CQC report explained · a residential care home
What the CQC found at Ridgeway Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safer risk assessments, appropriate safeguarding systems, safe medicines support and good infection control. One medicine recording issue was corrected immediately.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff had received additional dementia training and competency checks. People were supported with food, drinks, healthcare and choices.
- Caring?
- Good
- Staff were described as kind, patient and respectful. People and relatives were involved in care reviews, and inspectors saw privacy and dignity being maintained.
- Responsive?
- Good
- People received more personalised care, including support for distress linked to dementia. They were offered activities and individual experiences, and complaints were handled in line with the home's policy.
- Well-led?
- Good
- The management team had introduced action plans, audits, meetings and staff support systems. Inspectors found an open approach and better oversight of care quality.
What inspectors found, July 2023
Ridgeway Lodge Care Home rated Good; inspectors found safer, kinder and more personalised care after earlier failings.
This was an unannounced inspection over visits on 15 and 20 June 2023, with calls to relatives on 16 June. Inspectors spoke with people, relatives, staff and a visiting health professional. They also checked care records, medicines records, staff recruitment and training, and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer support for people living with dementia, better care records, improved activities and positive relationships between staff and people.
The previous rating was Requires Improvement, published on 22 December 2022, with breaches of regulation. The provider had made the required improvements and was no longer in breach. The overall rating therefore changed to Good.
Staffing
There were enough staff across the day, night and weekends. More permanent staff had joined, reducing and then stopping recent agency use.
“There were sufficient staff available to meet people's needs and provide safe care.” from the report
Kind and respectful care
Inspectors saw compassionate interactions. People were treated as individuals and staff respected their dignity, privacy and choices.
“Staff were observed to be compassionate and caring in their interactions.” from the report
Activities and inclusion
People were supported to do things they enjoyed, including individual events and support for people who preferred to stay in their rooms.
“People were supported to do activities they enjoyed and improvements were found in this area.” from the report
Management improvements
The provider accepted the earlier failings and introduced action plans, audits, meetings and staff support to track improvements.
“There were effective systems in place to monitor the quality and standards of the service.” from the report
Mental capacity records
needs fixingWork was still underway to improve mental capacity documentation and make sure all required assessments were completed.
“Work was ongoing to improve MCA documentation and ensure all necessary assessments took place.” from the report
Confidential information
minorSome daily care files containing personal information were left on a table in a communal area. They were put away immediately.
“We found some daily care files containing personal information about people on a table in a communal area.” from the report
Medicines record
minorInspectors found one recording issue involving a medicine that had not been returned to the pharmacy. The issue was corrected immediately.
“We found a recording issue for 1 medicine which had not been returned to the pharmacy which was rectified immediately” from the report
- 01How are you completing and checking mental capacity assessments and related records?
- 02What controls are now in place to keep care files and personal information away from communal areas?
- 03How do you check that medicines are returned to the pharmacy and recorded correctly?
- 04How do you maintain staffing levels without agency staff if people's needs increase?
- 05How do you use incident reviews and lessons learned to prevent similar events happening again?
This was an unannounced inspection to review breaches from the previous inspection and included infection prevention and control; all five key questions were rated during this inspection. This explanation was written from the published report of 8 July 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 2022
Ridgeway Lodge Care Home was rated Requires Improvement; inspectors found risks, staffing, dementia care and leadership needed improvement.
This was an unannounced inspection carried out over visits on 13, 18 and 27 October 2022. Inspectors spoke with people, staff and relatives, reviewed care records, staffing rotas, medicines and incident reports, and checked the home’s infection control arrangements.
The main concerns were dementia care and how distress was managed. Care plans and risk assessments were not always personalised or followed. Some sensor equipment was not working properly, and there were times when night staffing was below the home’s own safe level.
People were generally positive about feeling safe, staff kindness, medicines, healthcare support and infection control. However, inspectors found that staff did not always spend meaningful social time with people, and meals and activities were not always based on people’s preferences.
The overall rating and all five question ratings were Requires Improvement. Safe and well-led remained at this level from the previous inspection. Responsive also remained Requires Improvement. Effective and caring fell from Good to Requires Improvement. The provider remained in breach of four regulations and was asked to provide an action plan.
Medicines
Inspectors found that people received their medicines as prescribed. Medicines affecting mood were reviewed and people were not found to be over-medicated.
“We found people had received their medicines as prescribed.” from the report
Healthcare support
People were referred to health professionals when needed. People spoken with were confident that staff would seek GP support.
“People received health input from a GP or nurse as needed.” from the report
Kind interactions
People and relatives described staff as kind, and inspectors also saw staff treating people kindly.
“The staff are nice, we have a good rapport.” from the report
Infection control
Inspectors were assured about infection prevention, safe admissions, use of protective equipment and managing infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Risks were not consistently managed
seriousDementia-related distress, falls and sensor equipment were not always covered properly in care plans or followed in practice. Inspectors raised two safeguarding referrals because they believed people were at risk of harm.
“Systems and practices had not been established to always assess, monitor and mitigate risks to the health, safety and welfare of people living at the home.” from the report
Staffing shortages
seriousThere were periods when night staffing was below the home’s own safe level. There was also no clear guidance for senior staff when people did not arrive for a night shift.
“There were low staffing levels and systems were not in place to ensure this was monitored, assessed and managed in a safe way.” from the report
Dementia care was not personalised
needs fixingStaff training and knowledge were limited, and reviews did not consistently look for individual ways to reduce distress. People living with dementia did not always have suitable care plans or access to safe outside spaces.
“There was a lack of dementia expertise to promote a safe and personalised care experience for people.” from the report
People’s quality of life
seriousActivities and social contact did not consistently reflect people’s current or past interests. Some people said they felt bored, and dining did not always have a social atmosphere.
“People were not being consistently treated in a person-centred way which promoted their quality of life.” from the report
Leadership and checks
seriousManagers did not always investigate incidents, staffing shortages or equipment problems, and audits did not reliably identify concerns about care quality.
“There were key shortfalls with how the provider and managers assessed the quality of the care provided.” from the report
- 01What has changed to make sure night staffing does not fall below the level you have defined as safe?
- 02How do you now assess and review dementia-related distress, and how are staff checked to ensure care plans are followed?
- 03How often are sensor equipment, falls risks and other safety measures checked, and what happens when a problem is found?
- 04How are residents’ past and current interests used to plan activities and meaningful social contact?
- 05What action has been taken in response to the four breached regulations, and how are you checking that improvements are working?
This was an unannounced inspection of the care home covering all five key questions and infection control; it was prompted partly by a serious incident, but the report says it did not examine the circumstances of that incident. This explanation was written from the published report of 22 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.
Every inspection of Ridgeway Lodge Care Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2022Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2020Inspected but not ratedSafe: Inspected but not rated
- March 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017
Registered with the Care Quality Commission on 31 January 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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