CQC report explained · a nursing home
What the CQC found at Derwent Lodge Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that medicines, infection control, risk management, staffing and safeguarding arrangements were safe. They noted that staff did not always follow the home's own procedure when recording medicines.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the last inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the last inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the last inspection.
- Well-led?
- Good
- Inspectors found effective audits, a monthly improvement plan, experienced managers and a positive, person-centred culture. People, relatives and staff said they felt listened to and supported.
What inspectors found, August 2023
Rated Good; inspectors found safe, kind care and clear improvements, but staff did not always record medicines as the home's procedure required.
This was an unannounced, focused inspection on 7 August 2023. Inspectors observed care, spoke with people, relatives, staff and a visiting professional, and checked care records, medicines, the environment, audits and other records.
The home was rated Good for Safe and Well-led. Inspectors found enough suitable staff, safe medicines management, suitable risk assessments, effective infection control and systems to respond to safeguarding concerns, complaints and incidents.
People and relatives described kind care, good relationships with staff and a clean home. Managers were visible, staff felt supported, and audits and an improvement plan were being used to address problems.
The previous rating was Requires Improvement, published on 1 March 2023. This inspection found improvements and said the provider was no longer in breach of regulations. The overall rating changed to Good, but the other three key question ratings were carried forward from the previous inspection.
Safe staffing
There were enough staff, and inspectors saw staff respond promptly to people's requests and distress. Most care was provided by staff who knew people well.
“There were enough staff to care for people and keep them safe.” from the report
Medicines and risk
Medicines were managed safely and people received them as prescribed. Risks to people's safety and wellbeing were assessed, monitored and reviewed.
“Medicines were managed safely and people received these as prescribed.” from the report
Clean environment
Inspectors found effective infection control arrangements and saw staff cleaning during the day. People and relatives spoke positively about cleanliness and laundry.
“People using the service and their relatives told us the home was kept clean.” from the report
Visible leadership
Managers worked alongside staff and used audits, meetings and an improvement plan to identify and address problems. Staff described the management team as supportive.
“There were effective systems for monitoring and improving the quality of the service.” from the report
Kind, person-centred culture
People and relatives described friendly staff and a family atmosphere. Staff said they enjoyed their work and felt able to speak up and suggest ideas.
“There was a positive person-centred culture.” from the report
Medicine records
minorStaff did not always follow the home's own procedure when recording that medicines had been given. The manager agreed to address this with the staff concerned.
“However, the staff did not always follow the provider's own procedures when recording administration of medicines.” from the report
- 01What has been done to make sure staff always follow the home's procedure when recording medicines?
- 02How are medicines records checked now, and what happens if an error is found?
- 03What improvements were included in the monthly service improvement plan after the previous inspection?
- 04What were the home's previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
- 05How are families involved in meetings, social events and decisions about their relative's care?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 12 August 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 2023
Derwent Lodge Care Centre was rated Requires Improvement; inspectors found kind, personalised care but serious gaps in medicines, first aid and infection control.
Inspectors visited without notice on 17 January 2023. They spoke with people living at the home, relatives, staff and visiting professionals. They observed care, checked medicines, reviewed care and staff records, and carried out a partial tour.
People were generally treated kindly and respectfully. Inspectors found enough suitable staff, good training, personalised care plans, support with food and drink, activities and access to healthcare. People and relatives said they felt safe and were happy with the care.
However, some first aid items, blood glucose test strips and medical equipment were out of date or not properly checked or cleaned. A used lancet was stored with unused ones. The home acted immediately when these issues were found, but the failures led to a breach of Regulation 12 and ratings of Requires Improvement for Safe and Well-led.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed that staff gave people time, choices and encouragement.
“People were treated with kindness and respect. There was a relaxed and friendly atmosphere.” from the report
Enough trained staff
Inspectors found enough suitable staff, with thorough recruitment, induction and ongoing training. Staff said they felt supported.
“There were enough suitable staff, a rigorous recruitment process and in-depth training.” from the report
Personalised support
Care plans recorded people's needs and preferences and were regularly reviewed. The home supported communication, activities, cultural needs and independence.
“People received personalised care which met their needs and preferences.” from the report
Good health and nutrition support
People had access to food and drink suited to their needs, and staff worked with other professionals to monitor their health.
“People's healthcare needs were assessed, monitored and met.” from the report
Expired first aid supplies
seriousTwo first aid boxes contained items past their expiry dates, including items that had expired several years earlier. This meant they might not have worked properly if needed.
“We found out-of-date items in two first aid boxes.” from the report
Medicines and diabetes checks
seriousSome blood glucose test strips were out of date, and monitors were not always checked as the manufacturer required. This created a risk that readings used to guide insulin treatment were inaccurate.
“This meant there was a risk that blood glucose readings taken using these test strips may not have been accurate.” from the report
Infection control
seriousA used lancet was stored with unused lancets, and one blood glucose monitor was dirty and stained with blood. Inspectors said this created risks of infection and needle-stick injury.
“This presented a risk of cross infection and needle stick injury for staff.” from the report
Audits missed problems
needs fixingThe home's audits did not identify some expired supplies and medicines problems before the inspection. This contributed to the Requires Improvement rating for Well-led.
“The provider's systems and processes for auditing medicines and first aid supplies had not always been operated effectively.” from the report
- 01What checks now make sure first aid supplies and blood glucose test strips are in date?
- 02How often are blood glucose monitors quality checked, and who reviews the results?
- 03How do you keep used lancets separate from unused equipment and confirm that monitors are cleaned properly?
- 04What evidence can you show that the improvements made after the inspection have been maintained?
- 05How are medicines given covertly recorded, including whether relatives, family members or advocates were involved?
This inspection considered all five CQC questions, included infection prevention and control checks, and involved a partial tour of the environment. This explanation was written from the published report of 1 March 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.
Every inspection of Derwent Lodge Care Centre
7 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2017
Registered with the Care Quality Commission on 4 October 2017.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Hounslow
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.
Most charge £980 to £1,270 a week. 85 can care for a couple. 11 years' experience on average.
“Without his support we wouldn't have been able to navigate bringing and keeping Dad at home.”
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.