CQC report explained · a residential care home
What the CQC found at Imperial Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2024
Imperial Lodge is rated Requires Improvement; inspectors found risks in staffing, recruitment and management, although people's care plans and medicines were generally handled well.
This was an unannounced, focused inspection on 24 January 2023. Two inspectors spoke with people and staff, and checked care records, medicines, staff files, rotas, complaints and quality checks.
The home was rated Requires Improvement overall. Safe and well-led were rated Requires Improvement. Inspectors found gaps in recruitment checks, staff training, induction, supervision and staffing levels. The home relied heavily on agency staff without showing that they had suitable training or induction.
Responsive was rated Good. People's care plans were detailed and regularly updated. People were supported with healthcare, daily living skills, activities and plans for moving on. Medicines were administered safely, although staff medicine skills were not assessed regularly.
The previous overall rating was Good in 2018. This inspection was prompted partly by a serious incident and did not examine that incident because it was subject to a criminal investigation. The provider was required to submit an action plan, and CQC issued a warning notice about governance.
Detailed risk plans
People had clear risk assessments and plans telling staff how to reduce risks at home and in the community.
“People's individual risk assessments were detailed, clear and comprehensive.” from the report
Safe medicines administration
Medicines were given as prescribed, records were completed properly and stocks matched the records. Staff competency checks were not regular, so this should still be discussed.
“People's medicines were managed safely to help ensure people received their medicines as prescribed and in line with national guidance.” from the report
Personalised care planning
Care plans reflected people's wishes, strengths and goals. They were reviewed as people's needs changed.
“People's needs were met in line with their wishes and preferences.” from the report
Support with independence
People were supported to build daily living skills, use the community, cook, clean and work towards greater independence.
“People were supported to maintain their independence and gain new skills.” from the report
Recruitment checks
seriousThe home could not show that all staff had been checked properly before working there. Some files lacked references, induction records or other recruitment information.
“The provider had not always followed appropriate procedures for recruiting staff.” from the report
Staffing and training
seriousThere were not enough suitably trained permanent staff, and the home relied on agency staff. The provider could not show that new or temporary staff had received suitable induction, supervision or competency checks.
“The provider relied on agency staff to cover staff vacancies but had not ensured these temporary staff were trained to meet the needs of the people who used the service.” from the report
Weak safety monitoring
seriousHealth and safety, infection control and incident audits had stopped or were irregular. The home also did not show that it had reflected properly on a serious incident or other events.
“The provider did not have effective arrangements to assess, monitor and mitigate the risks relating to the health, safety and welfare of people and staff.” from the report
Limited contact with the manager
needs fixingSome people and staff said they had little contact with the registered manager. One person said they did not really like living at the home and wanted to move on.
“One person who used the service told us they never saw the registered manager.” from the report
- 01What action has been taken to make sure every new staff member has completed recruitment checks, induction and competency checks before working with residents?
- 02How many permanent staff are currently in post, and how do you make sure agency staff are trained for people's mental health and support needs?
- 03How often are staff now supervised and assessed in de-escalation, emotional support and medicines management?
- 04What changes have been made to health and safety, infection control and incident audits since the inspection?
- 05How do staff learn about each resident's interests, goals and worries, and how often can residents speak with the registered manager?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and the overall rating used previous ratings for those areas. This explanation was written from the published report of 22 March 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, February 2022
Inspected but not rated; inspectors found good COVID-19 infection control and visiting arrangements.
This was a targeted inspection on 21 January 2022. It was announced 24 hours in advance and focused on infection prevention and control, visiting arrangements, and whether staffing pressures linked to COVID-19 affected the home.
Inspectors found good practice. Visitors had checks, including temperature checks and lateral flow tests. Staff used personal protective equipment properly, and people were supported to go out safely.
The home had processes for regular COVID-19 testing, managing outbreaks, and supporting people who tested positive to isolate. It also had COVID-19 risk assessments for people living at the home and staff.
The home was inspected but not rated. This report therefore does not give an overall quality rating or ratings for most areas of care.
Safe visiting
People were supported to have visitors. The home used agreed visiting times, temperature checks and lateral flow tests, with different places available for visits.
“People living at the home were supported to have visitors and the provider ensured appropriate checks were carried out to comply with current guidance.” from the report
PPE and infection control
Staff had infection control and PPE training, and inspectors saw PPE being used properly.
“We were assured that the provider was using PPE effectively and safely.” from the report
Testing arrangements
The home had a process for monthly testing of people living there and weekly testing of staff.
“The provider had a clear process for supporting people with monthly COVID-19 testing and ensuring care workers carried out weekly COVID 19 tests in line with guidance.” from the report
Outbreak planning
The home had a process for preventing or managing an outbreak and supporting people who tested positive to isolate.
“The provider had a clear process in place to respond to an outbreak of COVID 19 with people who tested COVID 19 positive being supported to isolate.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently manage COVID-19-related staffing pressures, and could these affect the support people receive?
- 02What checks and testing are now required for visitors, and how can family visits be arranged?
- 03How often are people living here and staff tested when there is no outbreak?
- 04What happens if someone living here tests positive for COVID-19?
- 05How do you currently check vaccination or exemption status for staff and visiting professionals?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not assess the other key questions. This explanation was written from the published report of 18 February 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 Imperial Lodge
5 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- March 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- March 2018Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- January 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 19 January 2012.
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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At least 100 live-in carers within about an hour of Hillingdon
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,320 a week. 81 can care for a couple. 11 years' experience on average.
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
“She has an unusual combination of kindness and firmness, is quite unflappable, physically strong, extremely savvy”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.