CQC report explained · a residential care home
What the CQC found at Saxby Lodge Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Saxby Lodge Residential Care Home is rated Requires Improvement; inspectors found risks around safeguarding, medicines, food choices and management.
This was an unannounced focused inspection on 6 and 8 June 2023. Two inspectors spoke with six people, two relatives and 10 staff. They reviewed care records, medicine records, staff files and management records.
The home was not always safe or effective. Inspectors found that some abuse concerns were not recorded or investigated properly, some prescribed medicines had been missed for two days, and care plans were not always accurate. Food stocks were low at times, menus were not always followed, and people had limited choice.
The home was also not well-led. Management roles were unclear, checks did not identify important problems, and some earlier improvements had not lasted. The overall rating remains Requires Improvement, and this is the home's fourth consecutive rating at this level.
Access to healthcare
People were referred to health professionals when needed, including for eating and drinking, falls, mental wellbeing and pressure ulcers.
“People told us they experienced good access to medical care professionals.” from the report
Mental capacity practice
The home had appropriate legal authorisations where people were deprived of their liberty. Records showed capacity assessments and best-interest meetings where needed.
“The service worked in accordance with the Mental Capacity Act 2005 including the appropriate use of Deprivation of Liberty Safeguards (DoLS).” from the report
Family contact
People could receive visitors, and relatives said they were kept informed about their loved one's wellbeing.
“People were supported to stay connected with friends and family.” from the report
Staff checks
Inspectors found sufficient staff on the inspection days and appropriate recruitment checks to help ensure staff were suitable to work with people.
“Safe recruitment processes protected people from the recruitment of unsuitable staff.” from the report
Safeguarding concerns
seriousA reported physical assault was not recorded, investigated or followed by physical or welfare checks. Some people said another person's aggressive behaviour made them feel frightened and unsafe.
“There was a failure to act to investigate alleged abuse or the risk of abuse.” from the report
Missed medicines
seriousSome people did not have access to prescribed medicines on the first inspection day. Some had missed medicines for two days, including antipsychotic and epilepsy medicines.
“Some people had missed their prescribed medicines for two days.” from the report
Food choice and supply
seriousFood such as eggs, cheese, fresh fruit and potatoes regularly ran out, affecting the menu. People were not involved in menu decisions and had limited alternatives.
“There was a failure to ensure people's nutritional needs were met in a way that provided choice and met people's needs and preferences.” from the report
Weak management checks
seriousGovernance systems did not identify inaccurate care records, missing monitoring forms or failures to record incidents properly. The home had not sustained some improvements from previous inspections.
“There was a failure to ensure effective governance of the service.” from the report
Behaviour support
needs fixingBehaviour support plans did not give staff enough guidance, and staff had not been trained to support people with complex behaviours. This created a risk of avoidable harm.
“Staff had not been trained to support people with complex behaviours.” from the report
Infection control supplies
needs fixingToilets used by residents did not have hand wash and paper towels on either inspection day, despite this being raised on the first day.
“There was a failure to provide hand wash and paper towels in toilets used by people living at the service.” from the report
- 01How are safeguarding concerns now recorded, investigated and reported, including concerns about aggression or alleged assault?
- 02What checks ensure that every person receives all their prescribed medicines without missed doses?
- 03How do you make sure food supplies are maintained and that people can choose meals, snacks and alternatives?
- 04What training do staff now have to support people with complex behaviours and prevent avoidable harm?
- 05How are managers checking that care plans and monitoring records are accurate and completed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the overall rating used the previous ratings for the questions not inspected. This explanation was written from the published report of 19 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, February 2023
Rated Requires Improvement; inspectors found safe care, but leadership and some risk records still needed improvement.
This was an unannounced focused inspection on 10 January 2023. Two inspectors spoke with people, relatives, staff and managers. They also checked care plans, medicines records, recruitment files and management records.
The home was rated Good for Safe. People said they felt safe, medicines were given as prescribed, staffing was enough and infection control arrangements were suitable. Risks in care plans had been reviewed and staff generally followed the guidance.
The home was rated Requires Improvement for Well-led, so the overall rating remained Requires Improvement. Inspectors found that a best-interests decision about bed rails was not formally recorded, and maintenance work had not been properly risk assessed. The home had met the conditions previously placed on its registration and was no longer in breach of the regulations checked at the earlier inspection.
People felt safe
People and relatives told inspectors that people were safe and treated well in the home.
“This is a safe place to live. I wouldn't want to live anywhere else” from the report
Safe medicines support
Staff were trained and observed to give medicines patiently. The electronic medicines system helped identify possible problems promptly.
“The staff member waited patiently with people whilst they took their medicines, and offered pain relief medicine if people required this.” from the report
Personalised support
People received care that reflected their needs and preferences. Inspectors saw activities taking place and found that diverse communication and religious needs were recorded.
“People received personalised care that met their needs.” from the report
Maintenance work risks
needs fixingWork in a narrow corridor had not been fully risk assessed. Tools were sometimes left unattended, creating a trip hazard for people.
“Tools required by the workman had been left in the corridor posing a trip hazard.” from the report
Missing best-interests record
needs fixingA decision to use bed rails had been made in a person's best interests, but the decision was not formally recorded in their care record.
“For one person, although a best interests decision had been made in the use of bed rails, this was not formally recorded in their care record.” from the report
Call bell concerns
needs fixingOne person said they did not have a call bell and another said theirs did not work. The home said the system was checked and that people unable to use call bells were checked regularly.
“One person told us they did not have a bell to call staff, and another said they did have a bell in their bedroom, but it did not work.” from the report
- 01How do you now make sure every best-interests decision, including decisions about bed rails, is recorded in the care record?
- 02How will you keep people safe when maintenance work is taking place in narrow corridors?
- 03How often are call bells tested, and what happens if a person cannot use one?
- 04What actions remain from the previous inspection, and how are you checking that improvements are maintained?
- 05Which ratings were carried over from the previous inspection because they were not checked during this visit?
This was a focused inspection of Safe and Well-led; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 17 February 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.
Every inspection of Saxby Lodge Residential Care Home
7 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Saxby Lodge Residential Care Home →
- February 2023Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
Read what inspectors found at Saxby Lodge Residential Care Home →
- October 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2022Requires improvementup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2021Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021
Registered with the Care Quality Commission on 5 February 2021.
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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