CQC report explained · a residential care home
What the CQC found at Hawthorn Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2023
Rated Inadequate and placed in special measures; inspectors found serious safety and leadership failures, despite some safe recruitment and approachable management.
This was an unannounced focused inspection on 24 and 25 July and 2 August 2023. Inspectors looked at Safe and Well-led because of concerns about infection control, safeguarding and medicines. They spoke with people, relatives, staff and visiting professionals, observed care and the environment, and checked records.
Inspectors found people were at risk from unsafe water temperatures, fire door problems, poor infection control, missing risk information and unsafe medicines arrangements. Some people who smoked and used flammable creams were at risk of severe burns. Safeguarding records and reporting were also not always complete.
The home’s checks and management systems had not made lasting improvements. The service breached Regulation 12 on safe care and treatment and Regulation 17 on good governance. Inspectors served warning notices for both breaches.
The overall rating fell from Requires Improvement at the previous inspection to Inadequate. The home is in special measures, so CQC will keep it under review and usually re-inspect within six months if it does not propose cancelling the provider’s registration.
Safe recruitment
The staff files checked by inspectors had up-to-date DBS checks and the home used a dependency tool to plan staffing.
“Staff were recruited safely with relevant checks in place.” from the report
Approachable management
People, relatives and staff said the registered manager was approachable and that they could raise concerns.
“People, their relatives, and staff we spoke with felt the registered manager was approachable and they felt able to raise any concerns with the service.” from the report
Visits supported
People were supported to receive visits from relatives in their rooms and in shared areas.
“People were supported to receive visits from their relatives.” from the report
Improvement plan
A service improvement plan was put in place and updated weekly during the inspection process.
“The nominated individual also put a service improvement plan in place which they updated weekly and sent to the inspector.” from the report
Unsafe care and treatment
seriousPeople were exposed to several avoidable risks, including scalding, fire, poisoning, missed support, skin damage and unsafe medicines arrangements.
“Systems and processes were not effective in ensuring care and treatment was provided in a safe way. This placed people at risk of harm.” from the report
Poor infection control
seriousInspectors found discarded PPE, dirty areas, damaged furnishings and food storage problems. These issues increased the risk of infection and food poisoning.
“People were not always protected from the risk of infection.” from the report
Unsafe medicines management
seriousRisks from flammable creams, missing PRN protocols and incomplete cream records were not properly managed. A person also received the wrong medicines for about 27 days after a hospital discharge.
“Medicines were not always managed safely and in line with best practice.” from the report
Fire and environmental risks
seriousSome hot water taps were above safe temperatures, fire doors did not seal correctly and emergency evacuation information was not available in paper form in the grab bag.
“Fire risks were not always mitigated.” from the report
Weak safeguarding records
seriousPotential safeguarding incidents were not always fully recorded or reported to the local authority for review. The home acted to clarify the reporting process after concerns were raised.
“Concerns were raised by the local authority that not all incidents which met safeguarding thresholds, such as falls, were being reported to them for further review.” from the report
Call bell delays
needs fixingCall bells were sometimes sounding for a prolonged time. One person who could not move independently did not have access to a call bell until inspectors raised the issue.
“There were occasions observed where call bells were sounding for prolonged periods.” from the report
- 01What specific actions have you taken to meet the warning notice about safe care and treatment?
- 02How are you checking that flammable creams, PRN medicines and prescribed creams are now managed safely?
- 03How often are fire doors, water temperatures, infection control and damaged areas checked, and who reviews the results?
- 04How do you make sure safeguarding incidents, falls and their outcomes are recorded and reported to the local authority?
- 05How do you make sure people can call for help promptly, including people who cannot use a fixed call bell?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from the previous inspection. This explanation was written from the published report of 7 December 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, October 2022
Rated Requires Improvement; safety and leadership still need improvement, although the home left special measures after progress since the last inspection.
This was an unannounced follow-up inspection on 28 June 2022. Inspectors spoke with five people, 10 relatives, staff and a visiting health professional. They reviewed care plans, medicines records, recruitment files and management records.
The home had improved since its previous Inadequate rating. Medicines, staffing, safeguarding, care planning and staff training had improved. People were described as receiving kind, respectful and personalised care, with good support for their health, food, activities and choices.
The home was not always clean and hygienic. Kitchen cleaning records were incomplete, the freezer needed defrosting and some renovation work was still needed. Leadership and quality checks had improved, but the changes were still being embedded, so the overall rating was Requires Improvement.
The home was no longer in breach of regulations and was no longer in Special Measures. CQC said it would continue to monitor information about the service and could inspect sooner if concerns were received.
Safer medicines support
Medicines were handled safely by staff who had recent training and competency checks.
“Medicines were received, stored, administered and disposed of safely.” from the report
Kind and respectful care
Inspectors saw staff speaking to people kindly, protecting their dignity and supporting them patiently.
“People were supported in a respectful and dignified way and valued as individuals.” from the report
Personalised support
Care plans gave staff clear information about people's needs, preferences and independence.
“The care plans we reviewed were person-centred. Detailed information on people's needs and preferences were recorded about how they liked to be supported and what they liked to do independently.” from the report
Improved management oversight
The provider had introduced stronger audits, incident reviews and additional management support since the previous inspection.
“On this inspection we found this had significantly improved and the registered manager was now operating systems and processes which had increased managerial oversight of the service.” from the report
Cleaning and kitchen standards
needs fixingSome cleaning rotas were incomplete. The freezer needed defrosting and the cooker hob was greasy, although the hob was cleaned quickly after inspectors raised it.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Delayed fire door work
seriousTwo fire doors had not been replaced within the expected timescale. An environmental risk assessment was put in place, and evidence later showed the work had been completed.
“This placed people at risk should a fire break out.” from the report
- 01Have the incomplete kitchen cleaning records, freezer problem and other environmental issues now been fully resolved?
- 02How are cleaning rotas and kitchen hygiene checked, and what happens if checks show a problem?
- 03Have the two fire doors been replaced, and how are outstanding fire safety recommendations tracked to completion?
- 04What additional support do the two deputy managers provide, and how is the provider checking that improvements remain in place?
- 05What changes have been made since the inspection on 28 June 2022 to address the Requires Improvement ratings for Safe and Well-led?
This was an unannounced follow-up inspection of action from the previous inspection, including infection prevention and control; the report also recorded updated ratings for all five key questions. This explanation was written from the published report of 6 October 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 Hawthorn Lodge Care Home
7 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- December 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
- October 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- July 2022InadequateSafe: InadequateWell-led: Inadequate
- May 2022Inspected but not ratedSafe: Inspected but not rated
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 21 August 2012.
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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