CQC report explained · a residential care home
What the CQC found at Retreat Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found medicines were managed safely, risks were assessed, the home was clean and there were enough staff to support people safely. Recruitment checks were also described as robust.
- Effective?
- Good
- Staff had training and supervision, and people were supported with healthcare, food and drink, communication and specialist needs. The home followed mental capacity and best-interest processes.
- Caring?
- Good
- Staff were kind, patient and respectful. They understood how people communicated, supported choices and helped people develop independence.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People had activities based on their interests, support to keep in touch with relatives and a complaints process.
- Well-led?
- Good
- The provider had frequent audits and the manager was well regarded by staff and relatives. The manager was in the process of registering with the CQC.
What inspectors found, November 2019
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous Requires Improvement rating.
The inspection was unannounced and took place on 26 September 2019. One inspector spoke with the manager and care workers, reviewed care and medicines records, audits and staff files, observed how people were supported, and spoke with relatives afterwards.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable risk checks, clean surroundings and robust recruitment. Staff knew people well and supported their health, communication, choices, activities and relationships.
The previous inspection, published in September 2018, rated the home Requires Improvement overall, with Safe and Well-led also Requires Improvement. Inspectors found these areas had improved. The manager was still in the process of registering with the CQC, although the provider remained legally responsible for the service.
Improved medicines safety
The home had improved its medicines systems since the previous inspection. Stock checks, records and audits supported people receiving medicines as prescribed.
“At this inspection we found the provider had improved and medicines management was safe.” from the report
Kind and knowledgeable staff
Staff understood people well and treated them with kindness, patience and respect. They recognised different ways people communicated.
“People were cared for by staff who were kind and understood them well.” from the report
Personalised activities
People had activity programmes based on their interests, access to a sensory room and activity centre, and support to go out and take holidays.
“Each person had an activity programme in place based on their interests which included weekly aromatherapy massage for many.” from the report
Stronger oversight
The provider had improved its quality checks since the previous inspection. Audits covered different parts of the service and were carried out frequently.
“The provider had a robust system of frequent audits to check people received a high standard of care, covering all aspects of the service.” from the report
Manager registration
minorThe manager was not registered with the CQC at the time of inspection, although the registration process was under way. The provider was legally responsible for the service while this remained unresolved.
“The service did not have a manager registered with the Care Quality Commission, although the manager was in the process of registering with us.” from the report
Some staff wanted more cover
minorInspectors found enough staff to support people safely during the visit. However, some staff said they would sometimes prefer more staff on shift.
“There were enough staff although staff told us they would sometimes prefer more staff on shift.” from the report
- 01What is the current position on the manager's CQC registration?
- 02How do you decide how many staff are needed on each shift, including at busy times?
- 03How are restrictive interventions used as a last resort, and how are they reviewed?
- 04How will you develop and review advanced care plans for people who may need end of life care?
- 05How are people's communication methods recorded and shared with all staff?
This was an unannounced inspection covering all five CQC questions, with observations, record checks, staff and manager discussions, and feedback from relatives. This explanation was written from the published report of 13 November 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.
What inspectors found, September 2018
Requires Improvement; inspectors found kind and effective care, but serious problems with medicines, staffing and management checks.
This was an unannounced inspection on 11 September 2018. Inspectors met five people, spoke with five staff, two relatives and two healthcare professionals, and checked care records, staff files, medicines and management records.
The home was rated Good for Effective, Caring and Responsive care. People were supported with activities, healthcare, food, routines, relationships and personal choices. Staff were described as kind and knowledgeable about people's needs.
The overall rating fell from Good at the previous inspection in February 2016 to Requires Improvement. Inspectors found medicines records were not reliable, staffing had been reduced without a proper assessment of people's needs, recruitment checks were incomplete, and management systems had failed to identify these problems.
Kind and respectful care
Relatives and healthcare professionals described the staff as caring. Inspectors saw staff speaking politely and respecting people's privacy, dignity, culture, religion and sexuality.
“A significant strength for the service is the caring attitude displayed from staff towards the residents” from the report
Personalised routines
Staff understood that predictable routines were important to people and used care records to support their preferences and reduce anxiety.
“Sticking to these routines enabled people to be aware of what was happening now and what was due to happen next.” from the report
Activities and independence
People were supported with daily walks, community activities, holidays and household tasks. The home also had areas for developing kitchen and computer skills.
“Each person had a detailed weekly programme and staff ensured people engaged in a range of meaningful activities.” from the report
Staff training and healthcare support
Staff received regular training, supervision and appraisals. They worked with health professionals and supported people to attend health appointments.
“Staff told us and records confirmed they completed regular training to ensure they had the knowledge and skills to undertake their duties.” from the report
Medicines records and checks
seriousLoose tablet stock records were inaccurate, and records for medicines given when required did not match the medicines administration records. Inspectors could not be assured that medicines were always given as prescribed.
“Safe medicines management practices were not maintained in line with good practice guidance and we found the provider to be in breach of regulation 12 of the HSCA 2008” from the report
Staffing levels
seriousStaffing had recently been reduced by one person on morning and afternoon shifts. Staff reported higher stress and felt the reduction could affect routines, safety and people's access to appointments and activities.
“Staff also confirmed the recent reduction in staffing was a financial decision rather than based on the level of staff support people using the service required.” from the report
Incomplete recruitment evidence
needs fixingFor one staff member, gaps in employment history had not been explored. For another, the provider had not done enough to confirm that references were valid.
“We recommend the provider consistently adheres to safe recruitment practices to ensure all staff employed are suitable to support people.” from the report
Care records need more detail
needs fixingSome records did not give enough information about support for diabetes and seizures. The manager said these records would be updated, particularly for new and temporary staff.
“Some care records needed to be improved to ensure they contained detailed information about the support people required with their health needs.” from the report
- 01What changes have you made to medicines stock records and records for medicines given when required since the inspection?
- 02How do you now decide how many staff are needed on each shift, and how do you account for people's changing needs?
- 03What checks are now carried out on recruitment gaps and references before staff start work?
- 04What audits now cover medicines, care records, infection control and staffing?
- 05How have you acted on concerns raised by staff and relatives, and can we see the resulting action plan?
This was an unannounced inspection covering all five CQC key questions and the overall rating, following a previous Good rating in February 2016. This explanation was written from the published report of 28 September 2018 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 Retreat Lodge
3 rated inspections over 4 years: the service has held its Good rating throughout.
- November 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 30 August 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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At least 100 live-in carers within about an hour of Croydon
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.
Most charge £980 to £1,230 a week. 77 can care for a couple. 11 years' experience on average.
“She cared for my mum with Alzheimer's with endless patience and kindness, always arriving with a smile and a positive attitude”
“Terry has been of invaluable help to our family while working as a part-time live-in carer for our mother for approximately 6 months”
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.