CQC report explained · a residential care home
What the CQC found at Lapwing Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments did not always explain how to reduce risks, incidents were not always reviewed, and infection control, fire checks and some medicines storage arrangements were not robust. Staff training on recognising and reporting abuse also needed improvement.
- Effective?
- Requires improvement
- The home did not always follow the Mental Capacity Act or record consent properly. Staff training records were out of date, and staff had not had competency checks for a complex medicines procedure.
- Caring?
- Requires improvement
- People and relatives described staff as kind, and inspectors observed respectful care. However, a failure to report an incident left someone at risk, and people were not always protected from stressful environmental factors or fully involved in their care plans.
- Responsive?
- Requires improvement
- Staff did not always have enough information about people’s needs, particularly when someone came for respite. Care plans did not consistently include people’s goals, communication needs or activity schedules.
- Well-led?
- Requires improvement
- Audits were not regular or robust, action plans were not always used, and records were not always accurate. The manager responded to feedback, but improvements were not all fully in place.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind care and activities people enjoyed, but safety, consent, staff training and management systems were not reliable enough.
This was the home’s first inspection since it registered. It was an unannounced, planned comprehensive inspection on 21 and 25 July 2022. One inspector spoke with people, staff, the manager, relatives and professionals, and reviewed care plans, medicines records and management documents.
The home was not always safe. Risk assessments and incident reviews were incomplete, fire safety checks were not regular, infection control was not robust, and staff did not always know how to report abuse. One incident was referred to safeguarding after the inspection because of continuing risks.
Inspectors saw kind interactions and found that people enjoyed personalised activities, community visits, and food chosen to suit their wishes. However, people were not always involved in care planning, their choices were not always properly supported under the Mental Capacity Act, and staff training and competency records were incomplete.
All five areas were rated Requires Improvement. The home had to provide an action plan, and CQC said it would monitor progress with the provider and local authority.
Kind relationships
People and relatives said staff were kind and caring. Inspectors also observed respectful interactions and found that staff knew people well.
“We observed and heard care staff supporting people with a kind and respectful manner.” from the report
Personalised activities
People took part in activities suited to their interests, including community activities and attendance at a day centre.
“Staff supported people to participate in their chosen social and leisure interests.” from the report
Choice of food
People chose their meals, and records showed that monitored food and fluid intake was recorded and reviewed.
“People chose what they wanted to eat, and meals were provided according to people's wishes.” from the report
Family contact
Relatives were able to visit, and the home supported visits outside the home and regular contact with family and friends.
“People were supported to maintain contact with their relatives and/or friends on a regular basis.” from the report
Risks and safeguarding
seriousAn incident was not reported to the manager, followed by two similar incidents. Risk assessments and incident reviews did not always give staff enough guidance or prevent further harm.
“This placed the person at risk of harm and did not demonstrate a caring approach.” from the report
Consent and restrictions
seriousThe home did not always assess restrictions properly or record how the Mental Capacity Act had been considered. Staff had differing levels of understanding of the law.
“The service did not always consider the least restrictive option for people.” from the report
Staff skills
seriousTraining records were out of date, and staff had not been assessed as competent for a complex medicines task. Staff knowledge about restrictive practices and the Mental Capacity Act was also inconsistent.
“This was a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Infection and fire safety
seriousCleaning records had gaps, some areas were dusty, PPE was not always used, and some fire checks had not been carried out regularly. Admission testing and infection control guidance also needed improvement.
“We were not assured that the provider was using PPE effectively and safely.” from the report
Weak quality checks
seriousAudits were not completed regularly or robustly, and action plans were not always created. This meant problems were not consistently identified and corrected.
“Governance processes had not been effective in helping to keep people safe, protect people's rights, and provide good quality care and support.” from the report
Limited involvement in planning
needs fixingCare records did not always show people’s goals, preferences or involvement. People also lacked consistent activity schedules and accessible communication information.
“There was limited evidence people had been involved in creating their care plans.” from the report
- 01What action has been completed to improve risk assessments and prevent a repeat of the safeguarding incidents?
- 02How do you check that staff understand the Mental Capacity Act and use the least restrictive options?
- 03Which staff are trained and formally assessed as competent to carry out complex medicines procedures?
- 04How are fire checks, cleaning, PPE use and medicines storage temperatures now monitored?
- 05How do you assess whether a person coming for respite is compatible with people already living at the home?
This was the first planned comprehensive inspection of the newly registered home and covered all five key questions, including infection prevention and control. This explanation was written from the published report of 15 September 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 Lapwing Lodge
Each visit the CQC has published, newest first, back to the day the home was registered.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2021
Registered with the Care Quality Commission on 4 March 2021.
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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13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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.