CQC report explained · a nursing home
What the CQC found at Filsham Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2023
Filsham Lodge was rated Requires Improvement; inspectors found staff and medicines were generally safe, but risk records and management oversight were not reliable enough.
This was an unannounced focused inspection on 3 and 7 February 2023. Inspectors looked only at Safe and Well-led because they had received concerns about staffing, risk management and people's safety. They reviewed care, medicines and recruitment records, checked the premises, observed care, and spoke with people, relatives, staff and health professionals.
The home had enough suitably trained staff, safe recruitment checks and safe medicines practice. People said they felt safe, and infection control arrangements were satisfactory. However, some important risks were not properly assessed or recorded. These included choking, self-harm, mental health, continence, positioning and possible pressure damage.
The home's systems had not made sure that records were accurate and completed on time. The previous improvement plan had not been fully completed. The provider remained in breach of Regulation 12 on safe care and treatment and Regulation 17 on good governance.
The overall rating remained Requires Improvement, as did Safe and Well-led. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
Enough trained staff
Inspectors found enough suitably qualified staff to meet people's needs, including one-to-one support where required. Recruitment checks were also completed before staff started work.
“Staff were safely recruited and there were sufficient numbers of suitably qualified staff deployed to meet peoples' needs.” from the report
Medicines handled safely
Medicines were stored, given and disposed of safely. Staff who administered them had relevant training and competency checks.
“Medicines were stored, administered and disposed of safely.” from the report
Action was taken during inspection
The home acted immediately when inspectors found radiators that were very hot to touch. The radiators were turned off until the thermostat could be repaired.
“The radiators were turned off until the thermostat was repaired.” from the report
Risks were not always managed
seriousSome people's risks were not fully assessed or explained in their care records. This could leave staff without the information needed to support people safely.
“Risks to people were not always managed safely, potential risks were not always fully identified, assessed or mitigated.” from the report
Long periods in chairs
seriousSome people spent up to six hours in recliner or tilt chairs without regular position changes or continence care. Inspectors said this created a potential risk of skin and pressure damage.
“People spent long periods of time (up to 6 hours) sitting in recliner and tilt chairs without regular moving of position or continence care.” from the report
Incomplete care records
seriousRecords were not always accurate or completed promptly. Inspectors found missing or unsuitable risk assessments for choking, self-harm, continence and tissue damage.
“The provider had failed to maintain accurate, complete and contemporaneous record in respect of each service user.” from the report
Improvement had not been sustained
needs fixingThe action plan from the previous inspection had not been fully completed. Leadership changes and weak oversight had affected the home's ability to maintain improvements.
“The action plan from the last inspection had not been fully actioned.” from the report
Mental health and capacity records
needs fixingSome care plans and risk assessments did not accurately reflect people's mental health status or capacity. The home was advised to seek professional advice about using recline and tilt chairs.
“People's mental health status and capacity was not accurate on individual care plan or risk assessments.” from the report
- 01How have you updated care plans and risk assessments for choking, self-harm, continence and pressure damage?
- 02How do you make sure people in recliner or tilt chairs are regularly repositioned and receive continence care?
- 03How do you check that care records are accurate and completed at the time care is given?
- 04What action has been taken since the inspection to meet Regulations 12 and 17?
- 05What was the outcome of the external investigation into recruitment and culture concerns, and what changes followed?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection. 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.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found risks and record-keeping shortfalls during a period of management change.
This was an unannounced focused inspection on 5 and 9 May 2022. Inspectors looked at Safe and Well-led, including infection prevention and control. They spoke with people, relatives, staff and health professionals, observed care, and checked care records, medicines, rotas, training and safety documents.
The home had enough staff, safe recruitment, trained staff and safe medicines systems. People said they felt safe. However, inspectors found a blocked fire exit, unclean and unsuitable sluice areas, poor oral care records, gaps in nutrition records and some care records that did not reflect people's current needs. Not all accidents and injuries had been properly recorded.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The other three questions were not inspected at this visit, so their previous ratings were carried forward. The overall rating fell from Good at the previous inspection.
Enough staff
Inspectors found staffing levels and deployment met people's needs. Staff were recruited using appropriate checks.
“Staff numbers and the deployment of staff had ensured people's needs were met in a timely manner and in a way that met their preferences.” from the report
Safe medicines
Medicines were stored, given and disposed of safely. Staff who administered medicines had the required training and competence.
“Medicines were stored, administered and disposed of safely.” from the report
People felt safe
People told inspectors they felt safe, and staff understood how to recognise and report abuse.
“People told us they felt safe.” from the report
Improvement work had started
The current manager had carried out an audit and begun actions to address risks, including staff refreshers and checks on people's positioning.
“The management team demonstrated a commitment to improving outcomes for people.” from the report
Fire exit was blocked
seriousA first-floor emergency exit was blocked by clinical bins and a medicine cabinet. This was removed during the inspection, but it had created a risk during evacuation.
“One emergency fire exit on the first floor had been blocked by clinical bins and a medicine cabinet attached to the wall.” from the report
Risk records were incomplete
seriousSome care plans and risk assessments did not reflect changes in mental capacity, skin injuries, skin care, nutrition or oral health. This meant risks were not always properly assessed or monitored.
“The provider had failed to assess, monitor and mitigate risks to people.” from the report
Cleanliness and sluice areas
needs fixingInspectors found dusty rooms, sticky surfaces, unclean bathroom hoists and cluttered, grubby sluice rooms. The home said these areas were later cleared and deep cleaned.
“The sluice rooms were very cluttered, grubby and were not fit for purpose” from the report
Nutrition and mouth care
needs fixingThere was not enough assurance that people received mouth care. Food and fluid records were sometimes inaccurate or completed later, and nutritional risks were not always fully recorded.
“There was a lack of oversight of peoples' nutritional intake and risk.” from the report
Accidents and injuries not always recorded
needs fixingSome skin tears and injuries had no linked accident record or treatment plan. Inspectors said this needed improvement.
“Not all accidents and incidents were documented and recorded.” from the report
- 01What has been done to make sure all fire exits remain clear and safe to use?
- 02How do you now check and record mouth care, dentures, food intake, fluid intake and weight loss?
- 03How do you make sure care plans and risk assessments reflect changes in mental capacity, skin condition and nutrition?
- 04How are accidents, skin tears and injuries recorded, investigated and followed up?
- 05Who is currently responsible for the home, and how is management oversight checked after the recent leadership changes?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 6 July 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 Filsham Lodge
8 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2021GoodSafe: GoodWell-led: Good
- April 2021Inspected but not ratedSafe: Inspected but not rated
- September 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- February 2019Requires improvementstayed Requires improvementSafe: GoodCaring: GoodWell-led: Requires improvement
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- June 2017Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Inspected but not ratedSafe: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 11 July 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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