CQC report explained · a residential care home
What the CQC found at Devon Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that some medicine-related risks were not fully assessed or managed. They also found unclear reasons for some restrictions on drinks, snacks and kitchen access.
- Effective?
- Good
- People generally received personalised support from trained staff, with help from a specialist team. Training in some communication tools was still incomplete or delayed.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Well-led?
- Requires improvement
- Management systems did not reliably identify all safety and quality problems. Some care records were incomplete or inaccurate, and incident reviews did not always lead to improvements.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found better staffing and care, but ongoing medicine safety and management problems.
This was an unannounced focused inspection on 9 and 10 January 2023. Inspectors observed care, spoke with staff and professionals, and checked support plans, medicine records, recruitment files and management records.
The home had improved in several areas. There were more familiar staff, the environment was cleaner and more homely, and people had more support with activities and community access. Staff understood people's needs and families generally felt the home had improved.
However, known medicine-related risks were not always properly assessed or managed. Some restrictions on drinks, snacks and kitchen access were not clearly justified as the least restrictive option. Management checks were still not effective enough to find and correct problems in safety and care records.
The overall rating stayed at Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective improved from Requires Improvement to Good. This inspection did not assess Caring or Responsive, so their previous ratings were carried forward.
More consistent staffing
The home had enough staff with suitable skills, and agency use had reduced. Staff had accessible information about how to support each person.
“Improvements had been made and the use of agency staff had significantly reduced.” from the report
Personalised support
The specialist team helped staff understand people's communication, sensory needs and distress. Staff supported people with personal goals and independence.
“Overall people had care and support that was personalised and reflected their needs.” from the report
Improved environment
The home was cleaner, better maintained and more comfortable. Communal areas and private rooms had become more homely.
“Improvements had been made which ensured that overall, people's care and support was provided in a safe, clean, better equipped and well-furnished environment.” from the report
More activities
People had more opportunities for social, leisure and community activities, including walks, swimming, shopping and holidays.
“Since the last inspection, an activity coordinator had been appointed for 28 hours each week and there was evidence staff were supporting people to have more access to social, leisure and recreational activities in the local community.” from the report
Medicine-related risks
seriousSome risks were not properly assessed, planned for or reduced. This included out-of-date emergency guidance, a rescue medicine no longer kept at the home, and incomplete planning for rescue medicine during activities.
“We were not assured that all of the known medicines related risks had been appropriately assessed, planned for and mitigated.” from the report
Restrictions on choice
needs fixingSome restrictions affected people's access to drinks, snacks and the kitchen. Inspectors were not assured that these restrictions were necessary or the least restrictive option.
“There continued to be some evidence of restrictive practices being used which limited people's choices and for example, their access to drinks and snacks.” from the report
Weak management checks
seriousThe home's monitoring systems did not identify all safety and quality problems. Some care records were incomplete or inaccurate, and incident reviews did not always lead to action.
“A range of governance processes were in place but were still not being fully effective at identifying all of the areas where the quality and safety of the service was compromised.” from the report
Communication methods not always used
needs fixingThere was a gap between the communication methods recorded in plans and what staff used in practice. Some communication training had also been delayed.
“We were not assured therefore that the promoted communication techniques were always being used in practice.” from the report
- 01What has been done to update the emergency guidance and ensure rescue medicines are available when needed?
- 02How are medicine risks assessed for activities such as swimming, and who reviews those assessments?
- 03Why are drinks, snacks or kitchen access restricted for this person, and how are less restrictive options being tested?
- 04How are staff being trained and checked to use this person's communication methods in everyday care?
- 05What action has been taken since the warning notice to improve management checks and the accuracy of care records?
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 2 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.
What inspectors found, March 2022
Requires Improvement; inspectors found risks in medicines, staffing, care planning and the home’s leadership.
This was an unannounced inspection over 24 to 26 January 2022. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care records, medicines records, staff files and management records.
The home supported 10 adults with autism and learning disabilities. Inspectors found kind and individual support in some areas, including help with health appointments, positive behaviour support and contact with relatives. However, care was not always safe, consistent or focused on people’s goals and independence.
There were problems with risk assessments, medicines, recruitment checks, staffing levels, the condition of parts of the home and management oversight. Some safeguarding concerns had not been escalated. The home did not have a CQC-registered manager at the time, although a new manager was due to start in April 2022.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. The report says the provider must submit an action plan, and CQC will monitor progress and return for another inspection.
Specialist support
The provider’s specialist team worked with support staff to understand people’s communication, sensory needs and distress. This helped staff use personalised approaches.
“Peoples care was enhanced by the involvement of specialists employed by the provider who worked closely with the support staff to develop a collaborative and problem-solving approach to people's support.” from the report
Positive behaviour support
People had plans aimed at preventing distress and supporting recovery after incidents. These plans focused on communication and de-escalation rather than physical restraint.
“The plans did not include the use of physical restraint, instead, interventions focussed on the use of communication, body language, de-escalation, proximity and supportive stances.” from the report
Health support
People were supported with health checks, vaccinations, dental care and referrals to specialist services. They were also supported to use gyms and go swimming.
“Overall, the service promoted good health and wellbeing outcomes for people, including supporting people to have an annual health check with their local GP.” from the report
Support for family contact
Staff helped people keep in touch with relatives through video calls when needed. Relatives were able to visit in line with government guidance.
“Staff had facilitated the use of alternative forms of maintaining social contact with people's relatives, for example, one person's family read a story or shared a daily joke with their relative using video calls as a means of staying in touch.” from the report
Mealtime choices
Inspectors saw some meals where people could choose between options and combine different foods. Staff sometimes ate with people and provided encouragement and companionship.
“Another person was shown pictures of two meal options and chose an element of each for their meal.” from the report
Unmanaged safety risks
seriousSome risk assessments and seizure plans lacked important information or were not available to all staff. Inspectors also found unlocked chemical storage and inconsistent monitoring of health needs.
“This demonstrates a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Medicines records and storage
seriousRescue medicines, PRN guidance, cream records and fridge temperature checks were not consistently managed. One short-term medicine was given for longer than prescribed.
“Staff did not always follow systems and processes to administer, record and store medicines safely.” from the report
Staffing and consistency
needs fixingBetween 50% and 80% of staff on duty were agency workers during the period checked. High turnover and vacancies reduced consistency and limited activities and progress towards people’s goals.
“However, staff told us, and our observations and records would support, that the current skill mix of permanent to agency staff did at times impact upon the care people received.” from the report
Condition of the home
needs fixingSome rooms and bathrooms were not comfortable, clean or in good repair. Cleaning records had gaps, and inspectors found damaged flooring, blocked or broken toilets and soiled items.
“We were not assured that premises were consistently well maintained and adapted for people's needs.” from the report
Weak management checks
seriousAudits did not identify several problems found during the inspection. Changes in managers also affected oversight of incidents, care plans, medicines and safety.
“This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
- 01What has been done to make risk assessments and seizure plans complete, consistent and available to every member of staff?
- 02How are medicines, PRN instructions, topical creams and medicine fridge temperatures now checked and recorded?
- 03How many permanent and agency staff are currently working here, and how do you ensure agency staff know each person’s communication needs?
- 04What activities and support are now being provided to help each person reach their goals and develop independence?
- 05What repairs, cleaning improvements and changes to people’s bedrooms and bathrooms have been completed since the inspection?
This was a focused inspection prompted by concerns about safety and staffing and assessing Right support, right care, right culture; Safe, Effective and Well-led were inspected, while other ratings carried over from the previous inspection. This explanation was written from the published report of 26 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Devon Lodge
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2018GoodSafe: Requires improvementEffective: GoodWell-led: Good
- October 2016
Registered with the Care Quality Commission on 14 October 2016.
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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