CQC report explained · a residential care home
What the CQC found at Derby Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Medicines, staffing, infection control and safeguarding arrangements were found to be safe, although care planning and risk assessment records had gaps.
- Effective?
- Good
- This question was not rated in this inspection.
- Caring?
- Good
- This question was not rated in this inspection, although inspectors observed kind and respectful interactions.
- Responsive?
- Good
- This question was not rated in this inspection.
- Well-led?
- Good
- The home had effective leadership and quality checks. Its rating improved from Requires Improvement, and the previous breach about fire safety was no longer in place.
What inspectors found, February 2024
Rated Good; inspectors found safe, respectful care and stronger leadership, but care planning records were not always consistent.
Inspectors visited the home without notice on 23 and 24 January 2024. They spoke with people living there, relatives, staff and managers. They also checked the building, care and medicine records, staffing files and systems for checking quality.
The inspection was prompted by concerns about staff approach, medicines, risk management and staffing. The provider had taken effective action, and inspectors found no evidence that people were at risk of harm from these concerns. Medicines were managed safely, staffing levels were sufficient and people said they felt safe.
Care was described as kind and respectful. The main shortfall was that care planning and risk assessment records were not always consistent and had gaps. The overall rating was Good. Safe and Well-led were both rated Good. Well-led improved from Requires Improvement at the previous inspection, and the earlier breach about fire safety had been resolved.
Safe staffing
Inspectors found there were enough staff to meet people's needs promptly. Staff supported people patiently and gave them time when providing assistance.
“The provider consistently maintained sufficient staffing levels so that people's needs were met in a timely way.” from the report
Medicines managed safely
Staff gave medicines one person at a time, explained what they were doing and checked that medicines had been taken. Records, stock checks and audits supported this.
“Staff focused on 1 person at a time, explained what they were doing and checked they had taken their medication.” from the report
Kind and respectful care
Inspectors found consistently kind and respectful interactions with people and their relatives. People were supported to maintain their independence.
“Staff interactions with people and their relatives were consistently kind and respectful, with appropriate use of positive language.” from the report
Improved fire safety
The provider introduced a new fire risk assessment and updated staff training and guidance. The previous breach in this area had been resolved.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 17.” from the report
Gaps in care planning records
needs fixingCare plans generally showed how staff should support people, but the records were not consistent and had gaps. Inspectors recommended that the provider review current guidance and good practice on care planning and risk assessment.
“Although documentation sufficiently indicated how staff should support each person, this was not consistent and there were gaps in records.” from the report
- 01How are you updating the care plans and risk assessments that inspectors found had gaps?
- 02How do you check that care plans consistently reflect each person's needs, preferences and independence?
- 03What checks are now used to make sure medicines are given safely and on time?
- 04How do you maintain current fire safety training and check that staff understand what to do in an emergency?
- 05What changes were made in response to the earlier concerns about staff approach, risk management, medicines and staffing?
This inspection looked at Safe and Well-led only; Effective, Caring and Responsive were not rated in this report. This explanation was written from the published report of 10 February 2024 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, May 2022
Rated Good overall; inspectors found people were safe and cared for, but leadership systems and opportunities for independence still need improvement.
This was an unannounced focused inspection on 20 April 2022. Two inspectors spoke with people, relatives and staff, and checked care plans, medicines, recruitment, fire safety, maintenance and audit records.
The home was rated Good for Safe. Inspectors found suitable fire safety improvements, safe medicines systems, enough staff with the right skills, and care plans that recorded risks and people’s needs. People and relatives said they felt safe, and staff were described as kind and responsive.
The home was rated Requires Improvement for Well-led. New audits had started but were not yet fully established, and some staff meeting records were missing. The overall rating improved from Requires Improvement because the home had addressed earlier legal breaches, but this inspection only directly assessed Safe and Well-led.
Improved fire safety
The home had acted on the earlier recommendation about fire safety. Staff had received training, fire drills were recorded and equipment checks were up to date.
“The provider delivered training in fire safety procedures and staff understood the fire evacuation plan.” from the report
Safe medicines
Medicines were given as prescribed. Staff who administered medicines had training and their competence had been checked.
“Medicines had been given as prescribed. There was clear guidance to support staff decision making in the administration of 'as required' medicines.” from the report
Kind staff culture
Inspectors observed caring interactions and found staff committed to good outcomes. People were supported to maintain hobbies and personal interests.
“We found a positive culture amongst the staff and most residents.” from the report
Staff understood people’s needs
Inspectors found staff had good knowledge of people’s needs, likes and dislikes. Care plans recorded people’s needs and preferences.
“People living at Derby Lodge were kept safe; staff had good knowledge and skills about people's needs, likes and dislikes.” from the report
Audits were not yet established
needs fixingRoutine audits had only recently started. Inspectors could not yet be sure that concerns or issues would always be found and acted on.
“At this inspection we found routine audits commenced recently and the process was not yet fully embedded.” from the report
Limited independence and outings
needs fixingInspectors said the home offered limited opportunities for people to control their daily lives and develop independence. Some people also wanted to go out more.
“Derby Lodge is a large residential home with limited opportunities for people to be in control of their day to day lives and develop independence.” from the report
Incomplete meeting records
minorStaff meetings took place, but the minutes were not always recorded. The manager said this would change in future.
“Staff meetings were completed; however, the minutes had not always been recorded.” from the report
- 01How are the new audits being used now, and how do you make sure problems are identified and acted on?
- 02What regular opportunities will my relative have to go out and take part in their interests?
- 03How will you support my relative to have more control over daily decisions and develop independence?
- 04Are staff meetings now recorded, and how are staff suggestions or concerns followed up?
- 05How do you check that fire safety improvements and evacuation arrangements remain up to date?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 20 May 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 Derby Lodge
8 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- February 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2022Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- September 2021Requires improvementSafe: Requires improvementWell-led: Inadequate
- March 2021Inspected but not ratedSafe: Inspected but not rated
- November 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2020Requires improvementstayed Requires improvementSafe: InadequateEffective: GoodWell-led: Requires improvement
- October 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 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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85 live-in carers within about an hour of Lancashire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
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