CQC report explained · a residential care home
What the CQC found at Hunters Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found unsafe risk and medicines management, with a warning notice issued.
This was an unannounced, focused inspection on 1 and 3 August 2023. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care records, medicines records, staff files, audits and other documents.
The inspectors found that risks were not always properly assessed, monitored or reduced. Some people had been harmed in physical incidents, and records did not always show action was taken about dehydration, constipation, health conditions or repositioning. Medicines were not always given as prescribed, including time-sensitive medicines.
Management systems had not found these problems. The home was rated Requires Improvement overall, with Safe and Well-led both rated Requires Improvement. Effective, Caring and Responsive were not inspected during this visit, so their previous ratings were used to calculate the overall rating.
Kind and respectful staff
Staff treated people kindly and with respect. Staff were described as committed to the people living at the home.
“Staff interacted with people in a kind and considerate manner, treating them with dignity and respect.” from the report
Safeguarding and infection control
Staff understood how to recognise and report abuse. Inspectors were assured that infection prevention and control arrangements were being followed.
“We were assured the service were following safe infection prevention and control procedures to keep people safe.” from the report
Safe recruitment
The required checks were completed before new staff were employed.
“Safe recruitment practices were followed before new staff were employed to work with people.” from the report
Accessible managers
Relatives and staff said managers were available and supportive. People and relatives were able to give feedback and said concerns were listened to.
“Relatives and staff told us the registered manager and both deputy managers were always accessible, approachable and supportive.” from the report
Risk assessments were incomplete
seriousSome risks, including dehydration, constipation, health conditions and moving and handling, were not fully assessed or monitored. This increased the risk of people being harmed.
“The failure to effectively assess, monitor and mitigate risks was a breach of Regulation 12” from the report
Medicines were not always safe
seriousSome medicines were missed, given at the wrong time or not recorded properly. PRN medicines and creams did not always have clear, personalised guidance.
“The management of medicines was not always safe. This included in relation to 'as required' medicines, topical creams and time sensitive medicines.” from the report
Physical incidents and distress
seriousThere had been many physical altercations between people, some causing harm, and some people had self-harmed. Inspectors found that risks linked to distress and agitation had not been safely reduced.
“There were a high number of incidents of physical altercations between people, some of which had resulted in people being harmed.” from the report
Management checks missed problems
needs fixingAudits and quality checks did not identify the concerns inspectors found. Records were not always detailed or complete enough to support safe care.
“These systems were not always effective in identifying the concerns we found at this inspection.” from the report
Restrictions were not fully recorded
needs fixingRecords did not show that CCTV use and frequent checks had been considered within the Mental Capacity Act framework. Inspectors said this could compromise people's human rights.
“However, there were no records to demonstrate the use of closed-circuit television (CCTV) and frequent checks on people had been carried out in people's best interests.” from the report
Duty of candour records
minorRelatives were kept informed after incidents, but the home did not keep records that showed this properly. The provider was asked to improve its approach.
“However, records were not kept in line with this regulation.” from the report
- 01What specific changes have been made to risk assessments for dehydration, constipation, health conditions and moving and handling?
- 02How do you now make sure time-sensitive, PRN and topical medicines are given, recorded and reviewed correctly?
- 03What action has been taken to reduce physical altercations and self-harm, and how will you measure whether it is working?
- 04How are managers checking that medicines records and care records are complete and accurate?
- 05How are CCTV, sensor mats, bed rails and frequent checks now recorded under the Mental Capacity Act?
This was an unannounced focused inspection of Safe and Well-led only, prompted partly by concerns about people being hurt by others; the other ratings carried over from the previous inspection. This explanation was written from the published report of 3 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.
What inspectors found, August 2019
Rated Good; inspectors found kind, personalised care, with some medicines and record-keeping improvements still needed.
The inspection was unannounced and took place on 12 August 2019. Three inspectors spoke with people living in the home, relatives, staff and a visiting professional. They also observed care and checked care, medicines, recruitment and management records.
The home was rated Good overall, and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough safely recruited staff, kind care, personalised support, suitable training and systems for responding to concerns.
Inspectors had received earlier concerns about support for people who refused medicines. They found that action had been taken. However, medicines storage temperatures were not always checked daily, some 'as required' medicine plans lacked detail, and one mental capacity record was incomplete.
Kind and respectful care
People were treated with warmth and respect. Inspectors saw staff listening to people and supporting their choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Staffing and training
Inspectors found enough staff to meet people's needs. Staff had relevant training, supervision and recruitment checks.
“People received effective care from staff that were skilled, competent and suitably trained.” from the report
Personalised support
Care plans recorded people's needs, preferences and choices. Staff knew people well and changed support when needed.
“Care plans had been developed for each person. These provided sufficient information to enable staff to provide support in a personalised way.” from the report
Improved responsiveness
The home responded to feedback by arranging more outings and community transport. The Responsive rating improved from Requires Improvement to Good.
“At this inspection this key question has now improved to good.” from the report
Quality checks
The home used audits and reviewed incidents, falls, care plans and risk assessments to identify improvements.
“A quality assurance system was in place to assess, monitor and improve the service.” from the report
Medicines storage temperatures
needs fixingMedicine storage temperatures were not always checked daily. When temperatures were above the recommended level, inspectors could not see what action had been taken.
“Although the temperature of medicines storage was checked regularly, this was not always carried out daily.” from the report
Limited medicine instructions
needs fixingPlans for 'as required' medicines did not give enough detail about when to use them, when to contact a doctor and how to check whether they worked.
“However, staff would benefit from these care plans containing more information about the medicines, dose, when to use, when to escalate the use to a doctor and how to monitor for their effectiveness.” from the report
Incomplete capacity record
needs fixingFor one person's health investigation, the record did not show an assessment of their capacity to make that decision.
“However, a record of assessment of the persons capacity to make a decision about whether this investigation, had not been completed.” from the report
Incident trend analysis
minorIncidents were recorded and acted on, but there was not yet a formal system to look for wider patterns. A new electronic system was being introduced.
“The registered manager confirmed there was no system to formally analyse these and identify any trends or patterns in the service.” from the report
- 01How do you now check and record the temperature of medicines storage every day?
- 02What guidance do current care plans give staff about 'as required' medicines, including when to contact a doctor?
- 03How do you record mental capacity assessments and best-interest decisions?
- 04Has the electronic system for analysing incidents and identifying trends been introduced?
- 05What improvements have been made since the inspection on 12 August 2019?
This was an unannounced planned inspection based on the previous rating and covered all five CQC questions, including the care provided and the home premises. This explanation was written from the published report of 31 August 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 Hunters Lodge Care Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 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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