CQC report explained · a residential care home
What the CQC found at Deerswood Lodge
Rated Outstanding: inspectors found the home performing exceptionally well.
What inspectors found, October 2021
Deerswood Lodge is rated Good overall, but inspectors found quality monitoring was not yet consistent and rated well-led Requires Improvement.
This was a focused inspection on 24 and 25 August 2021. Inspectors spoke with people, relatives, staff and a health professional. They reviewed care plans, medicines records, staff files and management records.
The home had improved since the previous inspection. Inspectors found people were safe, medicines were managed safely, infection control was effective and there were enough trained staff. People were treated with kindness, supported to keep relationships and offered activities suited to their interests.
The main weakness was management oversight. Some checks did not reliably identify missing health advice records or delays in personal care and elimination records. Managers acted straight away, but the systems needed more time to become fully established. The overall rating improved from Requires Improvement to Good, although well-led remained Requires Improvement.
Safe care
Risks were assessed and reviewed. Staff knew how to safeguard people, respond to incidents and seek help from health professionals.
“Risks to people's health were assessed and people were supported to stay safe.” from the report
Safe medicines
Staff who gave medicines had been trained and assessed as competent. People received medicines as prescribed, including clear guidance for medicines taken when needed.
“People received their medicines as prescribed and medicines were regularly reviewed.” from the report
Personalised activities
People had activity profiles based on their interests, past occupations and abilities. They were supported to build friendships and keep in touch with important people.
“People were supported to develop and maintain friendships, follow their interests and take part in activities relevant to them.” from the report
Kind and respectful care
Inspectors saw people treated with dignity, including people receiving end of life care. Care plans reflected people's wishes and preferences.
“We observed staff ensuring people were comfortable and treating them with kindness and compassion.” from the report
Infection control
The home was clean and well maintained. Inspectors found suitable arrangements for PPE, testing, vaccinations, visiting and managing infection outbreaks.
“At this inspection we observed the home was clean, hygienic and maintained to a high standard.” from the report
Quality checks were not fully reliable
needs fixingManagement systems did not always identify missing records of advice from health professionals or possible delays in personal care and elimination support. Managers revised the processes during the inspection, but they were not yet fully embedded.
“Quality assurance systems in place were not yet fully embedded enough to consistently provide effective oversight of all risks to people's health, and ensure that people were receiving care in accordance to their assessed needs.” from the report
Health advice was not always recorded
needs fixingThe monitoring systems had not identified that some advice from health professionals had not been recorded. Inspectors found no evidence that people had been harmed, but said better oversight was needed.
“For example, systems had not identified advice given from health professionals had not been recorded.” from the report
- 01What checks are now used to make sure advice from health professionals is recorded in people's care plans?
- 02How do you monitor personal care when someone repeatedly declines support?
- 03How do you monitor people's elimination needs and identify any delay that could affect their health?
- 04What evidence can you show that the revised quality assurance systems are now fully embedded?
- 05How do you make sure there are enough permanent staff while vacancies are being filled?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 12 October 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.
What inspectors found, February 2020
Rated Requires Improvement; care had improved greatly, but inspectors still found gaps in meeting some people's needs and checking that improvements lasted.
This was an unannounced inspection on 14 January 2020. Inspectors observed care, spoke with people, relatives and staff, and checked care, medicine, staffing and management records.
The home had improved from Inadequate and was no longer in Special Measures. Inspectors found safer medicines systems, better staff training, kinder care and more person-centred support. However, some people did not always receive care that followed their assessed needs.
The overall rating was Requires Improvement. Effective and Caring were rated Good. Safe, Responsive and Well-led were rated Requires Improvement. The home must show that its new systems work consistently over time.
Improved safety systems
Medicines management and monitoring of falls, skin integrity, hydration and nutrition had improved. Staff also had clearer guidance for supporting people safely.
“The registered manager and provider had worked with external healthcare professionals to ensure medicines management was safe.” from the report
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff providing patient, sensitive support and respecting people's privacy, dignity and independence.
“People were cared for by kind and compassionate staff.” from the report
Better staff skills
Staff had received more relevant training, including support for people living with dementia. Their competence was checked for medicines and moving and positioning.
“New staff had completed their inductions and required training before providing support to people” from the report
More personalised care
Care plans had been rewritten in a clearer format. People and relatives were more involved in reviewing care, preferences and life histories.
“There was a greater emphasis on placing the person at the centre of the care that was being provided.” from the report
Health and nutrition support
People had access to health professionals, and there was better monitoring of nutrition and hydration overall. Weight had stabilised for people at risk of malnutrition.
“People assessed as being at increased risk of malnutrition and dehydration had received safe and effective care.” from the report
Care instructions were not always followed
seriousTwo people did not always receive support that matched their assessed needs. One person received high-sugar food despite advice to follow a low-sugar diet, and another person's fluid intake was not recorded consistently.
“We also found that two people had not always received appropriate support to meet their assessed needs.” from the report
Dementia information was not accessible enough
needs fixingSigns, bedroom doors, meal choices and complaint information were not always adapted for people living with dementia. The provider was recommended to seek further guidance.
“Information had not been adapted to meet the needs of some people living with dementia.” from the report
Activities had reduced
needs fixingPeople and relatives reported fewer activities and less stimulation since the previous inspection, particularly at weekends. The home said it was recruiting and planning to provide activities seven days a week.
“People and relatives told us that since the last inspection they had noticed a decrease in the amount of activities and stimulation provided” from the report
Management checks missed some problems
needs fixingNew audits and systems had not identified all the gaps in people's care or the lack of consideration about consent for photographs shared on social media. Managers acted when inspectors raised these issues.
“shortfalls in the delivery of two people's care found as part of this inspection, had not been identified by the newly implemented systems.” from the report
- 01How will you check that my relative's dietary, fluid and weight-monitoring instructions are followed every day?
- 02How will you adapt meal choices, signs, complaints information and other communication for someone living with dementia?
- 03What activities are now provided at weekends and on each of the seven days?
- 04How do your audits identify missed care or changes in people's needs before they become a problem?
- 05What conditions are currently on your registration, and what information must you provide to CQC?
This was an unannounced planned inspection based on the previous rating and covered all five key questions; the report also explains that the previous inspection was Inadequate and that this inspection checked whether improvements had been made. This explanation was written from the published report of 21 February 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Deerswood Lodge
7 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- October 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2019Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2019Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- October 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 17 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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