CQC report explained · a residential care home
What the CQC found at Highview Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Rated Requires Improvement overall, with Inadequate leadership and serious concerns about safety, staffing and personalised care.
Inspectors visited the home without notice on 17 and 20 October 2023. They spoke with people, relatives, staff and professionals, observed care, and checked care, medicine and management records.
They found that improvements promised after the previous inspection had not happened. Medicines were not always managed safely. There were not always enough staff, and some care was missed or delayed. Care plans sometimes gave conflicting information.
People and relatives said staff were kind, and inspectors saw kind and respectful care. However, care was often task-led rather than based on each person's choices. Some people had little social contact or activity.
The overall rating remained Requires Improvement. Safe, Effective, Caring and Responsive were all Requires Improvement. Well-led fell to Inadequate because leadership was unstable and checks had not found or fixed important problems.
Kind staff
People and relatives generally described staff as kind and caring. Inspectors also saw staff speaking to people in a kind, attentive and respectful way.
“Staff were kind, attentive and respectful when speaking with people.” from the report
Safeguarding awareness
Safeguarding concerns were reported appropriately. Staff had training and knew what to do if they were worried about abuse.
“Staff had received training and knew what to do if they had concerns about abuse.” from the report
Infection controls
Inspectors were assured about the home's infection prevention arrangements, including the use of protective equipment and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Health support
People were supported to attend health and social care appointments. The home worked with health and social care professionals.
“People were supported to have health and social care appointments.” from the report
Unsafe medicines management
seriousSome medicines were missed or not recorded properly. One person was left with covert medicines without supervision, and there was no risk assessment for this.
“People did not always receive their medicines in accordance with the prescriber's instructions.” from the report
Not enough staff
seriousPeople sometimes waited for help, and care was missed or delayed. Inspectors had to intervene five times to help keep people safe and meet their needs.
“We observed people waiting for support and on 5 occasions had to intervene to ensure people were safe and had their needs met.” from the report
Risks not acted on
seriousThe home had identified a higher number of falls in the evening and at night but had not taken action. Pressure care records and equipment were also not always adequate.
“No action had been taken in response to this analysis.” from the report
Care not personalised
needs fixingCare was often delivered to a shared timetable rather than at times chosen by each person. Preferences about staff gender and daily routines were not always respected.
“Care was not given at individualised times.” from the report
Limited social contact
needs fixingSome people who stayed in their rooms or beds had no social interaction apart from care tasks. Activities did not reach everyone.
“On our visits, people who stayed in bed, or in their rooms, did not have any social interaction, other than staff providing care tasks.” from the report
Unstable leadership
seriousThe registered manager had left and there had been three further managers, including one who had been in post for only three weeks. Management checks did not find important problems.
“This meant there was no stable leadership in the home and left people at risk of receiving a poor standard of care.” from the report
- 01What immediate changes have been made to prevent missed medicines and improve medicine records?
- 02How many staff are now deployed on each shift, especially in the evening and at night?
- 03What action has been taken to respond to the higher number of falls during the evening and night?
- 04How will you make sure care plans agree with each other and reflect each person's routines, preferences and risks?
- 05How will people who stay in their rooms or beds receive regular social contact and activities?
This inspection considered all five CQC questions, including infection prevention and control, after concerns were received about management, care and staffing. This explanation was written from the published report of 11 January 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, October 2022
Highview Lodge was rated Requires Improvement; inspectors found safety and management problems, although people generally felt safe and staff were kind.
This was an unannounced focused inspection on 8 September 2022. Inspectors looked at Safe and Well-led because of concerns about medicines, care standards, infection control and staffing. They spoke with people, relatives, staff and healthcare professionals, and checked care, medicine and management records.
Inspectors found problems with moving and handling, modified diets and medicines. Medicine records and stock counts did not always match. Agency staff induction and breaks could also leave shifts short. Some people experienced delays or care that was not fully dignified or person centred.
The home acted straight away after the inspection. It carried out audits, added checks, reviewed people's needs and provided more training. Inspectors said this reduced the immediate risks, but the problems showed that existing management checks had not been effective.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe was rated Requires Improvement. Well-led remained Requires Improvement. The other key questions were not inspected during this visit, so their previous ratings carried over.
People generally felt safe
People and relatives were generally positive about the staff and felt that needs were met. Inspectors saw staff responding to call bells and requests for help.
“People told us that their needs were met, and staff were nice. They told us they felt safe.” from the report
Infection controls
Inspectors were assured about infection prevention, the use of protective equipment and how the home would respond to infection risks. Visitors could continue to visit freely, with controls in place.
“We were assured that the provider was using PPE effectively and safely.” from the report
Respect for choice
The home was working within the principles of the Mental Capacity Act. Inspectors found that people were supported with choice and in the least restrictive way.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Medicines were not consistently safe
seriousSome medicine quantities did not match the records. Daily checks were not always completed, and plans for medicines given when needed were missing or did not contain enough information.
“We found some of those we counted did not tally with the records held.” from the report
Moving and handling risks
seriousSome staff needed more training, and inspectors saw people being held by their hands and arms in ways that could cause injury. Some moving and handling assessments also needed review.
“We also found that some staff needed further training to support people with moving and handling” from the report
Diet records and food consistency
needs fixingModified diets were not always provided in the correct form, and records did not always match people's actual needs. The home took action to review the affected needs and guide staff.
“We also found that assessments relating to the consistency of foods were not always followed.” from the report
Staffing during agency induction and breaks
seriousAn agency worker was left responsible for a unit alone for an hour while another worker was on a break. Another agency worker needed induction, which reduced the staff available to support people.
“This left people without the required staff members to support them.” from the report
Dignity and personal care
needs fixingSome people said they had to use continence products for all elimination needs, without other options being explored. Inspectors also saw that three people's nails or hair needed attention.
“We asked that this be reviewed to ensure people were receiving care that was person centred and promoted their dignity.” from the report
Management checks did not prevent problems
seriousThe home knew about some issues, but its audits and other checks had not dealt with them effectively. Inspectors said this had the potential to affect people's safety.
“There were continued issues within the governance, and this had a potential to impact on people's safety.” from the report
- 01What changes have been made to medicine reconciliation, stock recording and 'as needed' medicine plans since the inspection?
- 02What moving and handling training and supervision have staff completed, and how is the home checking that techniques are safe?
- 03How are modified diets recorded and checked so that the right food consistency is provided every time?
- 04How do you ensure enough staff are available during agency workers' induction and staff breaks?
- 05What new governance checks are in place, and what evidence shows that the earlier shortfalls have stayed fixed?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 14 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 Highview Lodge
6 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2021Goodstayed GoodSafe: GoodWell-led: Requires improvement
- May 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 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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