CQC report explained · a residential care home
What the CQC found at Dunheved Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, medicines, staffing, safeguarding, fire safety and infection control were managed appropriately.
- Effective?
- Good
- The report does not give a separate rating for Effective. It says timely healthcare referrals were made and staff followed professional advice about people's health and swallowing needs.
- Caring?
- Good
- The report does not give a separate rating for Caring. Inspectors said people received kind and compassionate care and that staff knew people well.
- Responsive?
- Good
- Care plans recorded people's preferences and people were supported to choose activities, travel arrangements, food, clothing and how their rooms were decorated.
- Well-led?
- Good
- The home had an open culture, sought people's views and used audits to check care quality. Managers recorded actions needed after checks and followed up their completion.
What inspectors found, August 2022
Dunheved Lodge was rated Good; inspectors found safe, kind and person-centred support with no breaches reported.
Inspectors visited on 31 May and 6 June 2022 without telling the home in advance. They spoke with three people, two staff members and managers. They reviewed four people's care records, medicines, staff files and management records.
People were supported to make choices, take part in activities and use local shops, cafes, parks and other services. Inspectors found that staff understood people's communication needs and supported contact with relatives and friends.
The home had systems for safeguarding, managing risks, medicines, infection control and learning from incidents. Inspectors also found regular quality checks and said the home had acted on issues found during an earlier infection control inspection.
The overall rating was Good. Safe, Responsive and Well-led were each rated Good. The report does not give separate ratings for Effective or Caring.
Choice and independence
People were supported to choose activities, travel arrangements and how their rooms were decorated. They were also supported to take part in community activities and trips.
“People were supported to live active lives over which they had choice and control.” from the report
Understanding communication
The home used pictures, video and knowledge of people's individual communication styles to help people understand choices and express themselves.
“Where people did not use speech, staff understood their unique ways of communicating.” from the report
Safe systems
Inspectors found suitable arrangements for safeguarding, risk management, medicines, fire safety and infection control. Medicines records checked were complete and matched the stock.
“People's MAR charts were completed correctly, contained no gaps in recording and matched the medicines stocks we checked.” from the report
Quality improvement
Managers used audits and external checks to identify actions. The provider had redecorated some areas and planned further work after an earlier inspection.
“Where actions were required following checks, these were stated in quality assurance records.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and support my relative's individual communication needs?
- 02How will my relative be supported to choose activities, travel arrangements and time in the local community?
- 03What health risks or swallowing needs would staff need to manage, and how would healthcare referrals be arranged?
- 04What improvements from the earlier infection control inspection have now been completed, and what communal area work remains?
- 05How will you keep me involved in care reviews and decisions about my relative's support?
This inspection considered Safe, Responsive and Well-led and the principles of right support, right care and right culture; the report does not give separate ratings for Effective or Caring. This explanation was written from the published report of 17 August 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, April 2022
Inspected but not rated; inspectors found good COVID-19 controls, but some infection-control policies and premises arrangements needed improvement.
This was an announced, targeted inspection on 28 February 2022. Inspectors looked at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19.
The home had enough staff and staff had infection-control training. People and staff were tested in line with government guidance, all staff had been vaccinated, and visits followed government guidance.
Inspectors were only somewhat assured in some areas. Visiting, admissions and infection-control policies did not contain enough detailed COVID-19 procedures. Inspectors also found waste and broken furniture in the garden, unsecured cleaning equipment, and empty or broken hand-sanitiser dispensers. The provider said these issues were fixed after the inspection.
The home was inspected but not rated. This report does not give an overall rating or a rated judgement for the five questions.
Staff training
Staff had training in infection prevention and control, including using and disposing of protective equipment and hand washing.
“Staff had received infection prevention and control training, including how to put on and take off personal protective equipment and dispose of it safely and hand washing.” from the report
Visiting arrangements
The visiting arrangements followed government guidance. People could also keep in touch with family and friends by video and telephone.
“The visiting arrangements and procedures followed by staff were in line with government guidance.” from the report
Testing and vaccination
People and staff were tested in line with government guidance, and all staff had been vaccinated.
“People and staff were tested for COVID-19 in line with government guidance and all staff had been vaccinated.” from the report
Staffing
The provider said it had measures to manage COVID-19-related staffing pressures, and inspectors found there were enough staff.
“The service had enough staff and had measures in place to deal with any staffing difficulties arising from COVID-19.” from the report
Incomplete written procedures
needs fixingThe visiting policy did not explain in enough detail how to protect people, families and staff during visits. The admissions and infection-control policies also lacked comprehensive COVID-19 information, although the provider updated them afterwards.
“The provider's visiting policy did not include specific procedures staff should follow to ensure people, families and staff were protected from COVID-19 infection when visits to the home took place.” from the report
Premises and cleaning equipment
needs fixingWaste and broken furniture were stored in the back garden, and mops and buckets were not stored securely. Empty or broken hand-sanitiser dispensers were also found. The provider said these issues were corrected after the inspection.
“During our inspection we found used building materials and broken items of furniture stored in the back garden.” from the report
Out-of-date infection policy
needs fixingThe infection prevention and control policy did not contain specific information about preventing and controlling COVID-19. It was updated after the inspection.
“However, the policy did not include specific information about how to prevent and control the spread of COVID-19 infection.” from the report
- 01Can you show us the updated visiting, admissions and infection prevention and control policies?
- 02How do you check that hand-sanitiser dispensers are working and refilled?
- 03How are mops, buckets and other cleaning equipment stored securely now?
- 04How do you make sure the garden is kept free of waste and broken furniture?
- 05What measures are currently in place if COVID-19 causes staff shortages?
This was a targeted inspection of COVID-19 infection control, visiting arrangements and staffing pressures; the service was inspected but not rated and the other four questions were not assessed. This explanation was written from the published report of 15 April 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 Dunheved Lodge
4 rated inspections over 6 years: the service has held its Good rating throughout.
- August 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2022Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodWell-led: Good
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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