CQC report explained · a nursing home
What the CQC found at Havenfield Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, medicines, staffing, recruitment, safeguarding and infection control were managed safely. People said they felt safe and there were systems to learn from accidents and incidents.
- Effective?
- Good
- People's needs were assessed before moving in and reviewed regularly. Staff had relevant training and supported people with nutrition, healthcare, communication and decision-making.
- Caring?
- Good
- Staff were kind, patient and respectful. People were involved in decisions, supported to communicate their wishes and encouraged to maintain privacy and independence.
- Responsive?
- Good
- Care plans were personalised and reflected people's needs, preferences and goals. People could choose activities, maintain relationships and raise concerns with staff.
- Well-led?
- Good
- Inspectors found visible and supportive management, good teamwork and suitable checks on quality and safety. Staff felt able to raise concerns and relatives could contact managers and staff.
What inspectors found, April 2023
Havenfield Lodge was rated Good; inspectors found kind, personalised care and safe systems, with the overall rating improving from Requires Improvement.
Inspectors made unannounced visits on 7 and 14 March 2023. They spoke with people living there, relatives, staff and visiting professionals. They observed care, checked the building and reviewed care, staff and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People were supported by staff who knew them well, respected their choices and helped them stay involved in activities, healthcare and relationships.
The home can accommodate up to 46 people, which does not fully fit the inspection guidance for people with learning disabilities and autistic people. Inspectors said this was reduced by providing private areas, smaller lounges and careful checks before people moved in.
Kind and respectful care
People were treated with kindness and patience. Staff allowed people time to communicate and understood their personalities, needs and preferences.
“People were treated well by staff who were kind and patient with them.” from the report
Personalised support
Care plans reflected people's individual needs, choices and goals. Each person had a key worker to help review their care.
“People received personalised care which met their needs and reflected their choices.” from the report
Safe medicines and staffing
Staff were trained to handle medicines safely, and checks were used to confirm their competence. Inspectors also found enough staff for activities and visits.
“People received their medicines safely and as prescribed.” from the report
Support for independence
People had private rooms and were encouraged to develop their skills and make choices about their daily lives.
“Staff and managers understood about encouraging and promoting independence and were able to give examples of how people's skills had been developed over time, in line with their preferences.” from the report
Good management
The manager was visible and knew people well. Staff felt supported, valued and able to speak up about concerns.
“The registered manager knew people well and was a visible presence within the service.” from the report
Large setting
minorThe home's capacity and large communal area did not fit fully with the inspection guidance for people with learning disabilities and autistic people. Inspectors said the provider reduced this risk through private areas, smaller lounges and careful decisions about new residents.
“As the setting could accommodate up to 46 people and there was a large communal area, this would not fit with the principles of right support, right care, right culture.” from the report
- 01How would you make sure my relative has enough private space and access to smaller lounges?
- 02How do you decide whether a new resident's needs and personality are a good fit for the home?
- 03How will you support my relative's individual communication needs and choices?
- 04What activities and opportunities for independence would be available for my relative?
- 05How would you keep me informed if there were an accident, incident or change in my relative's care?
This was an unannounced inspection covering all five key questions, including infection prevention and control, with visits on 7 and 14 March 2023. This explanation was written from the published report of 1 April 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, January 2021
Havenfield Lodge was rated Requires Improvement overall; safety and leadership were Good, but effectiveness remained Requires Improvement.
This was an unannounced focused inspection on 17 December 2020. Inspectors checked whether the home had acted on its previous improvement plan. They spoke with people living there, relatives and staff, and reviewed care records, staff files and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safer recruitment, suitable medicines systems and arrangements to reduce infection risks. They also found better risk assessments, staff training and checks on the quality of care.
Effectiveness was rated Requires Improvement. The building was homely and had different communal areas, but some large shared spaces did not meet all the needs of people with learning disabilities and physical disabilities. Refurbishment work was continuing but had been delayed.
The previous overall rating was Inadequate, with five breaches of regulations. The home was no longer in breach and had improved enough to leave Special Measures. The overall rating changed to Requires Improvement, and the home will continue to be monitored.
Safe care and staffing
People were protected by safeguarding arrangements, suitable recruitment and staffing levels that met their care needs.
“There were enough staff deployed to meet people's care and support needs in a timely way.” from the report
Medicines and infection control
Medicines were stored and given safely. Inspectors were also assured that infection prevention measures were in place.
“There were effective systems in place to ensure people received their medicines as prescribed.” from the report
Staff support
Staff received induction, training, supervision and appraisals. Care records showed that people's needs and preferences were assessed and reviewed.
“Staff were provided with an induction and relevant training to make sure they had the right skills and knowledge for their role.” from the report
Food and healthcare
People were supported with nutrition and access to health professionals. Inspectors saw a pleasant and unrushed lunchtime service.
“People enjoyed the food served at Havenfield Lodge.” from the report
Improved management
Quality checks, policies and follow-up systems had improved since the previous inspection. The home was no longer in breach of regulations.
“Significant improvements had been made by the provider and registered manager since the last inspection.” from the report
Refurbishment delays
minorRefurbishment of communal toilets and carpets was still under way and had been delayed because of coronavirus-related working restrictions.
“This programme was ongoing and had experienced some delays due to working restrictions imposed as a result of the coronavirus pandemic.” from the report
Safeguarding referral tracking
minorSafeguarding referrals were recorded, but there was not yet a tracker giving an overview of each referral. The manager agreed to introduce one.
“there was no tracker to keep an overview of what was happening with each referral.” from the report
- 01Which large communal areas might my relative use, and how will you support them if they find these areas difficult?
- 02What refurbishment work has been completed since the inspection, and what work is still outstanding?
- 03How do you now track safeguarding referrals and make sure actions are completed?
- 04Which ratings for Caring and Responsive were carried forward from the previous inspection?
- 05How will you show us that the improvements made since the previous Inadequate rating are being maintained?
This was a focused inspection of Safe, Effective and Well-led, including specific regulations from the previous inspection; Caring and Responsive were not assessed and their previous ratings were carried forward. This explanation was written from the published report of 27 January 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.
Every inspection of Havenfield Lodge
6 rated inspections over 7 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2021Requires improvementup from InadequateSafe: GoodEffective: Requires improvementWell-led: Good
- March 2020Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 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 24 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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