CQC report explained · a residential care home
What the CQC found at Nene Lodge Retirement Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing levels were sometimes below the level identified as needed, and people reported waiting for help. Inspectors also found shortfalls in medicine records, risk guidance, DoLS procedures and clinical waste disposal.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Outstanding
- This key question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Quality and safety systems did not reliably identify or address problems. Records, audits and checks were incomplete, and there was no improvement plan in place.
What inspectors found, December 2022
Nene Lodge Retirement Home rated Requires Improvement; inspectors found staffing and management checks were not consistently safe or effective.
This was an unannounced, focused inspection after concerns about risk management and staffing. Inspectors visited on 08 November 2022 and 09 November 2022. They spoke with people, relatives, staff and visiting health professionals, and reviewed care, medicine and management records.
The home was not always safe. Staff numbers were sometimes below the level identified as needed, and people described waiting for help. Medicine records and risk guidance were not always complete or up to date. Inspectors also found that a DoLS application was needed for one person, and clinical waste was not being disposed of correctly.
The home was not always well-led. Audits and checks had not found several of the problems identified during the inspection, and records did not always show what checks had been completed. People generally spoke positively about the staff and management, but the overall rating changed from Good at the previous inspection to Requires Improvement.
People felt positive about the home
People generally spoke positively about living at the home and about the management and staff team.
“It is very homely and friendly. I am very happy, and it is nice and quiet which I like.” from the report
Safeguarding awareness
Staff had safeguarding training and understood their responsibility to report abuse and avoidable harm.
“Staff had received safeguarding training and had access to the provider's policy and procedure to support them.” from the report
Clean environment and PPE
Inspectors found the home clean and hygienic, and staff had access to personal protective equipment.
“The service was found to be clean and hygienic. Staff had access to personal protective equipment.” from the report
Partnership working
Visiting health professionals gave positive feedback about referrals, following recommendations and support during visits.
“Feedback from three external visiting professionals was consistently positive.” from the report
Staffing and waiting for help
seriousThe provider did not consistently deploy enough suitably qualified and competent staff. People described waiting for assistance, including help to use the toilet.
“The provider had failed to consistently deploy sufficient numbers of suitable qualified, competent and skilled staff.” from the report
Weak management checks
seriousAudits and checks did not identify important problems with staffing, medicines, risks and records. The provider also had no improvement plan to drive ongoing improvement.
“The provider had failed to consistently assess, monitor and mitigate risks and to maintain accurate records.” from the report
Medicine records
needs fixingMedicine management did not consistently follow expected good practice. Records lacked some signatures, reasons for as-needed medicines and patch-rotation details, although no person had come to harm.
“Medicines management did not consistently follow best practice guidance.” from the report
Care plans and risk guidance
needs fixingSome care plans and risk assessments had not been reviewed when people's needs or risks changed. Staff understood people's needs, but the written guidance was not reliably current.
“Care plans and risk assessments had not consistently been updated.” from the report
Legal safeguards
needs fixingInspectors identified one person who needed a DoLS application. The management team had not recognised this before the inspection and agreed to act as a priority.
“We identified a person required a DoLS application submitting.” from the report
- 01How many care staff are now allocated to each evening shift, and how do you account for the building's size and layout?
- 02How quickly are call bells answered, and what changes have been made since people reported waiting for help?
- 03How are medicine staff competencies, MAR signatures, as-needed medicine reasons and patch rotation now checked?
- 04How do you make sure care plans and risk assessments are reviewed promptly when people's needs change?
- 05What action has been taken on the DoLS application and on the weaknesses in audits and governance records?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection published on 21 February 2020. This explanation was written from the published report of 1 December 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, February 2020
Rated Good overall, with Outstanding caring; inspectors found kind, personalised support and some records and notification systems needed improvement.
This was an unannounced inspection on 30 December 2019 and 9 January 2020. Inspectors spoke with people living in the home, relatives, staff, the manager, an owner and visiting healthcare professionals. They also reviewed care plans, recruitment files, training information and quality checks.
People told inspectors they received exceptionally kind and compassionate care. Staff understood people's preferences, supported their independence and involved people and relatives in care planning. Inspectors also found enough staff, safe medicines management, suitable training and good links with health professionals.
The home was rated Good in Safe, Effective, Responsive and Well-led. Caring was rated Outstanding, improving from Good at the previous inspection in 2017. Inspectors asked the home to improve some risk, care plan, laundry and premises records, and found that a serious injury had not been notified to CQC at the time.
Kind and respectful care
People consistently said staff were kind, compassionate and respectful. Inspectors saw a culture where staff went beyond basic duties to support people.
“Without exception, people told us that staff were warm-hearted, caring and kind.” from the report
Choice and independence
Staff respected people's routines and preferences and did not take over unnecessarily. People could make everyday choices and were supported to remain independent.
“Everyone we spoke with told us that staff encouraged them to express their views and make their own decisions about every aspect of their life.” from the report
Personalised support
Care plans included detailed preferences about personal care, mobility and food. Staff knew people's likes and dislikes and offered alternatives when needed.
“Care plans were well-organised and provided staff with detailed information on people's wishes and requirements in areas including personal care, mobility and diet.” from the report
Activities and relationships
The home had expanded its activities programme and supported hobbies, outings and links with the local community.
“Since our last inspection, the provider had expanded the activities programme and regular events now included music to movement, interactive quizzes such as Play Your Cards Right, visits from professional entertainers and outings” from the report
Supportive leadership
The owner and manager had a hands-on presence and staff felt supported. The home used feedback, meetings and audits to make changes.
“The owner and the registered manager both maintained a very visible, hands-on presence within the home.” from the report
Serious injury notification
seriousA serious injury had not been notified to CQC when it should have been. The manager submitted the notification later and changed administrative systems, but this was an important regulatory shortfall.
“However, during our inspection we found that a serious injury sustained by a person living in the home, had not been notified to us.” from the report
Risk records
needs fixingInspectors identified a need to formally record risks relating to room sharing and the use of stairs. The manager said action would be taken.
“Reflecting feedback from our inspector, the registered manager took action to formally document risks relating to room sharing and the use of stairs.” from the report
Care plan records
needs fixingThe manager said changes made during monthly care plan reviews would be documented more clearly.
“The registered manager said she would take action to ensure any changes to people's care plans were more clearly documented as part of the monthly review process.” from the report
Premises safety checks
minorThe home needed a more systematic way to audit the condition and safety of its premises.
“The registered manager said she would take action to ensure a more systematic approach towards auditing the condition and safety of the premises.” from the report
- 01What changes have you made to record risks linked to room sharing and the use of stairs?
- 02How are changes made during monthly care plan reviews now recorded and checked?
- 03What system do you use to make sure serious injuries are notified to CQC when required?
- 04How do you now audit the condition and safety of the premises?
- 05How have you improved the separation of laundry?
This was an unannounced inspection covering all five CQC questions; the overall rating remained Good from 2017, while Caring improved to Outstanding. This explanation was written from the published report of 21 February 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 Nene Lodge Retirement Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Requires improvement
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.