CQC report explained · a residential care home
What the CQC found at Hawthorne Lodge Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not properly assessed, including choking, bedrails and pressure-relieving equipment. Inspectors also found a medication error, fire doors that did not work correctly and some infection control concerns.
- Effective?
- Requires improvement
- People's everyday needs were generally met, but care records were sometimes poor, confusing or inaccurate. Mental capacity and consent were not always assessed according to the law.
- Caring?
- Good
- This question was not inspected during this focused inspection. The report says the rating from the previous inspection was used to calculate the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. The report says the rating from the previous inspection was used to calculate the overall rating.
- Well-led?
- Requires improvement
- Management checks did not identify several problems with risks, medicines, care records, fire doors and incidents. Staff and relatives said they felt supported, and the manager responded promptly to inspectors' concerns.
What inspectors found, May 2022
Requires Improvement; inspectors found risks with care records, medicines, fire doors, consent and management systems.
This was an unannounced focused inspection on 16, 17 and 23 March 2022. Inspectors reviewed safe, effective and well-led care because of concerns about records and infection control. They spoke with people living there, relatives and staff, observed care, and checked care, medicines, staff and management records.
People said they felt safe and there were enough staff. Staff had completed mandatory training and recruitment checks were robust. Staff worked with health professionals, and people gave positive feedback about the food and the support from staff.
However, some important risks were not properly assessed. Inspectors found problems with fire doors, medicines, infection control, care records and checks on incidents. Records about people's needs and mental capacity were sometimes unclear or inaccurate.
The overall rating changed from Good at the previous inspection, published in February 2019, to Requires Improvement. The home was found to be in breach of Regulations 11, 12 and 17. The provider and registered manager gave assurances that immediate risks and records would be addressed, and CQC said it would continue to monitor progress.
Enough staff
Inspectors found enough staff on duty to support people safely. People also said staff were usually available to help.
“There was enough staff on duty throughout the home to ensure people were supported safely.” from the report
Staff training
Staff training was up to date, and staff had supervision and appraisals or these were planned.
“Training was up to date for all staff. Refreshers had been undertaken and all staff had been supervised” from the report
Health support
Staff worked with health professionals and made referrals when people needed specialist help.
“Referrals to the SALT, dietician and Tissue Viability Nurses had been made in a timely way.” from the report
Positive relationships
People and relatives gave positive feedback about staff and said they felt welcomed and supported.
“Feedback from staff and relatives evidenced they felt engaged and well supported by the registered manager and provider.” from the report
Risk assessments
seriousSome people's risks were not properly assessed or managed. This included choking, bedrails and pressure-relieving equipment.
“Risks to people's health and wellbeing were not always appropriately assessed.” from the report
Medicines
seriousMedicine stock checks and records of missed medicines were not in place. Inspectors could not establish what had happened with one person's medicine.
“The lack of stock checks and counts meant issues with one person's medication count had not been identified.” from the report
Fire safety
seriousSome fire doors did not close properly, and smoke seals had been painted over. The provider said checks and remedial work were completed after this was raised.
“This places people at risk of harm during a fire.” from the report
Consent and records
seriousRecords about capacity and consent were inconsistent. Bedrails had not been considered as a potentially restrictive measure under the required legal framework.
“Inconsistencies in records and inaccurate information demonstrated a lack of knowledge of the principles of the Mental Capacity Act.” from the report
Management oversight
needs fixingAudits and checks did not identify several problems, and incidents were not routinely analysed for patterns. This meant opportunities to reduce risks could be missed.
“Governance and monitoring systems did not always identify some of the issues we highlighted during day one of our inspection.” from the report
Infection control and visits
needs fixingInspectors were only somewhat assured about preventing visitors from spreading infection. One visitor was not wearing protective equipment in a communal area, and other environmental issues were found.
“We were somewhat assured that the provider was preventing visitors from catching and spreading infections.” from the report
- 01What action has been completed to make sure every person's risks, including choking, bedrails and pressure damage, are assessed and recorded?
- 02How are medicines now checked, including stock counts, missed doses and investigating any discrepancies?
- 03Have all fire doors and smoke seals been checked and repaired, and how often will this be reviewed?
- 04How are mental capacity assessments and best-interest decisions recorded, especially when bedrails or other restrictions are used?
- 05How does the provider now analyse accidents, incidents and audits to identify repeated risks and make sure action is taken?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and earlier ratings were used to calculate the overall rating. This explanation was written from the published report of 5 May 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.
What inspectors found, March 2019
Rated Good overall; the home provided safe, kind and responsive care, but its environment and some care records needed improvement.
Inspectors visited on 7 and 11 February 2019. The first visit was unannounced and the second was announced. They observed care, spoke with people, relatives and staff, and checked care plans, medicines, recruitment and quality records.
The home was rated Good for Safe, Caring, Responsive and Well-led. People generally felt safe and well cared for. Staff were described as kind, respectful and supportive. Medicines were managed safely, staffing levels were sufficient, and leaders were seen as approachable.
The Effective rating was Requires Improvement. The home needed redecoration and better adaptations for people living with dementia. Some care plans did not include enough personal detail, and activities were limited. Radiator covers were fitted after the inspection following a potential burn risk.
People felt safe
People and relatives said they felt safe. Staff understood safeguarding procedures and how to report concerns.
“People were safe and protected from avoidable harm. Legal requirements were met.” from the report
Kind and respectful care
Staff promoted people's dignity, privacy and independence. Inspectors observed warm and familiar interactions.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Good staff support
Staff had relevant training, supervision and appraisals. They said managers were supportive and staff worked well as a team.
“All the staff we spoke with told us they worked well together as a team to deliver high standards of care.” from the report
Food and healthcare support
People received help with eating and drinking, could have snacks and alternative meals, and were supported to access healthcare.
“People received the support they needed to eat and drink and maintain a healthy and balanced diet.” from the report
Open management
People, relatives and professionals said managers were approachable and responded to concerns. Quality checks and an improvement plan were in place.
“The service was consistently managed and well-led. Leaders and the culture they created promoted high quality, person-centred care.” from the report
Hot radiators
seriousRadiator covers were not in place, creating a potential risk of burns. Covers were fitted after the inspection.
“However, there was a potential risk to people of burning as there were no radiator covers in place.” from the report
Environment needed improvement
needs fixingThe home looked tired, with damp stains and areas needing redecoration. It had limited signage and other adaptations for people living with dementia.
“The environment had not been adapted to meet the needs of those living with dementia.” from the report
Care plans lacked detail
needs fixingSome care plans did not fully record people's personal preferences and needs. The manager agreed to review them.
“Some care plans lacked personal detail. Peoples needs had been assessed, but there was not always consideration to people's individual preferences.” from the report
Limited activities
needs fixingSome people said they felt bored or lonely. Relatives and staff also said activities were not always varied or sufficient.
“Sometimes I get lonely and bored but my friends take me out in the local community.” from the report
Malodours
minorThe home was clean overall, but inspectors noticed unpleasant smells, especially in the stairwells.
“There were some malodours in the home, particularly in the stairwells leading to each floor.” from the report
- 01Have the planned redecoration and repairs been completed, including the work relating to damp stains?
- 02What changes have been made to help people living with dementia find their way around the home?
- 03How are personal preferences and routines now recorded and reviewed in care plans?
- 04What activities are available each week for people who may feel bored or lonely?
- 05Are radiator covers still fitted, and how are radiator temperatures checked?
This was a planned inspection covering all five key questions; the first day was unannounced and the second day was announced. This explanation was written from the published report of 12 March 2019 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 Hawthorne Lodge Residential Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- May 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Hawthorne Lodge Residential Care Home →
- March 2019Goodstayed GoodSafe: GoodEffective: Requires improvementWell-led: Good
Read what inspectors found at Hawthorne Lodge Residential Care Home →
- August 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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