CQC report explained · a residential care home
What the CQC found at Sonya Lodge Dementia Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment checks, thorough risk assessments and safe medicines management. They also found safeguarding arrangements and systems for learning from accidents and incidents.
- Effective?
- Good
- People had assessments and regularly reviewed care plans. Staff had training and supervision, people were supported with food and healthcare, and the home followed the Mental Capacity Act principles.
- Caring?
- Good
- Staff knew people's backgrounds, preferences and needs. Inspectors observed kind and respectful interactions, privacy being respected, and support for people's choices and independence.
- Responsive?
- Good
- Care plans contained personal information, interests and things that could cause anxiety. People were offered individual or group activities, accessible complaints information and support with end of life planning.
- Well-led?
- Good
- Inspectors found effective quality checks, adequate records and an open management approach. People, relatives and staff were involved through meetings and feedback systems.
What inspectors found, February 2020
Rated Good; inspectors found safe, kind and well-organised care, with improvements since the previous Requires Improvement rating.
Inspectors visited on 7 January 2020. The first day was unannounced and the second was announced. They spoke with people, relatives and staff, observed care, and checked care plans, medicines records, staff files and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, safely managed medicines, personalised care plans and respectful support. People were supported with their health, food, activities, communication and relationships.
The previous inspection, published in January 2019, rated the service Requires Improvement and found two breaches. This inspection found that the provider had made the required improvements and was no longer in breach of those regulations.
Safe staffing and recruitment
Inspectors found enough staff and appropriate checks before new staff started. Staff understood how to report abuse and other safety concerns.
“Appropriate checks had been completed, which included disclosure and barring service (DBS) checks before new staff started working.” from the report
Safe medicines
Staff had medicines training and competency checks. Medicines were stored safely and records showed that prescribed medicines were given as required.
“We observed there were no gaps or omissions in the medicines administration record (MAR) charts, which demonstrated people received their medicines as prescribed.” from the report
Kind and respectful care
Staff knew people well and supported their dignity, privacy, choices and independence. Inspectors saw staff engaging with people in a gentle and considerate way.
“The interactions between people and staff were positive, caring and inclusive.” from the report
Personalised support and activities
Care plans included people's histories, interests, preferences and anxieties. People could choose from group and individual activities, including trips and creative activities.
“Care plans were individualised, with a lot of personal information about people.” from the report
Improved management systems
The provider had improved its audits and record keeping since the previous inspection. Inspectors found that actions were identified and dealt with promptly.
“Quality assurance system had been reviewed and were found effective.” from the report
Previous odour concern
minorFeedback had previously mentioned that the home could occasionally smell of urine. The provider recruited an additional housekeeper, and inspectors said the service rarely had a bad odour during this visit.
“Where relatives had raised an issue such as 'the home can occasionally smell of urine.', we saw records which showed that the registered manager had acted on this by recruiting an additional housekeeper.” from the report
- 01How do you make sure there are enough staff each day for people's changing care and support needs?
- 02How are medicines competency checks kept up to date, and how do you investigate any medicines errors or missed doses?
- 03Who is responsible for managing the home when the registered manager is absent?
- 04How do you keep care plans updated when a person's health, risks, preferences or behaviour changes?
- 05What action would you take if a relative raised a concern about cleanliness or unpleasant smells?
This was a planned inspection of all five key questions and covered both the premises and the personal care provided; the report says the previous inspection had rated the service Requires Improvement. This explanation was written from the published report of 12 February 2020 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, January 2019
Rated Requires Improvement; inspectors found kind and responsive care, but recruitment checks and record keeping were not reliable enough.
Inspectors visited on 11 and 12 December 2018. The first day was unannounced and the second was announced. They spoke with people, relatives, staff and a healthcare professional. They also observed care and checked care records, staff files, rotas, audits and policies.
People were generally safe, and there were enough staff. Medicines were managed safely. However, five of 12 care staff recruited between June and December 2018 started before their DBS checks were completed. Some care records did not clearly show that planned checks, repositioning, fluid support or thickener instructions had been carried out.
The home was rated Good for Effective, Caring and Responsive. It was rated Requires Improvement for Safe and Well-led. The overall rating changed from Good at the previous inspection in October 2017 to Requires Improvement.
Kind, respectful care
Staff were described and observed as caring. They knew people's histories, preferences and needs, and protected privacy and dignity.
“People were supported by caring staff that were sensitive in manner and approach to their needs.” from the report
Safe medicines support
Medicines were stored safely, records had no gaps, and trained senior staff administered medicines.
“There were no gaps or omissions which indicated people received their medicines as prescribed.” from the report
Enough staff
The staffing levels matched people's needs. Inspectors saw staff available to provide support without appearing rushed.
“We observed that staff were visibly present and providing appropriate support and assistance when this was needed.” from the report
Personalised activities and care
Care plans included people's preferences and needs. Activities included group and individual options, with support to attend community activities.
“Activities were person centred.” from the report
Recruitment checks
seriousFive of 12 care staff recruited between June and December 2018 started before their DBS checks were completed. This was a breach of Regulation 19.
“Five started without being vetted through the Disclosure and Barring Service (DBS) before they started work.” from the report
Incomplete care records
needs fixingSome records did not show clearly whether planned repositioning, fluid support and thickener instructions had been completed. This made it difficult to confirm that care plans were being followed.
“This meant that comprehensive record keeping was lacking in some care records we looked at, which could be detrimental to people's needs.” from the report
Checks did not find problems
needs fixingThe home's audits did not identify the recruitment breach. The provider's systems also failed to ensure records were accurate, complete and consistent.
“The audit carried out did not identify the breach of Schedule 3 of the Health and Social Care Act.” from the report
- 01Have all staff now completed DBS checks before starting work, and how is this checked?
- 02How do you make sure daily records show that repositioning, fluid targets and thickener instructions have been followed?
- 03What action was taken in response to the two breaches, and what evidence can you show that it is complete?
- 04How often are care records audited, and what happens when a record is incomplete?
- 05How are families told about changes in a person's care needs or risks?
This was a comprehensive inspection covering all five CQC questions, carried out over two days, with the first day unannounced and the second announced. This explanation was written from the published report of 15 January 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 Sonya Lodge Dementia Residential Care Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Sonya Lodge Dementia Residential Care Home →
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Sonya Lodge Dementia Residential Care Home →
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 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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Most charge £980 to £1,260 a week. 33 can care for a couple. 12 years' experience on average.
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