CQC report explained · a residential care home
What the CQC found at Danmor Lodge Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, medicines were given safely, staff were trained in safeguarding, and there were enough staff. They found no evidence that people were at risk from the lift being out of order.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward from the last comprehensive inspection.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward from the last comprehensive inspection.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward from the last comprehensive inspection.
- Well-led?
- Good
- Inspectors found robust checks and audits, an open culture and managers who acted quickly on feedback and record-keeping issues. Managers understood their responsibilities and worked with other professionals.
What inspectors found, June 2022
Danmor Lodge Limited was rated Good; inspectors found safe, caring support and strong management, with minor record-keeping issues addressed during the inspection.
This was an unannounced focused inspection after concerns about managing risks while one lift was out of order. Inspectors looked mainly at Safe and Well-led. They found no evidence that people had been put at risk because of the lift concern.
People said they felt safe and were happy with the care. Inspectors found that risks were assessed and managed, medicines were handled safely, staffing was sufficient, and infection control measures were in place. Staff knew people well and supported their choices and interests.
The home had a stable staff team, an open culture and systems for checking quality. Inspectors found some minor shortfalls in care and monitoring records, but managers acted immediately. The overall rating stayed Good, as did Safe and Well-led.
Risk management
People's risks were assessed, recorded and managed. Staff understood the support people needed and followed their risk plans.
“People's care plans contained risk assessments which gave staff with a clear description of identified risks and guidance on the support people required.” from the report
Medicines
Medicines were received, stored, given and disposed of safely. Staff were trained and checked as competent.
“Medicines were received, stored, administered and disposed of safely.” from the report
Stable and caring staff
There was a stable staff team with suitable training and induction. Inspectors saw staff spending time with people and offering reassurance.
“Staff were very caring and spent time with people chatting and reassuring them.” from the report
Management and improvement
Managers were approachable and used audits, feedback and a quality improvement plan to develop the service. They responded quickly when inspectors identified record-keeping issues.
“There were robust governance and audit systems in place and these fed into and contributed towards the quality improvement plan.” from the report
Care records
needs fixingInspectors found some minor gaps in care and monitoring records at the start of the inspection. Managers took immediate action to correct them, but families should ask how record checks are maintained.
“At the start of the inspection, some minor recording shortfalls in people's care and monitoring records were identified.” from the report
Notification about the lift
minorThe manager needed prompting to notify CQC about the lift being out of order. The manager said they were then clear about when such events must be reported.
“However, we had needed to prompt the registered manager to send in a notification in relation to the lift being out of order.” from the report
- 01Has the lift that was out of order been repaired, and what arrangements are in place if it stops working again?
- 02What checks are now used to make sure care and monitoring records are complete and accurate?
- 03How will you make sure important events affecting safe running are reported to CQC promptly?
- 04What activities and contact with relatives would be available for someone who had to spend time in their bedroom?
- 05How would you assess and manage my relative's particular risks and medicines?
This was a focused inspection of Safe and Well-led after concerns about a lift; the other ratings were carried forward from the last comprehensive inspection in 2019. This explanation was written from the published report of 17 June 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, March 2019
Danmor Lodge Limited was rated Good overall; inspectors found safe, kind and personalised care with strong management.
This was an unannounced inspection on 11 and 12 February 2019. One inspector spoke with people living there, relatives, staff and health professionals. They also observed care, looked around the home and checked care plans, medicines records, staffing, training, accidents, complaints and quality checks.
The home supported up to 25 people, including some people living with dementia or physical disabilities. At the inspection, 23 people lived there. Inspectors found that people felt safe and happy, staff knew their needs, medicines were managed safely and there were enough suitably trained staff.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found a good standard of care and that legal requirements were met. The previous inspection, published in October 2016, was also rated Good.
Kind and respectful care
People and relatives described staff as kind, patient and warm. Inspectors observed staff supporting privacy, dignity and independence.
“There is definitely a genuine warmth from staff” from the report
Safe staffing and medicines
The home used a dependency tool to match staffing to people's needs. Inspectors found medicines were given as prescribed, stored securely and recorded clearly.
“People received their medicines on time and as prescribed from staff who had undertaken the relevant training and ongoing competency checks.” from the report
Personalised activities
The activities programme was changed to reflect people's abilities, interests and communication needs. People were supported with both group and one-to-one activities.
“We are determined not to leave anybody out.” from the report
Good health care support
Staff worked proactively with health professionals and helped people attend appointments and follow clinical advice.
“They are very proactive and know the residents well. They are good at working with us to get good outcomes for the residents.” from the report
Open management
People, relatives and staff said management was approachable and supportive. Regular audits, meetings and feedback were used to guide improvements.
“It's good team work here. I get on with everybody.” from the report
End of life planning
Care plans included people's end of life wishes. Staff received palliative care training and the home arranged support for people and relatives at this stage of life.
“Staff rotas had been developed for people on end of life care to ensure that there was always a staff member able to sit with them and provide comfort.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you use the dependency tool to make sure staffing levels match my relative's needs?
- 02How will you support my relative to take part in activities if they prefer one-to-one time or have communication, sight or mobility difficulties?
- 03How are medicines, including 'as and when required' medicines, reviewed and recorded?
- 04How will you involve my relative and our family in recording and reviewing end of life wishes?
- 05What changes have been made, or are planned, to the dining room and the shop with tea area mentioned in the report?
This was an unannounced, scheduled inspection covering the overall service and all five CQC questions; the previous inspection rating was also Good. This explanation was written from the published report of 29 March 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.
Every inspection of Danmor Lodge Limited
3 rated inspections over 6 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2019Goodstayed GoodSafe: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 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.
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