CQC report explained · a residential care home
What the CQC found at Ormsby Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2023
Rated Good; inspectors found safe, person-centred care, with formal medicine competency records still needing improvement.
This was an unannounced focused inspection. The inspector visited on 29 June 2023 and reviewed care and medicine records, staff recruitment files, incident records, audits and policies. They spoke with people, staff, relatives and an external professional.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable safeguarding arrangements, safe medicine systems and improvements in risk management, infection control and quality monitoring. People and relatives said they felt safe, and staff knew people well.
There were still some areas to improve. Formal records showing staff were competent to give medicines were not being completed. Quality monitoring systems also needed to become more effective and fully established. The home supports eight people, which is more than the six-person size recommended under the relevant guidance, although inspectors found people were supported to have choice, independence and inclusion.
The previous overall rating was Requires Improvement, published in December 2019. The provider had previously breached regulations about safe care and treatment, duty of candour and governance. Inspectors found enough improvement at this inspection and said the provider was no longer in breach. The overall rating changed to Good, but only Safe and Well-led were inspected in this visit. Other key question ratings were carried forward from the earlier comprehensive inspection.
People felt safe
People and relatives told inspectors they felt safe and well supported. Staff knew people well and could recognise changes in their behaviour.
“All relatives we spoke with, told us they felt their loved ones were safe and well supported.” from the report
Safe staffing
There were enough staff to meet people's needs and support activities. Agency staff were used regularly but were kept consistent so they could get to know people.
“People were supported by enough staff to meet their individual needs.” from the report
Person-centred support
Inspectors observed kind support that respected people's choices, privacy and dignity. People were supported with independence, daily living skills and activities they chose.
“We observed good person-centred care which put people at the centre of everything that happened.” from the report
Improved leadership
Management had improved systems for checking the quality of care since the previous inspection. Staff felt supported and the manager acted on feedback during the inspection.
“The provider had improved their auditing systems to monitor the quality of the service, following the last inspection.” from the report
Medicine competency records
needs fixingManagers observed staff giving medicines but did not formally record the competency checks. Inspectors made a recommendation to follow best practice and keep regular written assessments.
“We found the registered manager had not implemented a process to formally record these.” from the report
Quality monitoring still developing
needs fixingThe home's audits and monitoring had improved but were not yet fully established. Inspectors said they needed to be more robust at identifying when action was required.
“Systems and processes in place, required embedding and review.” from the report
Home size
minorEight people lived at the home, which is above the six-person number recommended in the guidance for this type of service. Inspectors still found that people had choice, independence and inclusion.
“The size of the service had not been designed in line with the principles and values that underpin Right support, right care, right culture, as the number of people living at the home exceeded the recommended number of six.” from the report
- 01How are medicine competency assessments now formally completed and recorded for every staff member who gives medicines?
- 02What changes have been made to make quality audits more robust and to identify action needed?
- 03How does the home make sure eight people can live together safely and still receive individual support?
- 04What were the ratings and findings for Effective, Caring and Responsive at the previous full inspection?
- 05How are consistent agency staff introduced to my relative's needs, risks and preferred ways of receiving support?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 24 August 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.
What inspectors found, December 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but ongoing safety and management failures meant there was an increased risk of harm.
This was a planned, unannounced inspection over 31 October and 5 November 2019. One inspector spoke with people, staff, families and health or social care professionals, and checked care records, medicine records, staff files and management records.
The home was caring, effective and responsive, all rated Good. People were treated kindly, supported to make choices and encouraged to be independent. Staff understood people's needs, supported healthcare access and provided personalised activities and communication.
Safe and well-led were both rated Requires Improvement, as at the previous inspection. Inspectors found continuing problems with infection control, medicines and risk assessments. Management checks had not found these issues, and the home did not follow the required process for being open and transparent after a person came to harm.
Personalised care
Care plans described people's routines, preferences and communication needs. Staff understood these plans and supported people to make day-to-day choices.
“Care plans had been developed for each person and provided sufficient information to enable staff to support people in a personalised way.” from the report
Skilled staff
Staff completed a broad range of training, received supervision and were supported with relevant qualifications. Families said staff were competent and well trained.
“Staff completed a comprehensive range of training to meet people's needs, which was refreshed and updated regularly.” from the report
Good links with healthcare services
The home worked with GPs, dentists and other professionals. Staff arranged appointments and followed specialist guidance when people's health needs changed.
“The service had developed strong links and worked closely with local healthcare professionals including a GP surgery, community learning disability nurses, mental health professionals, and dentists.” from the report
Infection control
seriousStaff sometimes opened bags containing soiled laundry and rinsed the contents in a hand-washing sink. The laundry room was not hygienic, and required infection control assessments and audits had not been completed.
“The laundry, which was in a brick outbuilding, was not hygienic.” from the report
Medicine safety
seriousStaff competence was not checked after initial training. Records did not reliably account for boxed medicines, some medicines were given at the wrong time, and insulin was stored insecurely.
“The arrangements for recording and monitoring the use of boxed medicines was not robust.” from the report
Missing risk assessments
seriousRisk assessments were missing for people at risk of falls and for a person taking blood-thinning medicine. A series of recent falls had not led to enough action.
“This put the person at risk of further falls.” from the report
Weak quality checks
seriousThe home's monitoring systems had not identified problems with infection control, medicines, staff files or falls. Inspectors found little evidence of continuous learning.
“There was not a robust quality assurance system in place and they did not have an effective process to assess, monitor and improve the service.” from the report
Duty of candour
seriousThe provider and manager did not understand their responsibilities to be open and transparent after a person came to harm. The family was told about the incident, but the required written information and apology were not provided.
“The provider did not have a duty of candour policy in place to guide staff.” from the report
End of life planning
needs fixingNo one was receiving end of life care during the inspection, but the home had not discussed people's wishes with them or their families. The manager said plans were in place to address this.
“there was no information in people's care plans to show that people's end of life wishes and preferences had been discussed with them or their families.” from the report
- 01What has been done to refurbish the laundry and prevent cross-contamination when handling soiled clothing and bedding?
- 02How are medicine staff's competence and medicine stocks now checked, including the timing of medicines and the storage of insulin?
- 03Which new risk assessments and monitoring arrangements are in place for falls and blood-thinning medicines?
- 04How does the home now check that its quality assurance system identifies problems promptly?
- 05How are people's end of life wishes discussed, recorded and reviewed with them and their families?
This was an inspection of the care home covering all five CQC questions, with records, staff files, care plans and medicine records reviewed; some conversations with people were limited. This explanation was written from the published report of 11 December 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 Ormsby Lodge
3 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- June 2017
Registered with the Care Quality Commission on 8 June 2017.
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 £1,240 a week. 38 can care for a couple. 10 years' experience on average.
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