CQC report explained · a residential care home
What the CQC found at Loughton Hall
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were not always supported to receive medicines safely. Other safety arrangements, including risk assessments, safeguarding, staffing and fire procedures, had improved.
- Effective?
- Good
- Staff training and supervision had improved. Care plans reflected people's needs, and people were supported with food, drink, healthcare and choices.
- Caring?
- Good
- This question was not rated in this inspection report.
- Responsive?
- Good
- This question was not rated in this inspection report.
- Well-led?
- Requires improvement
- Governance and audit arrangements had improved, but senior staff had not identified medicine errors through their checks. The home remained in breach of the good governance regulation.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found unsafe medicines management despite improvements in staffing, training and risk assessments.
Inspectors made two unannounced visits in December 2023. They spoke with people living in the home, relatives and staff. They reviewed care, medicine and staff records and observed how care was provided.
The home had enough staff and recruitment checks had improved. Risk assessments, safeguarding, staff training and support had also improved. People were supported to make choices, and their care plans generally gave staff clear guidance.
The main problem was medicines. Inspectors found unexplained gaps in medicine records and a concern that senior staff had not identified. This meant people were at risk of not receiving medicines safely or as prescribed.
The overall rating remains Requires Improvement. Safe and well-led were rated Requires Improvement, while effective improved to Good. The home remained in breach of regulations about safe care and treatment and good governance.
Enough staff
Inspectors found enough suitable staff to meet people's needs. Recruitment checks had improved since the previous inspection.
“The provider ensured there were sufficient numbers of suitable staff to meet people's needs.” from the report
Better staff training
Staff had received relevant training or were on track to complete it. Staff also received supervision and said they felt supported.
“Oversight in relation to training had improved and staff had now either received training relevant to their role or on track to complete training” from the report
Improved risk checks
Risk assessments contained clearer guidance, and environmental safety checks had improved. Fire drills and emergency plans were also being completed more consistently.
“Risks assessments had improved and contained information to guide staff to support people safely.” from the report
People's choices
The home was working in line with the Mental Capacity Act. Assessments and best-interest decisions were in place for restrictions such as bed rails and alert mats.
“People were supported to have maximum choice and control of their lives” from the report
Medicine errors and gaps
seriousInspectors found unexplained gaps in medicine administration records and a medicine concern that senior staff had not identified. This created a risk that people would not receive medicines safely or as prescribed.
“Systems were not effective at ensuring people consistently received their medicines safely or as prescribed. This placed people at risk of harm.” from the report
Weak medicine oversight
seriousDaily checks and audits had not identified the problems found during the inspection. The provider remained in breach of the good governance regulation.
“The provider's failed to keep effective oversight of medicines processes.” from the report
Some environmental repairs
needs fixingSome bathroom and toilet floors still needed work to stop dirt and grime building up. A relative also reported an unresolved bedroom leak, which the manager followed up.
“However, more work was needed to further improve the environment.” from the report
Inconsistent mealtime support
minorOne of two observed lunchtime experiences was positive, but staff were less interactive on the other occasion. The manager said work was under way to improve consistency.
“The registered manager told us they were currently working with staff in this area to improve consistency.” from the report
- 01What exactly caused the unexplained gaps in medicine records, and how will you check that each person receives medicines as prescribed?
- 02How often are medicine audits now completed, who reviews them, and what happens when an error is found?
- 03What further medicine training and senior staff competency checks have been completed since the inspection?
- 04Which bathroom, toilet and bedroom repairs are still outstanding, and when will they be finished?
- 05How are you making support during meals more consistent for people who need help or encouragement?
This inspection checked whether earlier legal requirements were being met and rated Safe, Effective and Well-led; Caring and Responsive were not rated in the report. This explanation was written from the published report of 6 February 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, June 2023
Rated Requires Improvement, with an Inadequate well-led rating; inspectors found unsafe medicines and risk management, although some immediate fixes were made.
This was an unannounced focused inspection. Inspectors visited on 12 and 14 April 2023, with inspection activity continuing until 24 April. They spoke with people, relatives and staff, observed care, and checked care plans, medicines, recruitment records and management audits.
The home was rated Requires Improvement overall. Safe and Effective were both rated Requires Improvement, while Well-led was rated Inadequate. Inspectors found gaps in medicines management, risk assessments, staff training, care records and quality checks. They also found that people were not always supported in the least restrictive way or through properly recorded best-interest decisions.
There were enough staff for the people living at the home, and people and relatives spoke positively about their care and the ability to raise concerns. A new manager had recently started and some safety issues were dealt with quickly. However, the report says the previous action plan had not led to enough improvement.
Staffing levels
Inspectors found enough staff to support the number of people living at the home, although agency staff were being used because of vacancies.
“There were enough staff to meet people's needs. Agency staff were used due to current staff vacancies.” from the report
People felt safe
People and relatives told inspectors they felt safe and that staff cared about them.
“I do feel safe here. Staff are very good, and politeness goes a long way.” from the report
Day-to-day choices
People were offered choices about food, drink and where they spent their time. Pictorial images were used to help people choose lunch.
“We observed people were offered choices about their day-to-day life, such as what they ate or drank or where they wanted to spend time.” from the report
Immediate response
The operations director and new manager responded quickly to some safety concerns found during the inspection.
“The operations director and the new manager were pro-active in responding to the safety concerns identified during the inspection and had actioned some concerns by day 2 of the inspection.” from the report
Medicines were not reliably recorded
seriousThere were gaps in medicine administration records, and audits had not identified them. Some as-needed medicines did not have the required guidance, and one poor competency assessment had not been followed up.
“We could not be assured people were receiving their medicine as prescribed as we found numerous gaps on medicine administration records (MAR), which had not been picked up on audits or any action taken.” from the report
Risks were not consistently controlled
seriousInspectors found unsafe cleaning products, unsecured wardrobes, inaccurate evacuation plans and incomplete guidance for distressed behaviour. Some fire door and bathroom concerns also needed action.
“Some people had incidents of distressed behaviour, but there was no detailed risk assessment or guidance for staff to minimise or de-escalate any distress.” from the report
Poor management oversight
seriousMost audits had not been completed since 2022 and did not show whether problems had been fixed. The provider also failed to identify some important care and safety shortfalls.
“Audits in place had not been completed since 2022 and these did not record whether any actions had been taken to resolve concerns found.” from the report
Staff training gaps
seriousSome staff had not completed relevant training, including moving and handling, first aid and food hygiene. Supervision records were also missing for some staff.
“The provider had not ensured staff were provided with the necessary training and to support people safely.” from the report
Care records and nutrition monitoring
needs fixingFood, fluid and repositioning records were not always completed correctly. Inspectors also found concerns about oral care and limited menu choices.
“Daily records related to food and fluid intake and repositioning charts were not being recorded effectively and care plans were unclear if this was necessary.” from the report
- 01What checks now make sure every medicine dose is recorded correctly, including as-needed medicines?
- 02How are risks such as falls, distressed behaviour, fire evacuation and unsafe equipment assessed and reviewed?
- 03Which staff have completed moving and handling, first aid, food hygiene and distress-support training?
- 04How are food, fluid, repositioning and oral care records checked for accuracy each day?
- 05What actions have been completed in response to the governance warning notice, and how is progress being independently checked?
This was a focused inspection of Safe, Effective and Well-led only; the Caring and Responsive ratings were carried over from the previous inspection. This explanation was written from the published report of 1 June 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.
Every inspection of Loughton Hall
7 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- August 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2021Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- September 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019
Registered with the Care Quality Commission on 6 November 2019.
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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Most charge £1,020 to £1,260 a week. 25 can care for a couple. 10 years' experience on average.
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