CQC report explained · a nursing home
What the CQC found at Lofthouse Grange and Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, suitable risk assessments, safe medicines systems and improved monitoring of falls.
- Effective?
- Good
- This area was not assessed during this focused inspection.
- Caring?
- Good
- This area was not assessed during this focused inspection.
- Responsive?
- Good
- This area was not assessed during this focused inspection.
- Well-led?
- Good
- The home had an approachable management team, regular quality checks and systems for learning from accidents and incidents. Inspectors found a delay in sharing information with one relative after a serious incident.
What inspectors found, August 2022
Rated Good; inspectors found safe, well-managed care, with some delays in sharing information after a serious incident.
This was an unannounced focused inspection on 04 August 2022. It followed a serious incident involving a person who was injured, with concerns about how falls were managed. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable risk assessments, safe medicines systems and good infection control. They found that lessons from the serious incident had led to improvements in accident reporting and falls monitoring.
The home had good leadership and regular checks on quality and safety. However, some parts of the policy about being open after something goes wrong had not been fully followed. There had been a delay in giving one relative information after a serious incident.
Only Safe and Well-led were inspected in this visit. The report does not give new ratings for Effective, Caring or Responsive.
Staffing and recruitment
People said there were enough staff to meet their needs. Recruitment checks included references and criminal record checks.
“People told us that there were enough staff to meet their needs.” from the report
Risk management
Care plans included detailed assessments of individual risks. Accidents and incidents were reviewed so that patterns could be identified and action taken.
“Accidents and incidents were recorded and then analysed by the management team.” from the report
Learning after incidents
The home strengthened its systems for managing falls after the serious incident. Lessons were also shared with other services run by the provider.
“The regional support manager had strengthened systems and processes relating to falls in the home following a serious incident.” from the report
Person-centred support
Care plans included personal details and preferences. Staff were described as getting to know the people they supported.
“People were supported by staff with a person-centred approach.” from the report
Quality oversight
The management team carried out regular audits and used them to identify and address improvements.
“The provider and registered manager regularly completed a range of audits to assess the quality and safety of the service.” from the report
Information after a serious incident
needs fixingThe policy about being open and honest after something goes wrong was not fully implemented. One relative experienced a delay in receiving information after a serious incident.
“However, some aspects of the policy had not been fully implemented.” from the report
Medicine delivery delay
minorThere had been a delay in delivering a large amount of medicines. The management team acted promptly to make medicines available and followed this up to reduce the chance of it happening again.
“Prior to the inspection the service experienced a delay in a large amount of medicines being delivered.” from the report
- 01What changes were made to falls monitoring after the serious incident?
- 02How will you make sure relatives receive prompt and complete information after a serious incident?
- 03What arrangements are in place if a delivery of medicines is delayed?
- 04How do you use accident and incident reviews to prevent similar events happening again?
- 05When were Effective, Caring and Responsive last fully assessed, and what were their ratings?
This was an unannounced focused inspection of Safe and Well-led only, prompted by a serious incident; the report does not give new ratings for Effective, Caring or Responsive. This explanation was written from the published report of 24 August 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 2020
Lofthouse Grange and Lodge was rated Good; inspectors found kind, safe care, with some questions about staff deployment and one capacity assessment.
This was an unannounced, planned inspection. Inspectors spoke with 13 people, 14 relatives, 11 staff and a visiting health professional. They reviewed care records, medicines records, staff recruitment files and management information.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff to meet people's needs, safe medicines systems, suitable training, good health care support and kind, respectful care.
There were some areas to watch. People and relatives gave mixed views about staffing and staff presence in communal areas. One capacity assessment was not fully completed, and there were minor recording errors in some care plans.
The overall Good rating was unchanged from the previous inspection, published on 12 July 2019. The report says the service was consistently managed and people's needs were met.
Kind and respectful staff
People and relatives praised staff for being kind, caring and compassionate. Staff supported people's dignity, privacy and independence.
“People and their relatives praised staff for their kindness and compassion.” from the report
Personalised care
Care plans included people's backgrounds, preferences, communication needs and support needs. Staff showed that they knew people's personalities and routines.
“Care plans generally contained good person centred information and were updated regularly.” from the report
Safe medicines
Medicines were stored, recorded and given safely. Staff had competency checks and clearly recorded why some medicines were not given.
“Systems and processes around storage, recording and administration of medicines were safe.” from the report
Good involvement
People and relatives could give their views through meetings, surveys and a 'you said, we did' board. The manager used feedback to plan improvements.
“There were frequent 'residents and relatives' meetings where the manager discussed issues within the home as well as plans for improvements to the service.” from the report
Staff deployment
needs fixingInspectors found enough staff to meet people's needs, but some people and relatives had mixed views about staffing levels. Inspectors also saw a communal area without a staff member briefly and recommended a review of staff deployment.
“We recommend the provider review systems and processes around staff deployment.” from the report
Incomplete capacity assessment
needs fixingOne capacity assessment was not fully completed and did not show that other professionals had been involved. The manager said a new assessment would be carried out.
“We found one capacity assessment where the capacity test was not fully completed and there was no evidence that other professionals had been involved in the assessment.” from the report
Minor record errors
minorInspectors found minor recording errors in care plans. These were discussed with the manager during the inspection.
“We found minor recording errors which we discussed with the manager during the inspection.” from the report
- 01How have you changed staff deployment since the inspection, especially in communal areas?
- 02How do you check that there are enough staff present throughout the day and evening?
- 03Has the incomplete capacity assessment been redone, and how do you make sure future assessments are complete?
- 04How do you check care plans for the minor recording errors found by inspectors?
- 05Has the manager now registered with CQC, and if not, what is the current position of the application?
This was an unannounced planned inspection covering all five CQC questions, the premises and the care provided; the overall and five question ratings remained Good from the previous inspection. This explanation was written from the published report of 6 June 2020 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 Lofthouse Grange and Lodge
5 rated inspections over 4 years: the service has improved, from Inadequate to Good.
- August 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2020Goodstayed GoodSafe: GoodWell-led: Good
- July 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2019Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2018InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2017
Registered with the Care Quality Commission on 28 December 2017.
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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