective equipment, testing, hygiene and visiting.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
New management action
The new manager had introduced systems for risk reviews and quality monitoring. Inspectors saw that regular reviews were taking place under the new system.
“Under the new management team ongoing monitoring of the quality of the service and risk management reviews were being completed.” from the report
Partnership working
The home worked with healthcare professionals and shared more detailed information to help tailor advice to people's needs.
“Staff are now providing more detailed information during telephone triages. This is essential to tailor advice accurately to meet resident needs.” from the report
Medicine safety
seriousMedicine refrigerator temperatures had gone outside the recommended range without recorded action. Variable doses were not always recorded, and some when-required medicines lacked the right protocols.
“People's medicines were not always managed safely, and people were at risk of not receiving their prescribed medicines.” from the report
Missed risk reviews
needs fixingTwo people's care plans had not had their risks reviewed during August and September 2021. The home linked this to management changes and staff leaving.
“Risks to people's health and welfare had not always been regularly reviewed.” from the report
Missing earlier records
needs fixingSome historical quality records, audits and incident records could not be found. This limited assurance about how safety and care quality had been monitored before the new manager started.
“Some historical records and audits could not be located to show how the service monitored the quality of the service previously.” from the report
Systems not yet established
needs fixingNew governance arrangements had started, but inspectors could not yet see that they had produced lasting improvement.
“Although these systems had not been embedded long enough to demonstrate a sustained improvement.” from the report
Mixed staffing experience
needs fixingStaff described staffing levels as variable and said the lack of staff had been difficult, although inspectors saw enough staff to respond to people during the visit.
“We've got a job to do but it's been difficult with the lack of staff.” from the report
Limited family feedback
minorPeople and relatives wanted more opportunities to give feedback. Some relatives did not know about the change in manager.
“People and relatives told us they would like more opportunity for feedback.” from the report
- 01How are medicine refrigerator temperatures checked now, and what action is taken when they are outside the recommended range?
- 02How do you make sure variable doses and when-required medicines are recorded and supported by the correct protocols?
- 03How are people's risk reviews kept up to date, including after an incident or a change in their needs?
- 04What evidence can you show that the new quality monitoring and governance systems have been completed consistently and acted on?
- 05How will people and relatives be given regular opportunities to provide feedback?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 1 March 2022 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 Cepen Lodge
6 rated inspections over 9 years: the service has improved, from Requires improvement to Good.
- December 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2021Goodstayed GoodSafe: Requires improvementWell-led: Good
- December 2017Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2014Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 30 November 2010.
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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