CQC report explained · a residential care home
What the CQC found at 6 Lamberts (Foxglove)
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Staffing and risk management had improved, but some fire safety concerns remained and were assessed as a moderate risk. Some agency staff were not trained to administer rescue medicines, and staff responsibilities were unclear on one shift.
- Effective?
- Good
- People's nutrition, hydration, weights and healthcare support were monitored well. Staff training and support had improved, although inspectors said health professionals needed to work together more closely.
- Caring?
- Good
- Staff knew people well, treated them respectfully and promoted choice, independence and involvement in daily decisions. Relatives described improvements and felt less worried about the care.
- Responsive?
- Good
- Care plans were personalised and activities had increased, including community activities and visits to relatives. Inspectors noted that night-time routines were not specifically recorded and agency staff found communication needs harder to support.
- Well-led?
- Good
- New management arrangements, quality checks and an improvement plan had strengthened oversight. Inspectors still found that some fire safety issues should have been identified earlier.
What inspectors found, January 2023
Rated Good overall and no longer in special measures; safety still Requires Improvement.
Inspectors visited over two days, including at different times of day and evening. They spoke with a person living there, relatives, staff and managers. They observed care and checked care plans and other records.
The home had improved greatly since its previous inspection, when it was rated Inadequate and breached four regulations. Inspectors found better staffing, care planning, management oversight, activities and living conditions.
Safety was not consistently assured. Inspectors found remaining fire safety concerns, some agency staff were not trained to give rescue medicines, and staff responsibilities were unclear on one shift. Infection control practices also needed improvement.
The overall rating is Good, but this is not the rating for every area. Safe is Requires Improvement, while Effective, Caring, Responsive and Well-led are Good. The home is no longer in special measures and was no longer in breach of regulations at this inspection.
Major improvement
The home had moved from an Inadequate rating to Good overall. Management, staff teamwork and the culture of care had improved.
“The service had turned around its rating of inadequate to good.” from the report
Personalised support
Staff understood people's routines, communication and support needs. Care plans and risk assessments gave staff clear guidance.
“Care plans and risk assessments helped inform staff what support and care were necessary.” from the report
Choice and activities
People were supported to choose how they spent their time and to take part in more activities inside and outside the home.
“People were empowered to live their lives in line with their preferences and were given the opportunity to have new and repeated experiences.” from the report
Improved environment
The home had been refurbished and was cleaner, more comfortable and better suited to people's needs.
“Extensive refurbishment across the house had meant people now had a comfortable, safe space in which to live.” from the report
Kind and respectful care
Inspectors saw positive interactions. Staff gave people time, choices and meaningful attention.
“We observed staff offering and promoting choices to ensure people were spending their time as they wished.” from the report
Fire safety
seriousThe fire safety officer identified remaining concerns assessed as a moderate risk. The provider said immediate action was being taken, but inspectors said some issues should have been found through the home's own checks.
“Some areas of concern remain and identified as a moderate risk.” from the report
Rescue medicines
seriousTwo agency staff working together had not been trained to administer rescue medicines. The provider said training was being arranged, but this should be checked before relying on agency staff in an emergency.
“On the first day of our inspection two agency staff were working together who had not been trained to administer rescue medicines.” from the report
Unclear shift responsibility
needs fixingWhen two agency staff were working together, it was not clear who led the shift or who was responsible for decisions.
“It was not clear who the shift lead was and who would take overall responsibility for decisions made.” from the report
Infection control practice
needs fixingInspectors were not always assured about infection prevention. Visitors were not asked to complete a COVID-19 symptom and contact form on the first visit, and some staff wore masks incorrectly.
“We were mostly assured that the provider was preventing visitors from catching and spreading infections.” from the report
Night-time care records
minorCare plans described people's daytime routines but did not specifically record their night-time routines. This was discussed with management.
“There was nothing specifically in place around people's night care routines which were as equally as important as their day routines.” from the report
- 01What specific actions have been completed to address the fire safety officer's concerns, and when will they be checked again?
- 02Are all permanent and agency staff trained and assessed as competent to administer each person's rescue medicine?
- 03On every shift, including shifts covered by agency staff, who is responsible for leading the shift and making decisions?
- 04How are people's night-time routines recorded and passed on to staff?
- 05How will families be updated about the improvement plan and involved in future surveys or a family forum?
This was an unannounced and then announced follow-up inspection over two visits, checking improvements after the previous inspection and infection prevention and control under Safe; all five key question ratings were reported. This explanation was written from the published report of 26 January 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, June 2022
Rated Inadequate and placed in special measures; inspectors found serious safety, staffing and leadership failures.
This was an unannounced inspection prompted partly by concerns about medicines, staffing and staff training. Inspectors visited on two days, observed care, spoke with staff and relatives, and checked care, medicines, staff and management records.
The home was not consistently safe. Inspectors found poor infection control, unsafe or damaged areas, gaps in safety checks, an insecure garden and too few staff, especially at night. Some medicines were not stored securely.
Care was not always personal or effective. People had limited access to activities and the community, their records did not consistently reflect their wishes, and mental capacity paperwork was incomplete. Staff were sometimes kind and respectful, but low staffing meant care could become task-focused.
The home had no registered manager. Audits and checks had not led to needed improvements. The overall rating is Inadequate, so the home was placed in special measures and will be monitored and reinspected.
Some respectful care
Inspectors saw staff knocking before entering bedrooms and explaining care. People were also encouraged to do parts of tasks independently.
“Staff were observed to knock before entering people's bedrooms and explained what they were going to do while supporting people.” from the report
Personal touches
People were supported to choose bedroom decorations and clothing. Bedrooms included meaningful personal items.
“People's bedrooms were personalised in their decoration and content, including meaningful items such as photographs and items of individual importance.” from the report
Some safe medicines practice
Staff giving medicines had training and competency checks, and inspectors saw safe procedures being followed. Written guidance and an incident reporting system were also in place.
“We saw that people received their medicines from staff who followed safe procedures.” from the report
Infection and environmental safety
seriousInspectors found poor cleanliness, damaged surfaces, unsafe storage and weak infection control during a known COVID-19 outbreak. Cleaning records were incomplete.
“There were poor infection, prevention, control practices in place, and government guidance was not being followed.” from the report
Too few staff
seriousStaffing levels did not safely meet people's assessed needs, including the need for two staff to support some transfers. Night staffing also did not meet identified fire evacuation risks.
“Sufficient levels of staff were not in place to keep people safe during the day and overnight.” from the report
Limited activities and choice
needs fixingPeople did not regularly access meaningful community activities. Staffing and transport problems meant people often left only for medical appointments.
“The provider's own audits identified that people were not regularly accessing meaningful activities in the community, and instead, were only leaving the service to attend medical appointments.” from the report
Mental capacity records
seriousCapacity assessments and records of least restrictive and best-interest decisions were not consistently completed. Staff training about the Mental Capacity Act and safeguards was also incomplete.
“People's care records lacked consistent completion, of decision specific, capacity assessments; this did not demonstrate adherence with the MCA.” from the report
Weak leadership and checks
seriousThere was no registered manager. Provider audits identified risks, but actions were not completed, and some records contained incorrect names or addresses.
“The provider had poor governance and oversight arrangements in place to maintain standards and drive improvement at the service.” from the report
- 01How many staff are now on each shift, especially overnight, and how do you safely support people who need two staff for transfers?
- 02What has been done to fix the infection control problems, including cleaning, PPE, bathroom conditions, limescale and safe storage of risk items?
- 03How are people's capacity assessments, best-interest decisions and least restrictive options now recorded and reviewed?
- 04What meaningful activities and community outings are available to each person, and how are staffing and transport arranged?
- 05Who is currently responsible for managing the home, and how are audit findings, complaints and incidents being followed up?
This was an unannounced focused inspection prompted by concerns about safe running, including medicines, staffing and training; the report gives ratings for all five key questions. This explanation was written from the published report of 9 June 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 6 Lamberts (Foxglove)
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- January 2023Goodcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2020
Registered with the Care Quality Commission on 10 December 2020.
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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