CQC report explained · a residential care home
What the CQC found at Friars Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Risks were assessed, staffing levels were safe, medicines were managed safely and the home was clean.
- Effective?
- Good
- Staff had suitable training and supervision. People had enough to eat and drink, could access health services, and consent and mental capacity arrangements were in place.
- Caring?
- Good
- People said staff were kind, friendly and respectful. Staff supported people's choices, dignity, privacy and independence.
- Responsive?
- Good
- Care was personalised and reviewed with people and relatives. Complaints were dealt with, but end-of-life information was not always detailed in care plans.
- Well-led?
- Good
- The home was described as well managed. Audits, meetings, feedback and partnership working were used to monitor and improve care.
What inspectors found, March 2020
Friars Lodge was rated Good; inspectors found safe, kind and personalised care, with less detail in some end-of-life plans.
This was an unannounced, planned inspection on 27 February and 4 March 2020. Inspectors spoke with three people and five staff, observed care, reviewed care and medicines records, checked staff files and examined management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they were happy, felt safe and were treated kindly. Inspectors found enough staff, safe medicines practice, suitable training, personalised care and good systems for checking quality.
There were some areas that could be better. End-of-life wishes were not always recorded in enough detail in care plans, although separate paper records were available. Staff also said people could have more opportunities to follow hobbies and interests if there was an activity coordinator.
Kind and respectful care
People told inspectors that staff were kind, caring and respectful. Inspectors also observed respectful interactions.
“People said staff were kind, caring, friendly, and they provided care in a respectful manner.” from the report
Safe staffing and medicines
Inspectors found enough staff to provide safe care. Medicines were stored, given and recorded safely, with regular checks.
“There were enough staff to support people safely.” from the report
Personalised support
Care plans described people's needs and preferences. People and relatives were involved in reviews, and staff could update records quickly.
“People told us they received personalised care to meet their needs.” from the report
Good management checks
The provider used audits, meetings and feedback to identify shortfalls and make improvements.
“The provider had systems to assess and monitor all aspects of the service.” from the report
End-of-life plans lacked detail
needs fixingCare plans did not always explain in detail how people wanted to be supported at the end of their lives. Separate paper records were available and staff knew where to find them.
“People's care plans did not always contain detailed information about how they wished to be supported at the end of their lives.” from the report
More individual activities may be needed
minorStaff said people could have more opportunities to follow their hobbies and interests if the home had an activity coordinator.
“Staff said people could have more opportunities to pursue their hobbies and interests if they had the support of an activity coordinator.” from the report
- 01How will you make sure my relative's end-of-life wishes are recorded clearly in their care plan?
- 02Where are the separate paper records about end-of-life wishes kept, and how would staff access them quickly?
- 03What individual activities are available for people who do not enjoy group activities?
- 04Are you planning to appoint an activity coordinator, and what activities would this add?
- 05How do you keep consent records clear and up to date when a person's ability to make decisions changes?
This was an unannounced planned inspection covering the overall service and all five CQC questions, including care observed, records, staff files and management systems. This explanation was written from the published report of 21 March 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.
What inspectors found, November 2017
Friars Lodge was rated Good across all five areas; inspectors found kind, safe and responsive care, with occasional late-afternoon staffing concerns.
This was an unannounced inspection on 6 October 2017. One inspector and an expert by experience spoke with people, relatives, the manager and staff. They observed care and checked care records, staff records, medicines, complaints and quality checks.
The home supported 16 people and could support up to 20. Inspectors found that people were protected from avoidable harm, medicines were managed safely, and there were enough suitably trained staff for people's needs. They also found that people received suitable food, drinks and healthcare.
People were treated with kindness, dignity and respect. Their care was personalised and reviewed, and they could take part in activities and keep in touch with relatives. The manager was approachable and regular checks were used to monitor the quality of the service.
The home was rated Good for Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as at the previous inspection.
Safe medicines system
The electronic medicines system gave staff clear instructions and flagged incomplete actions to the manager. Inspectors found that medicines were given regularly and on time.
“This meant that there was immediate accountability because any issues would flag up to the manager immediately” from the report
Kind and respectful care
People were treated with kindness, dignity and respect. Staff knew people's preferences and supported their privacy and independence.
“We observed positive interactions between staff and people who used the service.” from the report
Personalised support
Care plans reflected individual needs and were reviewed with people and their families. The home responded to changes such as pain, preferred bedtimes and room needs.
“We saw that care plans were personalised and written for each individual” from the report
Open management
The manager was visible and approachable. Regular audits, staff meetings and contact with families helped the home monitor and improve its service.
“There was an effective quality assurance system in place.” from the report
Staffing later in the day
minorSome people felt there could occasionally be too few staff after tea time. The manager knew about this and said the provider was looking for extra cover for one to two hours.
“Some people did however say that after tea time there would occasionally seem to be a lack of staff.” from the report
- 01How do you make sure there are enough staff after tea time and in the late afternoon or evening?
- 02What extra staffing cover has been arranged since the inspection?
- 03How will my relative's care plan be reviewed with them and our family?
- 04How are medicines, including medicines given when needed, recorded and checked?
- 05What activities and support are available for people who stay in their rooms?
This was an unannounced inspection covering all five CQC questions; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 14 November 2017 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 Friars Lodge
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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