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CQC report explained · a residential care home

What the CQC found at Lupin House

Goodpublished 21 July 2022, 4 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People told inspectors they felt safe, and there were enough staff. Risks and medicines were generally managed safely, although one person lacked a necessary Positive Behaviour Support care plan and one medicine stock record had discrepancies.
Effective?
Good
People's needs were assessed before they moved in, staff received training, and people were supported with food, health care and communication. Some mental capacity assessments had not been completed where required.
Caring?
Good
People and relatives described staff as kind, patient and caring. Staff supported people's dignity, privacy, choices and independence.
Responsive?
Good
Care was planned around people's individual needs and preferences. People were supported to follow interests, see family, try new experiences and communicate in ways they understood.
Well-led?
Requires improvement
People and staff generally said the home was managed well, but quality checks had not always identified incomplete records or medicine recording discrepancies. New management checks were being introduced.
The latest report, explained

What inspectors found, July 2022

Rated Good overall, but inspectors found weaknesses in the home's quality checks and record keeping.

This was the home's first inspection. It was unannounced and took place on 14 June 2022. One inspector spoke with people, relatives, staff and a healthcare professional, and checked care, medicine and management records.

Inspectors rated Safe, Effective, Caring and Responsive as Good. People were supported to make choices, stay independent, take part in activities and use local services. People and relatives said staff were kind and people felt safe.

Well-led was rated Requires Improvement. Checks had not always found missing or incomplete records, including some mental capacity assessments, care plans and medicine records. The home began taking action during and after the inspection.

What inspectors praised
  • People felt safe

    People told inspectors they felt safe and protected. Staff understood their safeguarding responsibilities and the manager had made referrals when needed.

    “People were safeguarded from the risk of abuse and told us they felt safe.” from the report
  • Kind and respectful care

    People and relatives said staff were caring and patient. Inspectors saw staff respond sensitively when someone was upset about a bereavement.

    “Relatives also confirmed people were treated well by kind and caring staff.” from the report
  • Choice and independence

    People were involved in everyday decisions and their care. Staff supported them to do tasks for themselves and to live in ways that suited them.

    “People were supported to have maximum choice and control of their lives” from the report
  • Community life and activities

    People had regular opportunities to pursue interests, visit places and maintain family relationships. Staff encouraged people to try new experiences.

    “Records showed people had regular opportunities to pursue social interests within their local community.” from the report
  • Good access to health care

    Staff worked proactively with health professionals and used digital technology to help identify changes in people's health quickly.

    “They [staff] have been very proactive in getting support from healthcare professionals.” from the report
What inspectors were concerned about
  • Quality checks missed record gaps

    needs fixing

    Management checks did not always identify incomplete care plans, missing mental capacity assessments or medicine recording problems. This led to the Requires Improvement rating for Well-led.

    “However, these checks had not always identified improvements needed with record keeping.” from the report
  • One behaviour support plan was missing

    needs fixing

    One person did not have a necessary Positive Behaviour Support care plan. Inspectors said this could mean staff did not respond consistently, although staff knew how to support the person and the manager acted after the visit.

    “However, one person did not have a necessary 'Positive Behaviour Support' care plan” from the report
  • Medicine records needed checking

    needs fixing

    A new electronic medicine recording system was not fully embedded. Inspectors found discrepancies in one person's medicine stock records, and the manager investigated during the visit.

    “We found discrepancies in the recording of one person's medicines stock.” from the report
  • Some mental capacity records were incomplete

    needs fixing

    Inspectors were confident people were supported in line with the Mental Capacity Act principles, but some required assessments had not been recorded.

    “Some mental capacity assessments had not been completed where required.” from the report
Questions to ask them, based on this report
  1. 01Have all missing mental capacity assessments now been completed, and how do you check they remain up to date?
  2. 02Has every person got a complete Positive Behaviour Support care plan where one is needed?
  3. 03What checks are now in place to make sure electronic medicine records and stock counts match?
  4. 04How do you make sure care plans are complete and updated when people's needs change?
  5. 05What evidence can you show of the new secondary management checks introduced after the inspection?

This was the first 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 21 July 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.

The story over the years

Every inspection of Lupin House

Each visit the CQC has published, newest first, back to the day the home was registered.

  1. July 2022Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Lupin House →

  2. July 2021

    Registered with the Care Quality Commission on 22 July 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.

Next steps

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