CQC report explained · a residential care home
What the CQC found at Humfrey Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, accurate risk assessments and safe medicines management. They said records had improved since the previous inspection.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found positive management, good communication and regular quality checks. Staff and relatives said the management team was approachable and kept them informed.
What inspectors found, January 2022
Humfrey Lodge was rated Good; inspectors found safe, well-managed care, with some refurbishment still planned.
This was an unannounced, focused inspection on 8 and 10 December 2021. Inspectors looked mainly at whether people were safe and whether the home was well-led. They spoke with people, staff, managers and relatives, and reviewed records.
The home was rated Good overall. Inspectors found enough staff, safe recruitment, accurate care records and safe medicines management. Risks such as choking and pressure sores had been assessed, and staff knew how to support people safely.
The management team was described as open and supportive. Relatives and staff gave positive feedback about communication, including during COVID-19 restrictions. Regular checks and audits were used to improve care.
This inspection did not reassess Caring, Effective or Responsive. Those ratings were carried forward from the previous comprehensive inspection. The Safe rating improved from Requires Improvement in 2017 to Good, while Well-led remained Good.
Enough staff
Inspectors found enough staff on duty and observed people receiving prompt attention. Staff worked together and supported each other when needed.
“We found there were sufficient staff on duty to keep people safe.” from the report
Improved care records
Care plans and risk records were more accurate than at the previous inspection. Risks such as choking had been fully assessed and documented.
“At this inspection we found things had improved the recording was factual and accurate.” from the report
Safe medicines
Only trained senior staff gave medicines. Records were accurate, storage was safe and checks were carried out.
“Senior staff carried out robust checks which ensured they had a good oversight of the medicines people had received.” from the report
Good communication
Relatives said the home kept them informed, including during visiting restrictions and when incidents occurred. Managers were described as accessible and open.
“Relatives were positive about how well the service had communicated during COVID-19, such as letting them know about restrictions and testing.” from the report
Learning from incidents
The manager investigated incidents and recorded actions to reduce the chance of them happening again. Accidents and incidents were also checked for patterns.
“There were systems in place to monitor and learn from accidents and incidents.” from the report
Some areas needed refurbishment
minorThe regional manager had a plan to refurbish parts of the home because some areas looked tired. Inspectors said they would check the effect of this work at the next inspection.
“The regional manager told us they had a plan of works in place for some refurbishment of the service as some areas looked tired.” from the report
- 01What refurbishment has been completed since the inspection, and what work is still planned?
- 02How do you check that staffing levels remain enough when people’s needs change or staff are absent?
- 03How will you keep our family informed about visiting restrictions, testing and any incidents affecting our relative?
- 04How are choking, pressure sore and other personal risks recorded and reviewed?
- 05What checks are made to ensure medicines are given and recorded safely?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 26 January 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, November 2017
Rated Good overall, but Safe Requires Improvement because records and some risk controls were not always reliable.
Inspectors visited over two days on 11 and 13 October 2017. The first day was unannounced and the second was announced. They spoke with people, relatives, staff and health professionals, observed care, and reviewed care, medicine, staffing and monitoring records.
The home had improved since the previous inspection. Staffing levels were better, medicines were managed safely, the home was cleaner, and people were supported by kind staff. However, inspectors found contradictory night-time records, gaps in guidance about moving equipment, and a choking risk that had not always been managed.
The overall rating was Good. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, so families should understand that the home had made progress but still needed to strengthen some safety systems.
Kind and respectful care
People and relatives were positive about the care. Inspectors saw staff being patient, kind and reassuring, while respecting privacy and supporting independence.
“We saw numerous examples of staff demonstrating patience and kindness whilst supporting people.” from the report
Medicines managed safely
People received prescribed medicines on time. Staff were trained and checked as competent, and medicine records matched stock during the inspection.
“Medicines were managed safely and people received their prescribed medicines on time.” from the report
Improved staffing
Inspectors found enough staff during both visits to meet people's needs. Call bells were answered promptly and the staff team worked together.
“At this inspection, we found some improvement. There were sufficient staff available on both the two days of our visit to meet people's needs.” from the report
Open management
People, relatives and staff said the manager was approachable and visible. The home had meetings, handovers and audits to identify and address concerns.
“There was an open culture where people felt comfortable to air their views and, provide honest feedback.” from the report
Unreliable care records
seriousContradictory night-time entries meant inspectors could not be sure that some recorded fluid monitoring and repositioning had actually happened. The manager took immediate action during the inspection, but this was a significant safety concern.
“We were not assured that care support recorded as given had actually been provided.” from the report
Choking risk
seriousOne person needed dentures in place to eat safely, but staff did not initially ensure they were returned before lunch. Inspectors had to intervene when the person struggled to eat.
“The risks to people from choking had not always been mitigated.” from the report
Moving equipment guidance
seriousSome care plans did not clearly explain which equipment or sling to use, or how to use it safely. The manager updated relevant plans and added photographs during the inspection.
“care plans did not always identify that this equipment was in use or provide guidance for staff how to safely use these.” from the report
Weight monitoring
needs fixingOne person's weight had increased by 10 kilograms over four months without a dietician referral. The manager said an immediate referral would be made.
“One person's weight had increased by 10KG within the four months since they had moved to the service.” from the report
Some cleaning delays
minorThe home was cleaner than at the previous inspection, but dropped food was not always cleaned quickly and some kitchenette surfaces needed deeper cleaning.
“food dropped during lunchtime in people's rooms was not always cleaned quickly.” from the report
- 01How do you now check that night staff complete fluid balance and repositioning records accurately?
- 02What systems are in place to make sure people who need dentures or other support can eat without a choking risk?
- 03How do staff know which sling and moving equipment to use for each person, and where is this guidance recorded?
- 04How are changes in people's weight monitored, and when are dieticians or other specialists contacted?
- 05What activities or one-to-one contact are available for people who are cared for in bed?
This was a two-day comprehensive inspection covering all five key questions, with the first day unannounced and the second day announced. This explanation was written from the published report of 16 November 2017 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 Humfrey Lodge
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- January 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- November 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2016Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- September 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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