CQC report explained · a residential care home
What the CQC found at Navara Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection prevention arrangements, including PPE, testing, visitor controls, social distancing and cleanliness. They were only somewhat assured that infection control policies and processes were up to date because a spillage kit was missing and the infection control audit had not been reviewed since March 2020.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2021
Inspected but not rated; inspectors found good COVID-19 infection controls, but some policies and audits were not up to date.
This was an announced, targeted inspection on 25 February 2021. It looked at infection prevention and control during the COVID-19 pandemic, rather than giving a full inspection rating.
Inspectors were assured about visitor safety, shielding, social distancing, admissions, PPE, testing, cleanliness and managing infection outbreaks. People were also supported to keep in touch with their families.
There were some gaps. Not all health and safety policies and risk assessments had been reviewed for COVID-19 risks, the home did not have a spillage kit at the visit, and its infection control audit had not been reviewed since March 2020. The provider later supplied evidence that these issues had been addressed.
The service was inspected but not rated. This report does not provide a full overall rating or ratings for care quality areas other than the targeted infection control checks.
Family contact
People were helped to stay in touch with relatives and friends by phone, video calls, letters and cards during the pandemic.
“People had been supported to keep in touch with their families throughout the COVID-19 pandemic.” from the report
Visitor safety
Visitors had a separate access route, guidance, PPE, health screening and temperature checks.
“Visitors were asked to enter the home from the back of the property where they were provided with guidance, personal protective equipment (PPE) and health screening was completed.” from the report
Infection control
Inspectors found clear coronavirus procedures, regular staff testing, vaccinations and no visible concerns about cleanliness or infection control during the visit.
“At the time of the inspection there were no visible signs or concerns regarding infection control or the cleanliness of the home.” from the report
Compassionate support
People were supported in a person-centred way when pandemic procedures caused distress or disruption.
“We heard of examples of how individuals had been supported with real compassion and understanding when they had become distressed during this time.” from the report
Policies and emergency planning
needs fixingSome health and safety policies and risk assessments had not been reviewed for COVID-19 effects, including fire safety and evacuation arrangements. The provider later said these had been reviewed.
“Not all health and safety policies, procedures and risk assessments had been reviewed for a COVID 19 impact.” from the report
Infection control audit
needs fixingThe latest infection prevention and control audit had been completed in March 2020, with no further review by the inspection. A spillage kit was also missing at the visit, although the provider later supplied evidence that one had been bought.
“We noted the last infection prevention and control audit had been completed in March 2020 and no further review of this audit had taken place at the time of inspection.” from the report
- 01How often are infection prevention and control audits now completed and reviewed?
- 02Can you show how the spillage kit is kept available and checked?
- 03What changes were made to fire safety procedures and personal evacuation plans after this inspection?
- 04How are staff testing, vaccination and infection control procedures kept up to date?
- 05What recent inspection or review covers the quality of care areas that this targeted report did not assess?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it was inspected but not rated and did not provide a full assessment of the other care quality areas. This explanation was written from the published report of 18 March 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, March 2019
Navara Lodge was rated Good; inspectors found kind, personalised care, with a few minor records and activity issues.
This was an unannounced inspection carried out on 26 February and 5 March 2019. One inspector observed care, spoke with people, relatives, staff and visiting professionals, and checked care plans, medicines, staffing, complaints and safety records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training, clean premises and care that respected people's choices, dignity and independence.
Inspectors also found some smaller issues. One staff reference was missing at first, one training topic was overdue, team meetings were not routinely recorded and some people wanted activities more often. The reference was obtained before the inspection ended.
Enough staff
Inspectors found staffing levels were sufficient during both the day and night, including cover for emergencies and special activities.
“There were sufficient staff during the day and night.” from the report
Kind and respectful care
Staff were described as dedicated and caring. They knew people well and supported their dignity, choices and independence.
“People were supported by a dedicated and caring staff team who knew them well and treated them with respect.” from the report
Personalised care planning
Care plans contained detailed information about people's individual needs, choices, communication and risks.
“People's health and support needs were effectively assessed and were recorded and updated in detailed and accessible care plans.” from the report
Safe medicines
Inspectors found trained staff, secure storage and clear instructions for regular and as-needed medicines. There had been no medicines errors in the previous year.
“There had been no medicines errors in the last 12 months.” from the report
A recruitment reference was initially missing
minorThe most recent work-related reference for one new staff member was not in place when inspectors checked. It was obtained before the inspection finished and was positive.
“We noted that the most recent work related reference was not in place for one of the latest staff members recruited.” from the report
One training topic was overdue
minorOne staff member had not completed one training topic by the inspection. The home said it was due to be completed.
“One staff member was overdue for one topic but we were told that this was due for completion.” from the report
Team meetings were not routinely recorded
needs fixingThe home held team meetings, but did not routinely keep records of them. Inspectors recommended recording them to support training and reflection.
“We noted that team meetings were not routinely recorded and recommend that this is considered for training and reflection purposes.” from the report
Some people wanted more activities
minorThe home provided activities suited to people's abilities and preferences, but some people said these could happen more often.
“Some people did comment that these could be more frequently held.” from the report
Health and safety procedures were due for review
needs fixingThe provider said it would review all health and safety procedures to ensure they met the latest guidance.
“The provider undertook to review all health and safety procedures” from the report
- 01How often are activities held now, and how are people's preferences used to plan them?
- 02How do you make sure all staff complete their required training on time?
- 03Are team meetings now recorded, and how are actions shared with staff?
- 04Has the review of all health and safety procedures been completed, and what changed as a result?
- 05How do you check that all required recruitment references are obtained before staff start work?
This was an unannounced planned inspection covering all five ratings, including both the premises and the care provided. This explanation was written from the published report of 22 March 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 Navara Lodge
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- March 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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