CQC report explained · a residential care home
What the CQC found at Herons Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Staffing, recruitment checks, risk management, medicines systems, fire safety and incident learning had improved.
- Effective?
- Good
- Staff had completed training and competency checks, and people were supported with their health, eating and drinking, consent, and access to other professionals.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward, but the report does not state that rating here.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward, but the report does not state that rating here.
- Well-led?
- Requires improvement
- Management systems, communication and oversight had improved, but inspectors needed more time to see that the changes were fully embedded and sustained.
What inspectors found, February 2024
Rated Good overall; inspectors found safer, kinder care, but the home was not yet consistently well-led.
This was an unannounced focused inspection on 10 January 2024. Inspectors observed care, spoke with managers and staff, contacted five relatives, and reviewed care records, medicines, staffing, training, audits and other records.
The home had improved since the previous inspection. Staffing levels, night cover, medicines checks, risk assessments, staff training, communication and support for people's choices had all improved. Inspectors rated Safe and Effective as Good.
Well-led was rated Requires Improvement. Inspectors found better management systems and oversight, but said the changes had not been in place long enough to show they were fully embedded and sustained. The overall rating rose from Requires Improvement to Good.
Improved staffing
Staffing levels had increased, including at night. This improved safety and gave people more opportunities to take part in activities.
“The provider had increased the numbers of staff on duty. This included the availability of staff at night.” from the report
Safe medicines support
Staff responsible for medicines had extra training and competency checks. Monitoring systems were found to be effective.
“People's medicines were managed safely. Improvements had been made to staff training, and staff had completed competency assessments of their practice.” from the report
Staff knew people well
Inspectors found staff to be kind, caring and aware of people's individual needs. Relatives spoke positively about the staff.
“Staff were kind, caring and knew people well. Relatives were positive and spoke highly of the staff.” from the report
Better support for choices
Care plans had been updated to reflect people's routines and preferences. Staff were supported to respect people's choices and promote their independence.
“Support plans had been reviewed and updated to support staff of people's wishes and what was important to them.” from the report
Management changes not yet established
needs fixingThe home had improved its quality and safety systems, but inspectors said more time was needed to show that these improvements would continue consistently.
“However, given the short length of time since our last inspection, further time was required for the improvements to become fully embedded and sustained.” from the report
- 01How will you keep the improved quality and safety checks consistent over time?
- 02What staffing levels, including night staffing, will be in place for my relative's individual needs?
- 03How will you make sure my relative's routines, preferences and choices are recorded and followed?
- 04How are staff training, supervision and competency checks kept up to date?
- 05How will you involve my relative and our family in care reviews, activities and decisions?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 2 February 2024 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 2023
Rated Requires Improvement, with unsafe staffing and weak management systems, and a Well-led rating of Inadequate.
This was an unannounced focused inspection on 9 and 10 October 2023. One inspector spoke with relatives, staff and managers, observed care, and checked care, medicine, recruitment, training and management records.
Inspectors found too few staff for people's individual needs. Risk guidance was not always followed, including guidance about choking, mobility and moving people safely. Medicines records and staff competency checks were not always complete. Staff training, supervision and pre-admission assessments also had gaps.
Care was often kind, relatives spoke positively about staff, and the home was clean. However, management checks had failed to find important problems, and incidents were not properly reviewed for learning. The home was rated Requires Improvement overall, with Safe and Effective also Requires Improvement and Well-led Inadequate.
Kind staff
Inspectors observed positive and caring interactions. Relatives also spoke highly of the staff's approach.
“Overall, observations of staff engagement with people were positive, kind and caring.” from the report
Clean environment
The home was generally clean and hygienic, with safe infection-control practices observed.
“People were protected from the risk of infection as staff were following safe infection prevention and control practices.” from the report
Food and drinks
People received enough food and drink, with choices offered and their intake and weight monitored.
“We saw people were offered choices of meals and drinks.” from the report
Health support
Records showed that people's health needs were monitored and that staff helped them access health professionals.
“Care records confirmed people's health needs were monitored and people received support to access health services” from the report
Too few staff
seriousStaffing levels did not match people's individual care and support needs. This reduced people's routines, choices and opportunities and increased the risk of harm.
“The provider did not ensure there were sufficient numbers of suitable staff.” from the report
Risks not followed
seriousStaff did not consistently follow risk guidance. Examples included an unlocked kitchen for someone at risk of choking and one staff member supporting someone who required two.
“We observed the kitchen unlocked throughout our inspection and the person alone in the kitchen.” from the report
Weak medicines practice
needs fixingGuidance for some medicines was limited, including when to use medicines prescribed as needed. Staff medicine competency checks were also incomplete.
“Staff medicine administration competency check documents had not been consistently completed.” from the report
Training gaps
needs fixingTraining in learning disability and autism was limited, and staff had not received mental health awareness training. Supervision was not happening as often as expected.
“Staff had not received training in mental health awareness despite some people living with mental health needs.” from the report
Poor management oversight
seriousThe provider's audits did not identify several important problems. Incidents and monitoring records were not analysed for patterns or learning.
“The provider's governance system did not always effectively monitor the quality and safety of care provided to drive improvements.” from the report
Choice and routines
seriousStaff raised concerns that people's choices about when they went to bed and got up were not always respected. Inspectors referred these concerns to the local authority safeguarding team.
“Staff raised concerns about people's lack of choice of when they went to bed and got up.” from the report
- 01How many staff are now deployed on each shift, including at night, and how is this matched to each person's needs?
- 02What has changed to make sure staff follow individual risk guidance, including choking, mobility and moving and handling plans?
- 03How are medicines prescribed as needed recorded, and how do you check every staff member's medicine competence?
- 04What training has staff completed in learning disability, autism and mental health, and how often are supervision meetings now held?
- 05How are incidents, safeguarding concerns and complaints reviewed for patterns, learning and action?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 22 November 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.
Every inspection of Herons Lodge
4 rated inspections over 8 years: the service has held its Good rating throughout.
- February 2024Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- January 2019Goodstayed GoodSafe: Requires improvementEffective: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 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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