CQC report explained · a residential care home
What the CQC found at Conifer Lodge Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Good; inspectors found kind, personalised care and improvements since the previous inspection, with some work still under way.
This was an unannounced inspection on 16 and 17 March 2023. The inspector spoke with people, relatives and staff, observed care, and checked care, medicine, accident, incident and recruitment records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from harm, received their medicines and were supported by trained staff. Care was described as kind, respectful and based on people's choices.
The rating improved from Requires Improvement at the inspection published in March 2021. Inspectors said earlier improvements had been maintained. Some activities, accessibility arrangements and building improvements were still being developed.
Improvement maintained
Inspectors found that improvements identified at the previous inspection had become part of the way the home was run.
“Improvements to the service we found at our previous inspection had been embedded.” from the report
Personalised care
Care plans recorded people's needs, preferences and important personal information. Staff knew the people they supported and adapted care to their choices.
“People were provided with person centred care that met their preferences and wishes.” from the report
Kind and respectful staff
Inspectors saw warm interactions. People and relatives said staff were caring, and people's dignity, privacy and independence were respected.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Safe staffing and medicines
There were enough trained staff, recruitment checks were completed and medicines were given as planned. Staff administering medicines had regular competency checks.
“There were enough appropriately trained staff employed to ensure people's needs were met.” from the report
Good management oversight
The provider and registered manager used audits and reviews to monitor quality, safety, incidents and safeguarding concerns.
“The registered manager and provider had oversight of the service through a schedule of audits which checked all aspects of the quality and safety of the service.” from the report
Activities still being developed
minorFeedback about activities was mixed. One relative felt there should be more activities to stimulate people and occupy their time, while the provider was consulting people about the choices available.
“There could be more activities to help stimulate residents and occupy their time.” from the report
Accessible information knowledge
needs fixingThe provider and registered manager said they were not fully familiar with the Accessible Information Standard. They agreed to review the requirements, although inspectors found support was already in place for people's communication needs.
“The provider and registered manager accepted they were not fully conversant with the AIS.” from the report
Building work ongoing
minorBathrooms and flooring were being refurbished, with further improvements planned. This was work in progress rather than a reported safety breach.
“Bathrooms and flooring were in the process of being refurbished, and further improvements were scheduled to be undertaken.” from the report
- 01What activities are currently available, and how have you used residents' feedback to increase their variety?
- 02What improvements to the bathrooms, flooring, décor and facilities have been completed since the inspection?
- 03How do you support my relative's communication needs, including hearing, sight, pain or difficulty expressing choices?
- 04How will my relative's care plan be reviewed as their needs, preferences or health conditions change?
- 05How do you check that staff have the right training and medicines competence to support my relative safely?
This was an unannounced inspection covering all five key questions and infection prevention and control; the overall rating improved from Requires Improvement at the previous inspection. This explanation was written from the published report of 14 April 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 2021
Rated Requires Improvement; inspectors found major progress in safety and leadership, but improvements still need to be firmly established and maintained.
This was an unannounced focused inspection on 26 February 2021. The inspector spoke with relatives and staff, reviewed care, medicines, recruitment and management records, and checked infection control. The inspection looked only at Safe and Well-led.
The home had made significant improvements since its previous Inadequate rating. Inspectors found safer care plans, risk assessments, medicines systems, staffing and recruitment checks. Infection control had also improved, including cleaning, PPE, testing and COVID-19 risk assessments.
Leadership and oversight had improved. The provider had introduced audits, training, competency checks and an action plan. Relatives and staff gave positive feedback, but inspectors said the new systems needed to become established and continue over time.
The overall rating is Requires Improvement. The home was previously Inadequate and had been in Special Measures. It is no longer Inadequate or in Special Measures, and the previous breaches were no longer in place at this inspection.
Safer care planning
Care plans and risk assessments were detailed, reflected people's needs and were reviewed when needs changed.
“Detailed risk assessments and care plans had been introduced following the previous inspection.” from the report
Infection control
The home had introduced stronger infection control, cleaning, testing and PPE arrangements to reduce the risk of infectious diseases.
“The provider had implemented robust infection control procedures and followed government guidance to ensure people were now protected as far as possible from the risk of infectious diseases such as COVID-19.” from the report
Staffing and recruitment
Inspectors found enough staff, safer recruitment checks and less reliance on agency staff. Relatives also reported that staff had more time to support people.
“A recruitment drive had resulted in vacancies being filled across the service.” from the report
Improved openness
The home had improved how it reported incidents, worked with relatives and communicated with outside professionals.
“All legally required notifications were now being submitted to CQC and the local authority.” from the report
Environment
Earlier environmental hazards had been addressed, and parts of the building had been renovated or redecorated.
“Previous concerns over the safety of the environment had been addressed.” from the report
Changes need to last
needs fixingThe inspection found improvement, but the systems and new ways of working were not yet shown to be firmly established over time.
“Improvements identified needed to be embedded in practice and sustained over time to ensure people were always safe.” from the report
Governance still developing
needs fixingThe new audits and management systems had improved oversight, but inspectors said they still needed to be embedded and sustained.
“Improvements made to the governance and systems and processes introduced need to be embedded and sustained over time.” from the report
- 01How do you check that the new care plans and risk assessments stay up to date when someone's needs change?
- 02How do you monitor staffing levels on each shift, including sickness and vacancies?
- 03What checks show that medicines are still being given correctly and on time?
- 04How are infection control procedures, cleaning and COVID-19 testing kept up to date?
- 05What evidence can you show that the new audits and governance systems have continued since this inspection?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were not reassessed and previous ratings were used in the overall rating. This explanation was written from the published report of 27 March 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 Conifer Lodge Residential Home
6 rated inspections over 7 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Conifer Lodge Residential Home →
- March 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Conifer Lodge Residential Home →
- December 2020Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- January 2020Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 1 December 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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