CQC report explained · a residential care home
What the CQC found at Loveys 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
- Fire safety assessments did not adequately consider alternative actions for people who might not leave during a fire. Staffing cover was limited, although medicines, safeguarding and infection control arrangements were mostly described positively.
- Effective?
- Good
- This question was not assessed during this focused inspection.
- Caring?
- Good
- This question was not assessed during this focused inspection, although relatives said people were happy and staff provided care they valued.
- Responsive?
- Good
- This question was not assessed during this focused inspection.
- Well-led?
- Requires improvement
- Quality checks did not identify important risks or show how feedback was being used. The home had not developed a strong culture of learning and had not notified the CQC about a serious injury.
What inspectors found, January 2021
Rated Requires Improvement; inspectors found better infection control and safe medicines practice, but serious fire safety and management checks needed improvement.
This was an unannounced focused inspection on 11 and 26 November 2020. The inspector spoke with one person, staff and relatives, observed care, and checked records including risks, medicines, recruitment and quality checks.
The home had improved its infection control after an earlier review. Staff generally used protective equipment and followed infection control guidance. Medicines were stored and recorded safely, and relatives said people were safe and happy.
However, fire risk assessments did not fully consider what to do if someone would not leave during a fire. Staffing cover was also limited, with some occasions when one staff member worked alone.
The home was rated Requires Improvement overall, and for Safe and Well-led. This was a fall from Good at the previous inspection, published on 6 July 2018. The CQC found breaches relating to safe care and treatment and good governance.
Improved infection control
The home acted on concerns from an earlier infection control review. Staff generally used protective equipment and followed measures intended to reduce infection transmission.
“The action provided assurance that the provider was preventing visitors from catching and spreading infections and staff were meeting social distancing rules.” from the report
Medicines handled safely
Staff had training and clear instructions for giving medicines. Records were accurate, and medicines were stored securely and at the right temperature.
“Medicines were stored securely, and action taken to make sure they were kept in the correct conditions.” from the report
Safeguarding awareness
Staff understood how to recognise and report possible harm. Relatives said they felt their family members were safe at the home.
“Staff told us they had received safeguarding training and they understood what to do to protect people from harm, and how to report concerns.” from the report
Positive staff relationships
Staff described a friendly and supportive team. Relatives also described the home as homely.
“Teamwork and friendliness is good. There is nothing I don't like about working there.” from the report
Fire safety plans
seriousThe fire risk assessment did not fully consider alternative ways to protect people who might not move during a fire. The CQC said this created an increased risk of harm.
“The assessments in place in regard to fire safety did not adequately assess alternative actions to reduce the risks to people and did not adequately recognise the significant risk involved.” from the report
Quality checks were ineffective
seriousThe home's audits did not reliably identify risks or show how care was being improved. Feedback from relatives and staff was collected, but the home could not show meaningful analysis or actions.
“There were ineffective processes in place to monitor and improve the quality of the service provided and this placed people at greater risk to their safety.” from the report
Limited staffing cover
needs fixingThere were no additional staff to cover sickness or annual leave, and staff sometimes worked alone or covered extra shifts. The CQC recommended reviewing staffing levels.
“There were no additional staff to cover sick leave or annual leave.” from the report
Serious injury not reported
seriousThe manager had not notified the CQC about a serious injury that happened during the inspection period. The report said the duty to be open and honest was not always followed.
“However, a serious injury to one person that occurred during this inspection had still not been notified to us.” from the report
- 01What changes have you made to the fire risk assessment, especially for a person who may not leave during a fire?
- 02How do you make sure there are enough staff to cover sickness, annual leave and behaviour that may challenge?
- 03What action have you taken to improve quality audits and make sure lessons are shared across the home?
- 04How do you record, investigate and report serious injuries or other incidents to the CQC?
- 05What feedback have relatives and staff given recently, and what changes have you made as a result?
This was a focused inspection of Safe and Well-led only, prompted partly by infection control concerns; the other three key questions were not assessed during this visit. This explanation was written from the published report of 22 January 2021 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, November 2020
Inspected but not rated; inspectors found cleaning and testing, but were not assured about all infection-control procedures.
This was an announced, targeted inspection on 22 October 2020. It looked only at infection prevention and control during the coronavirus pandemic, not the full quality of the home.
Inspectors found that staff cleaned throughout the day and did extra cleaning at night. Whole-home testing of staff and residents had also taken place over the previous few months, with everyone taking part.
The inspectors were assured about access to testing and about the home's layout and hygiene practices. However, they were not assured that all safe infection-prevention and control procedures were being followed. The service was inspected but not rated, so this report does not give an overall quality rating.
Regular cleaning
The home cleaned throughout the day and carried out extra cleaning at night to keep the premises hygienic.
“Staff carried out cleaning throughout the day and completed more cleaning at night to make sure the home was hygienic.” from the report
Testing arrangements
Staff and residents had taken part in whole-home testing over the previous few months.
“Whole home testing of staff and people living at the service had been carried out for the last few months, with everyone taking part.” from the report
Access to testing
Inspectors were assured that the provider was accessing testing for staff and residents.
“We were assured that the provider was accessing testing for people using the service and staff.” from the report
Infection-control procedures
needs fixingInspectors were not assured that the home was following all safe infection-prevention and control procedures. They signposted the provider to resources to develop its approach.
“We were not assured the service were following safe infection prevention and control procedures to keep people safe.” from the report
- 01Which infection-prevention and control procedures were inspectors not assured about?
- 02What changes have been made since the inspection to address the concerns?
- 03How often are staff and residents tested now, and who takes part?
- 04How are daytime and night-time cleaning checks recorded?
- 05What resources did the provider use to develop its infection-control approach?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide a full service rating or assess the other four key questions. This explanation was written from the published report of 19 November 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 Loveys Lodge
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- January 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- July 2018GoodSafe: GoodWell-led: Good
- October 2016
Registered with the Care Quality Commission on 4 October 2016.
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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