CQC report explained · a residential care home
What the CQC found at Lobswood House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Staffing, recruitment, medicines and infection control were found to be safe, although some risk assessments did not give complete guidance.
- Effective?
- Good
- People's needs were assessed and staff supported consent, nutrition and healthcare. Staff had suitable training, although supervision had been delayed during the management change.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff involved people in decisions, respected their choices and supported their independence.
- Responsive?
- Requires improvement
- Care plans were being rewritten but some still contained old or conflicting information about people's current needs and risks. Inspectors found that immediate action was taken to correct the records they identified.
- Well-led?
- Requires improvement
- The new manager had made important improvements, but accident and incident records had not been analysed recently. There was also no registered manager in post and no formal meeting process for staff to discuss practice and improvements.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found safe, effective and caring support, but care planning and management oversight were not consistent.
Inspectors made an unannounced visit on 21 March 2022. They spoke with people, staff, the management team and relatives. They reviewed care records, medicines records, staff files and quality checks. They also observed care and looked around the home.
The home was rated Good for Safe, Effective and Caring. People were described as safe and treated with kindness, dignity and respect. Staff knew people well, medicines were managed safely, and there were enough staff to meet people's needs.
The home was rated Requires Improvement for Responsive and Well-led. Some care plans and risk assessments were out of date or gave conflicting information. Accident and incident records had not been analysed recently, and there was no registered manager in post at the time of the visit.
The overall rating remained Requires Improvement. The report says improvements had been made since the 2019 inspection and the home was no longer in breach of regulations. However, this was the home's second consecutive Requires Improvement rating.
People felt safe
People and relatives said they felt safe. Staff responded promptly to call bells and the home had enough staff to meet people's needs.
“Without exception people and relatives told us they felt safe and that the quality of care delivered was safe.” from the report
Safe medicines practice
Medicines were given by trained staff who had been checked as competent. Records for giving and disposing of medicines were complete and up to date.
“Medicines were administered by trained and competency assessed staff.” from the report
Kind and respectful care
Inspectors saw warm and caring interactions. Staff respected privacy, supported independence and involved people in everyday choices.
“People were treated with kindness, dignity and respect.” from the report
Food and drink support
People were offered choices and received help to eat and drink enough. Staff monitored weight and took action when people lost weight unexpectedly.
“People were offered a choice of food and drink and supported in line with their needs.” from the report
Improvements since 2019
The provider had addressed earlier breaches involving safeguarding, risk management, consent and governance. The provider was no longer in breach of regulations at this inspection.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Out-of-date care information
needs fixingSome care plans and risk assessments had not been updated and contained conflicting information. This could mislead staff, particularly staff who were new to the home.
“Care plans and risk assessments still in the old format had not been updated to reflect people's current risks and needs.” from the report
Limited oversight of incidents
needs fixingThe manager had not recently analysed accidents and incidents. This meant the home did not have a clear view of possible patterns or repeated risks.
“Accidents and incident logs to drive improvement had not been analysed recently.” from the report
No registered manager
needs fixingThere had been no registered manager since October 2021. A new manager had applied to become the registered manager, but the application had not been completed at the inspection.
“A registered manager had not been in post since October 2021.” from the report
- 01Have all care plans and risk assessments now been updated, including information about diabetes, bedrails and wellbeing checks?
- 02Is there now a registered manager in post, and if not, when is this expected to happen?
- 03How are accidents and incidents now analysed, and what changes have resulted from that analysis?
- 04Have regular team meetings and formal ways for staff to share concerns and suggestions been restarted?
- 05What progress has been made with the new online care planning system since the inspection?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control measures; no one was receiving end of life or palliative care during the visit. This explanation was written from the published report of 24 May 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, June 2019
Lobswood House was rated Requires Improvement; inspectors found kind, personalised care, but gaps in safety, consent and management oversight.
This was an unannounced inspection on 24 and 26 April 2019. One inspector spoke with people living at the home, relatives, staff, managers and health professionals. They reviewed care records, medicine records, staff records and quality checks.
People generally said they felt safe and were treated kindly. Inspectors found that staff knew people well, respected their privacy and supported personalised care, activities, food choices and access to healthcare. Medicines were managed safely.
However, some windows above ground level were not restricted or risk assessed, creating a risk of falls. Safeguarding procedures were not followed promptly, and records did not always show that the Mental Capacity Act had been followed when decisions were made for people.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also Requires Improvement, while Caring and Responsive were Good. The home had previously been rated Good in December 2016. The provider was required to report what action it would take, and the CQC said it would continue to monitor the home.
Kind and respectful staff
People and relatives described staff as kind and caring. Inspectors found that privacy, dignity and independence were respected.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support
Staff knew people well and care plans recorded their likes, dislikes, history and needs. Activities and time with staff were tailored to people's interests.
“People received individualised care and support from staff who knew them well.” from the report
Medicines managed safely
Medicines were stored, administered and recorded safely. Staff were trained and their competence was checked regularly.
“People's medicines were managed, stored and administered safely and appropriately by staff who had been trained and assessed as competent to do so” from the report
Good activities and community links
People could join a wide range of activities and had opportunities to go into town, to the seafront and to local facilities.
“Activities were designed to encourage social interaction, provide mental stimulation and promote people's well-being.” from the report
Falls risk from windows
seriousSome windows above ground level had no restrictors and had not been risk assessed. This created a risk that people could fall from height.
“Some windows above ground level were not restricted or risk assessed placing people at risk of falls from height.” from the report
Safeguarding procedure not followed
seriousA safeguarding referral requested by inspectors on the first day had not been made by the second day. It was made after the inspection.
“People were not always protected from the risk of abuse or avoidable harm.” from the report
Mental Capacity Act records
seriousCapacity assessments and best-interests decisions were not always completed before restrictions or applications to deprive people of their liberty. This risked people's rights not being protected.
“A mental capacity assessment had not been completed to show that the person did not have capacity to consent to these arrangements or whether this was being carried out in their best interests.” from the report
Weak quality oversight
needs fixingThe provider's checks did not identify the problems found by inspectors. Policies were in place but were not always followed.
“Quality assurance systems were not always effective as they did not identify the issues we found at this inspection.” from the report
- 01Have all above-ground windows now been fitted with restrictors and included in documented risk assessments?
- 02How are safeguarding concerns identified, recorded and referred to the local authority without delay?
- 03For people who may lack capacity, how do you record mental capacity assessments and best-interests decisions before applying restrictions or making DoLS applications?
- 04How often are quality checks reviewed, and how do you make sure they identify risks that need action?
- 05What improvements have been completed since the Requires Improvement rating, and what evidence can you show the family?
This was a planned, unannounced inspection of the whole care home, including both the premises and the care provided, and it assessed all five CQC questions. This explanation was written from the published report of 11 June 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 Lobswood House
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
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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