CQC report explained · a nursing home
What the CQC found at Country Lodge Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were identified and managed, medicines were given safely, staffing was sufficient and infection control arrangements were effective. A concern about night staffing was investigated by the manager.
- Effective?
- Good
- Care plans and monitoring records for food and fluids had improved. Staff supported people's choices, obtained consent and helped people access healthcare services.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Good
- The home had effective audits, regular management meetings and an action plan addressing previous concerns. People, relatives and staff were involved in suggesting improvements.
What inspectors found, March 2022
Country Lodge Nursing Home was rated Good; inspectors found safe, effective and well-led care, with improvements since the previous inspection.
The unannounced inspection took place on 7 February 2022. Inspectors spoke with eight people, three relatives and members of the management and care teams. They reviewed care plans, medicine records, staff recruitment files and records about how the home was run.
People were found to be safe. Staffing was considered sufficient, medicines were managed safely and infection control arrangements were in place. People received help with food, drinks and healthcare, and staff asked for consent before providing care.
The home had improved since its previous inspection, which was rated Requires Improvement and published in April 2020. The overall rating changed to Good. The inspection covered Safe, Effective and Well-led. The Caring and Responsive ratings were not inspected and were carried forward from the previous inspection.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and found that medicines were administered and recorded safely.
“All aspects of medicines management were undertaken safely.” from the report
Improved risk management
Risks such as falls, poor food intake and fluid needs were assessed, monitored and acted on.
“Risks were identified, assessed and managed safely.” from the report
Individual food and drink support
The home updated nutrition records and offered food and drinks suited to people's preferences, beliefs and dietary needs.
“Care plans had been reviewed and updated to ensure information about people's nutrition and hydration needs was current.” from the report
Good oversight
Audits covered care plans, staff files, water safety and incidents. Managers recorded actions when they found areas to improve.
“A robust system of audits monitored and measured the quality of care and the home overall.” from the report
Night staffing concern
minorOne person felt there were not enough staff at night and described an incident from the previous night. The manager investigated the concern and provided assurance that it would not happen again.
“Another person felt there were not enough staff on duty at night and related an incident that had occurred the night before.” from the report
Activities staffing change
minorThe activities co-ordinator had recently left. Care staff were organising activities while a replacement was in place.
“The activities co-ordinator had left recently and had been replaced, but in the meantime, care staff were organising activities with people; this was observed at inspection.” from the report
- 01How many staff are usually on duty overnight, and how do you check that night staffing is enough for residents' needs?
- 02What happened after the concern about the night shift, and how do you check that the same problem has not happened again?
- 03Who now organises activities, and how do you make sure activities match each resident's interests and abilities?
- 04Has the suggestion to offer small, medium or large meal portions been introduced?
- 05How are care plans and monitoring charts checked when a resident's health, nutrition or hydration needs change?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 10 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.
What inspectors found, April 2020
Rated Requires Improvement; inspectors found kind, responsive care but gaps in risk checks, records and legal decision-making.
This was an unannounced inspection over three visits. Inspectors spoke with people living in the home, relatives, staff and the owners. They observed care and checked care records, medicines records, health and safety records, policies and accident records.
People said they felt safe and valued the staff. Inspectors found kind and respectful care, enough staff, activities and support to keep in touch with family and friends. However, some risks were not managed well, including bed rail safety, an incorrectly set air mattress, hydration records and medicines records.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were rated Requires Improvement, while Caring and Responsive were rated Good. The new owners and manager acted quickly after the inspection, but inspectors could not yet judge whether the improvements would last.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw staff communicating with kindness and found that people felt respected and involved.
“People were cared for by staff who knew them well and were kind and compassionate.” from the report
People felt safe
People said they felt safe, and staff understood how to recognise and report abuse. Inspectors also found enough staff to meet people's needs.
“People felt safe and spoke highly of the staff who supported them.” from the report
Personalised support
Care records included people's preferences and histories. Staff knew people's needs and adapted support when those needs changed.
“People appreciated care and support delivered by a core team of staff who knew them well.” from the report
Activities and relationships
People had activities, entertainment and informal time with staff. They were supported to maintain contact with relatives and friends.
“There were organised activities, informal chats and entertainment which provided people with meaningful things to do with their time.” from the report
Quick response to findings
The manager and new owners acted promptly when inspectors identified problems. They produced a detailed action plan and put new systems in place.
“The registered manager and new owners of the home were extremely responsive in reviewing and addressing shortfalls identified.” from the report
Risk checks were not reliable
seriousSome risks had not been identified or managed properly. Examples included missing bed rail bumpers and an air mattress set incorrectly.
“Some risks had not been identified because care practice in the home had not been kept up to date.” from the report
Hydration records were incomplete
needs fixingFluid records were not consistently completed and did not show that people were offered extra drinks when their intake was low.
“These records were not consistently completed and were not effective tools for monitoring hydration.” from the report
Mental capacity processes were not followed
seriousSome mental capacity assessments had not been completed appropriately. One authorised Deprivation of Liberty Safeguards arrangement had expired without a further application.
“Mental capacity assessments had not been completed appropriately.” from the report
Some care records were out of date
needs fixingInspectors found that some records did not reflect current needs or were not used effectively. One dietary care plan was not being followed.
“The recording of some aspects of care was not up to date.” from the report
Improvements not yet proven
needs fixingThe home acted on the inspection findings, but inspectors could not assess whether the new plan and systems would continue to work over time.
“We have not been able to assess the sustainability of this plan at the time of reporting.” from the report
- 01What checks now make sure bed rails have the required bumpers and that specialist mattresses are set correctly?
- 02How do you record and respond when someone is not drinking enough?
- 03How do you make sure care plans, including diet plans, are reviewed and followed when people's needs change?
- 04How do you complete mental capacity assessments and best-interest decisions for people who cannot make a specific decision?
- 05How do you monitor whether the action plan has continued to work since the inspection?
This was a planned, unannounced inspection covering all five CQC key questions; the report also compares the ratings with the previous inspection published in May 2017. This explanation was written from the published report of 24 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.
Every inspection of Country Lodge Nursing Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 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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