CQC report explained · a residential care home
What the CQC found at Great West Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable risk assessments, emergency evacuation plans, safe recruitment and enough staff. Medicines were generally managed safely, but medicines cabinet temperatures had not been recorded.
- Effective?
- Good
- No separate rating or detailed findings were given for this question in the report.
- Caring?
- Good
- No separate rating or detailed findings were given for this question in the report, although people and relatives said they were satisfied with the care.
- Responsive?
- Good
- No separate rating or detailed findings were given for this question in the report. The report says care plans were regularly reviewed and people could ask for changes.
- Well-led?
- Good
- The home had systems to monitor quality and staff felt supported. However, inspectors found that medicines administration records were not evidenced as being audited weekly, and the provider changed its auditing system after the inspection.
What inspectors found, March 2023
Rated Good; inspectors found safe, kind and person-centred care, but medicines checks needed to be more robust.
Inspectors visited without notice on 22 December 2022. They spoke with four people, staff, a healthcare professional and relatives. They reviewed care records, medicines records, staff files and management records.
The home was rated Good overall. Safe was rated Good, with suitable risk assessments, enough staff, safe recruitment and good infection control. People said they felt safe and staff were approachable.
The home was also rated Good for being well-led, although inspectors found that medicines administration records were not being shown to be audited weekly. The manager acted straight away and later provided evidence of improved checks.
The previous rating was Good, published in May 2018, and the rating remained Good. This inspection looked at Safe and Well-led.
People felt safe
People told inspectors they felt safe and found staff friendly and approachable.
“I feel very safe here. The manager is always available, and staff day and night” from the report
Suitable staffing
The home had enough staff and followed recruitment checks, including criminal record checks, references and employment history.
“The provider had enough staff and did not use agency staff.” from the report
Person-centred support
Staff adapted support to people's individual needs, routines, communication preferences and cultural or religious activities.
“The service was person centred and open.” from the report
Good partnership working
The home worked with health and social care professionals and was described as responsive in its communication.
“Communication with [health provider] is good. They will ask if they need anything. They are very proactive.” from the report
Medicines cabinet temperatures
needs fixingTemperatures in medicines cabinets were not recorded. Inspectors said this meant the effectiveness of medicines may have been affected. The provider sent evidence of action taken after the inspection.
“However, during the inspection we identified the temperature in medicines cabinets was not recorded which meant the effectiveness of the medicines may have been affected.” from the report
Medicines audit records
needs fixingThe provider's audit did not show that medicines administration records were being checked weekly. The manager took immediate action and later provided evidence of changes.
“It did not evidence medicines administration records were being audited weekly to help ensure medicines were administered as prescribed.” from the report
- 01How are medicines cabinet temperatures recorded now, and what happens if a temperature is outside the safe range?
- 02How often are medicines administration records audited now, and who checks that the audits are completed?
- 03What changes were made to the medicines auditing system after the inspection?
- 04How will my relative's care plan be reviewed and changed if their needs or preferences change?
- 05How will the home involve relatives and other professionals in my relative's care, if my relative wants this?
This was a focused inspection of Safe and Well-led; the report does not give separate ratings or detailed findings for Effective, Caring or Responsive. This explanation was written from the published report of 3 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, May 2018
Rated Good; inspectors found safe, kind and person-centred care, but some staff and medicines checks were not fully recorded.
This was an unannounced inspection on 27 March 2018. It was the first inspection since the home registered in May 2017. Seven of the nine available places were occupied.
Inspectors spoke with five people, the registered manager and two care workers. They observed care, checked four care records and six staff files, and reviewed medicines records, audits and other information. They also received feedback from healthcare professionals.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were supported by trained staff, had care plans based on their needs and preferences, and had access to healthcare and activities.
There were some recording gaps. Regular medicines competency checks were not written down, some staff competency assessments were incomplete or unsigned, and inspectors asked for more detail in people's advance statements about end of life care.
People felt safe
People told inspectors they felt safe. The home had safeguarding procedures, risk plans and checks on the environment.
“People using the service told us they felt safe.” from the report
Respectful care
People described staff as kind and respectful. Inspectors saw that people were involved in decisions and could maintain privacy in their rooms.
“People using the service said they were treated kindly and with respect.” from the report
Personalised care plans
Care plans included people's needs, preferences and goals. People were involved in planning and reviewing their support.
“The care plans we viewed were all comprehensive, person centred and regularly reviewed with the person whose care plan it was.” from the report
Good links with professionals
The home worked with mental health, social care and health professionals. Inspectors found that people's changing health needs were monitored and acted on.
“The provider worked closely with the mental health team and other professionals such as social workers, GPs and the police” from the report
Medicines checks were not recorded
needs fixingThe manager said regular medicines competency assessments were taking place, but these checks were not written down. The manager agreed to keep records in future.
“The registered manager said he undertook regular medicines competency assessments but was not writing them down.” from the report
Some staff assessments were incomplete
needs fixingNot every staff member had a competency assessment, and some assessments had not been signed off. The manager said these would be completed annually.
“However, not all staff had them and of those who did, not all were signed off.” from the report
Advance care wishes needed more detail
minorPeople's advance statements about end of life care were recorded, but inspectors asked the home to make them more detailed.
“We discussed making this more detailed, which the registered manager agreed to do.” from the report
- 01How do you now record medicines competency assessments and observations for each member of staff?
- 02Have all staff now had their competency assessments completed and signed off?
- 03How are people's advance statements about end of life care reviewed and made more detailed?
- 04How often are care plans reviewed with the person, and how are changes in mental health needs recorded?
- 05How are complaints recorded and followed up, given that the report says there had been no complaints in the previous year?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 22 May 2018 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 Great West Lodge
2 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018GoodSafe: GoodWell-led: Good
- May 2017
Registered with the Care Quality Commission on 14 May 2017.
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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At least 100 live-in carers within about an hour of Hounslow
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Most charge £980 to £1,270 a week. 85 can care for a couple. 11 years' experience on average.
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