CQC report explained · a residential care home
What the CQC found at Franklyn Lodge 9 Grand Avenue
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2023
Rated Requires Improvement overall; inspectors found kind, safe care but weaknesses in quality checks, staff breaks, training and activities.
The unannounced inspection took place on 17 August 2023. One inspector observed care, spoke with family members, staff and managers, and reviewed care records, medicines records, recruitment files and quality checks.
The home provides residential care for six people with learning disabilities. Inspectors rated Safe, Effective, Caring and Responsive as Good. They found kind and respectful care, safe medicines management, personalised support and staff who knew people well.
The overall rating remains Requires Improvement because Well-led was rated Requires Improvement. Quality checks did not reliably identify and fix problems. Inspectors also found concerns about staff rest between shifts, gaps in training and whether activities helped people develop skills and relationships.
The home breached Regulation 17 on good governance. CQC asked for an action plan and said it would monitor progress with the provider and local authority.
Kind and respectful care
Inspectors saw a calm atmosphere and positive interactions. Staff respected people's dignity, privacy, individuality and preferred ways of communicating.
“There was a calm and relaxed atmosphere in the service. People received kind and compassionate care.” from the report
Safe medicines
Medicines were given as prescribed, stored safely and supported by guidance for medicines given when needed. Inspectors found no gaps in the medicines records they reviewed.
“There were no gaps in the Medicines Administration Records (MARs) we reviewed which provided assurance medicines were being given as prescribed.” from the report
Personalised support
Care plans described people's needs, preferences, health needs and goals. Staff knew people well and used their individual communication methods.
“People had care and support plans that were personalised and reflected their needs and aspirations, and included physical and mental health needs.” from the report
Consistent staff team
The home had low staff turnover and regular staff who knew the people living there. Families said this consistency helped their relatives feel settled.
“The staff in the home are the same. This means [my relative] knows the staff. There is consistency. It does make a difference.” from the report
Quality checks did not work reliably
seriousAudits did not consistently identify or fix problems. Inspectors found incomplete medicines audits and weaknesses linked to staff breaks, training and activities.
“The current auditing systems in place were not robust enough to show that the quality of the service had been assessed and improvements to the safety and quality of the services being provided to people had been made.” from the report
Long shifts and short rest periods
needs fixingSome staff worked 15-hour days and had only nine hours between shifts, rather than the 11 hours of rest referred to in the report. CQC recommended that shift patterns be reviewed.
“This meant they continuously worked 15 hour days.” from the report
Training records had gaps
needs fixingInspectors could not confirm that some staff had completed training in areas including epilepsy, diabetes, dementia awareness and dignity in care. The manager said this would be reviewed.
“We could therefore not be sure that they were aware of what to do in such situations.” from the report
Activities were not always meaningful
minorPeople had activity timetables, but inspectors found limited evidence that activities matched individual interests, developed skills or supported social relationships in the community.
“There was a lack of evidence that people were supported by staff to try new things and develop their skills.” from the report
- 01What has changed in the quality assurance system since the inspection, and how do you check that known problems are now fixed?
- 02How do you make sure staff receive enough rest between shifts, particularly after long shifts?
- 03Which staff still need training or refresher training in epilepsy, diabetes, dementia awareness or dignity in care?
- 04How are activities chosen for my relative's interests, skills and communication needs?
- 05How will you involve families in regular feedback, given that the last family survey mentioned in the report was in 2020?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the report also compares the findings with the previous inspection published on 7 May 2020. This explanation was written from the published report of 6 October 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, May 2020
Rated Requires Improvement; inspectors found kind, personalised care, but safety and management checks were not always reliable.
Inspectors made an unannounced visit on 6 and 12 February 2020. They spoke with staff, the manager, relatives and care professionals. They observed care and checked records about five people and the running of the home.
People appeared settled and received respectful, personalised care. Staff supported people with food, health care, communication, activities and independence. Medicines were given as prescribed, staffing levels were adequate, and staff had suitable training.
The home was not always safe or well managed. Inspectors found a missing diabetes risk assessment, unsuitable window restrictors and incomplete fire drill records. One staff member had worked long hours with only a short break. Some audits had not found these problems.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led had fallen from Good at the previous inspection and were rated Requires Improvement.
Kind and respectful care
Inspectors saw positive interactions and received positive feedback from relatives and care professionals. People were treated with dignity and respect.
“On both days of the inspection, we observed positive and caring interaction between people and staff.” from the report
Personalised support
Care plans recorded people's needs, preferences and abilities. Staff knew how to support individual routines, communication and behaviour.
“People received personalised care and support.” from the report
Good communication support
The home used pictorial information, picture books and objects of reference. Care records explained how people communicated when they were happy, distressed or needed help.
“People's care plans and other important documents were in pictorial form so that people could understand them more easily.” from the report
Activities and independence
People were supported to take part in activities such as shopping, swimming, walks and day services. Staff also encouraged people to help with household tasks and choose their clothes.
“There was a programme of specific activities for each person depending on their interests.” from the report
Missing health risk assessment
seriousA person with diabetes did not initially have a risk assessment. The completed assessment was sent to inspectors soon after the inspection.
“We noted that there was no risk assessment for a person with diabetes.” from the report
Staff working hours
seriousOne staff member worked long hours with only a six-hour break over two days. Inspectors said this could affect people's safety and recommended a review.
“We noted that a staff member had worked long hours with only a short break of six hours over a two-day period.” from the report
Fire drill records
needs fixingFire safety arrangements were in place, but the home did not record who took part in fire drills. Inspectors recommended that these names should be recorded.
“The names of staff and people present during fire drills were not recorded.” from the report
- 01What has been done to make sure every person, including anyone with diabetes, has a current and detailed risk assessment?
- 02How do you prevent staff from working excessive hours and make sure they have enough rest?
- 03Are the names of staff and residents now recorded during every fire drill?
- 04How do your audits now identify problems such as environmental safety issues before they affect people?
- 05Have you analysed the relatives' satisfaction surveys and created an action plan from the results?
This was an unannounced comprehensive inspection covering all five key questions; Safe and Well-led fell from Good, while Effective, Caring and Responsive remained Good. This explanation was written from the published report of 8 May 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 Franklyn Lodge 9 Grand Avenue
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Franklyn Lodge 9 Grand Avenue →
- May 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Franklyn Lodge 9 Grand Avenue →
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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