CQC report explained · a nursing home
What the CQC found at Faro 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
- Risk assessments and care plans did not properly manage risks, including the risk of someone leaving unsupported. There were also gaps in medicine protocols, practical medicine checks and welfare-check guidance.
- Effective?
- Requires improvement
- Mental capacity assessments had not been completed, even though best-interest decisions and deprivation of liberty applications were in place. Training and care plans also had gaps, including around PEG feeding and nutritional support.
- Caring?
- Requires improvement
- Staff were observed treating people respectfully and supporting communication, but people had not been fully involved in care planning and capacity assessments were missing.
- Responsive?
- Requires improvement
- Staff provided personalised support, but care plans did not show that people's capacity or involvement had been assessed. Communication information was recorded in a way that could make it difficult for some people to understand.
- Well-led?
- Requires improvement
- Audits and management systems had not found or fixed all the problems. The provider had not acted effectively on concerns raised at the previous inspection, and records did not always give a clear picture of people's days.
What inspectors found, August 2021
Rated Requires Improvement; inspectors found serious gaps in risk planning, mental capacity assessments and management oversight.
This was a comprehensive inspection after concerns that a person had left the home without staff support. The inspector spoke with relatives, staff and a health professional, and reviewed care, medicine, staff and management records.
The home was not always safe. Risk assessments and care plans did not give staff enough guidance, and one person left unsupported and was put at high risk of harm. Staff were also unsure how often some welfare checks should happen. Mental capacity assessments had not been completed before best-interest decisions and deprivation of liberty applications were made.
All five areas were rated Requires Improvement. The rating had stayed the same for Safe, Effective and Well-led since the previous inspection. Caring and Responsive had fallen from Good. The provider had not made enough progress after the last inspection, and the CQC required an action plan and further monitoring.
Respectful support
Inspectors saw staff interact respectfully and support the person to communicate choices in their preferred way.
“During the inspection, we observed staff interact with people in a respectful manner.” from the report
Personalised choices
Staff were observed giving a person opportunities to make choices and supporting their actions.
“Staff supported people in a personalised way. Staff were observed allowing the person the opportunity to make their choice” from the report
Staffing and safeguarding
There were enough staff on the inspection day, and staff could explain how they would recognise and report abuse.
“Sufficient staff were deployed on the day of the inspection.” from the report
Risk of leaving unsupported
seriousA person known to be at risk of leaving did leave without staff support. The care plan did not explain the steps staff should take to reduce this risk.
“This resulted in this person leaving the service unsupported by staff during their stay putting them at high risk of potential harm.” from the report
Mental capacity and consent
seriousThe home used best-interest decisions and deprivation of liberty applications without recording capacity assessments first. This meant restrictions may not have been appropriate.
“We found no evidence that people's capacity had been assessed. This placed people at risk that not all restrictions being placed on them were appropriate.” from the report
Incomplete care guidance
needs fixingSome care plans lacked important details or conflicted with professional advice. This could lead to unsafe or inconsistent support.
“A care plan was in place detailing how to support this person with their nutritional intake, however an assessment from a Speech and Language Therapist (SALT) gave conflicting information.” from the report
Medicine procedures
needs fixingThere were no required protocols for some as-needed medicines, and not all staff had practical medicine competency checks. A tablet crusher was also missing until the inspection identified the issue.
“One person who required use of a nebuliser due to their health conditions had no protocol in place for the use of this medication.” from the report
Weak management checks
seriousAudits did not identify all the problems, and the same risk-management concerns had been raised at the previous inspection. This contributed to a person being put in danger.
“Appropriate and timely action had not been taken as a result of our last inspection at this service, and some of the same areas highlighted still require improvement.” from the report
- 01What detailed risk assessment and staff plan is now in place for anyone who may leave the home without support?
- 02How do you complete and record mental capacity assessments before making best-interest decisions or deprivation of liberty applications?
- 03How do you make sure care plans agree with Speech and Language Therapist advice and contain enough detail about communication, nutrition and welfare checks?
- 04Have all staff completed practical checks for medicines and PEG feeding, and are protocols in place for every as-needed medicine?
- 05What changes have been made in response to the previous inspection, and how do your audits now check that these changes are working?
This was a comprehensive inspection covering all five CQC questions, following concerns that a person had left the home unsupported. This explanation was written from the published report of 12 August 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, April 2020
Rated Requires Improvement; inspectors found kind, personalised care, but gaps in risk records, consent checks and management oversight.
This was a planned inspection on 11 February 2020. One inspector spoke with a person using the home, a relative, staff and managers. They also reviewed care, medicine, recruitment and management records.
The home provided respite care for up to six people with a learning disability. Inspectors found kind and respectful staff, personalised support, safe medicines handling and enough staff during the visit. People were supported with food, healthcare, activities and developing independence.
There were important gaps in records and legal checks. Risk assessments and some care plans were not detailed enough. Mental capacity assessments and applications for Deprivation of Liberty Safeguards were not always completed. The home's audits had not found these problems.
The overall rating was Requires Improvement. Caring and Responsive were rated Good. Safe, Effective and Well-led were rated Requires Improvement. The rating had fallen from Good at the previous inspection, published on 26 April 2017.
Kind and respectful care
Staff were observed to interact warmly with people and to respect their privacy and dignity.
“Staff and management interacted with people in a warm and friendly manner.” from the report
Personalised support
Staff understood people's different needs and supported them with independence, activities and plans for their future.
“Staff and managers fully understood people's individual needs, and delivered care which was personalised to them.” from the report
Staffing and recruitment
There were enough staff during the inspection, and recruitment checks were completed before staff started work.
“There were enough staff to support people's needs.” from the report
Food and healthcare
People's dietary needs were identified, healthy choices were encouraged and healthcare support was arranged when needed.
“People's nutritional and dietary needs were identified and supported by staff, who told us they encouraged healthy options for people.” from the report
Legal consent checks
seriousThe home had not always completed detailed mental capacity assessments or applied for Deprivation of Liberty Safeguards. This meant some restrictions might not have had the required legal authority.
“The management team had not always created detailed capacity assessments or made DoLS applications to ensure that any restrictions that may be required to be placed on people, were lawful.” from the report
Missing risk information
needs fixingSome risks, including epilepsy, leaving the home without staff knowing and forming safe relationships, were not covered by detailed written risk assessments.
“There were not any detailed and suitable risk assessments in place to document how staff should manage and mitigate these risks.” from the report
Incomplete care planning
needs fixingOne person's file contained information from an old provider but did not contain a sufficiently detailed care plan from the home.
“Information from an old care provider was present within their file, but little else had been documented by the service who were currently providing them with care.” from the report
Weak quality checks
needs fixingThe home's audits had not identified the missing consent applications, incomplete risk assessments or gaps in care planning. Similar improvements had also been outstanding since the previous inspection.
“Appropriate and timely action had not been taken as a result of our last inspection at this service, and some of the same areas still required improvement.” from the report
One incomplete medicines record
needs fixingMost medicines records were completed correctly, but one record named only a blister pack instead of listing the medicines.
“One MAR we saw did not have the names of the medicines recorded, and just had 'Blister pack' written on it instead.” from the report
- 01Have all required Deprivation of Liberty Safeguards applications now been made, and how do you review them?
- 02Are detailed mental capacity assessments now completed for each relevant decision?
- 03Have the missing risk assessments and detailed care plans been completed and checked?
- 04How does the home make sure its audits identify gaps in care records, consent checks and risk management?
- 05Who is currently responsible for managing the home while recruitment of a registered manager is taking place?
This was a planned inspection of the care home covering all five CQC questions, including accommodation and nursing or personal care, with four people's care records and medicine records reviewed. This explanation was written from the published report of 15 April 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.
Every inspection of Faro Lodge
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- August 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- November 2013
Registered with the Care Quality Commission on 1 November 2013.
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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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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