CQC report explained · a nursing home
What the CQC found at South Haven Lodge 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, February 2023
Requires Improvement; inspectors found progress, but medicines, repositioning records and quality checks were still not reliable.
This was an unannounced focused inspection. An inspector visited on 7 December 2022, 3 January 2023 and 4 January 2023. The inspection looked mainly at safety and how the home was managed.
There had been improvements since the last inspection, including staff recruitment, equipment checks and the management structure. Families and visitors gave positive feedback about the staff team and the cleanliness of the home.
Important problems remained. Medicine records did not match the medicines in stock. Records about repositioning people were inconsistent, and some people were not repositioned on time. The home’s checks had not found these problems, and there was no formal system for gathering feedback from people or relatives.
The overall rating was Requires Improvement. Safe improved from Inadequate to Requires Improvement, while Well-led remained Requires Improvement. The home was still in breach of regulations and must send CQC an action plan.
Improving staff team
Recruitment checks had improved and the home had a more stable nursing team. Relatives and visitors spoke positively about staff.
“Feedback from relatives and visitors was positive about the staff team.” from the report
Equipment checks
Hoists and other equipment were serviced and maintained. Pressure-relieving mattress settings were checked and recorded.
“Equipment such as hoists were serviced and maintained appropriately.” from the report
Clean and infection-aware
Inspectors were assured about infection prevention, including the use of protective equipment and the cleanliness of the home.
“We were assured that the provider was using personal protective equipment effectively and safely.” from the report
Incident learning
The manager investigated accidents and incidents and looked for trends and lessons. Changes had been made to include skin checks in assessments.
“This included analysing incidents to identify trends, actions and learning.” from the report
Medicine records
seriousMedicine records did not match the stock held in the home. Some as-needed medicines did not have clear protocols, creating a risk that medicines might not be given safely or consistently.
“The failure to ensure the proper and safe management of medicines was a repeated breach of regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Repositioning people
seriousCare plans and computer records sometimes gave different repositioning times. Records showed that people were sometimes repositioned one or two hours late, or longer.
“Sometimes, people were not supported to reposition for longer which meant their skin may be at risk of injury.” from the report
Weak quality checks
needs fixingThe home’s audits had not identified the medicine and repositioning problems. Governance systems had improved but were not yet reliable or fully embedded.
“Whilst the governance systems had improved since the last inspection, these were not robust or fully embedded.” from the report
Consent and privacy records
needs fixingPhotographs of people had been posted on social media without valid consent recorded. Records also did not show consent or best-interest decisions for some sensor mats.
“South Haven Lodge had its own public social media page which contained photographs and names of people living in the home.” from the report
Limited resident and family feedback
needs fixingThere was no formal system for gathering feedback from people or relatives, and planned residents’ meetings had not taken place.
“There was not a formal system in place to seek and receive feedback from people or their relatives.” from the report
- 01How will you make sure medicine records match the stock held, including medicines prescribed for severe pain or anxiety?
- 02How will you make sure each person’s repositioning schedule is clear, accurate and followed on time?
- 03What checks will now identify missed repositioning and medicine-record problems before they put people at risk?
- 04When will residents’ meetings and a formal feedback system for relatives begin?
- 05What consent or best-interest records are now in place for social media photographs and sensor mats?
This was a focused inspection of Safe and Well-led; the other key questions were not inspected and their previous ratings carried over. 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.
What inspectors found, January 2022
South Haven Lodge Care Home was rated Requires Improvement, with Safe rated Inadequate because people faced avoidable risks, medicine errors and weak oversight.
This was an unannounced inspection on 4 November and 1 December 2021. Inspectors first looked at concerns about safety and staffing, then extended the visit to Safe and Well-led. They spoke with staff and management, observed people, and checked care plans, medicines, recruitment and management records.
Inspectors found that risks were not always properly reduced. Staff did not always follow guidance, an untrained staff member helped with a hoist transfer and a person slipped, some skin concerns were not reported, and people did not always receive medicines as prescribed. Staffing was also a concern, with agency use and some shifts having only one nurse when two were expected.
Management and record keeping were not reliable. Some records were incomplete or unsecured, audits had not always been completed, and the home had not sought feedback from people, relatives, staff or professionals during the year. There was no registered manager at the time, although the new manager had started making some changes.
The overall rating stayed at Requires Improvement, as it had at the previous inspection. Safe fell from Requires Improvement to Inadequate. Well-led remained Requires Improvement. The other three areas were not inspected, so their previous ratings were used.
Infection control
Inspectors were assured that infection prevention arrangements covered visitors, personal protective equipment, testing, social distancing and outbreak management.
“We were assured that the provider was using personal protective equipment effectively and safely.” from the report
Safeguarding awareness
Staff had safeguarding training and could explain the types of abuse and what they would do if they had concerns.
“Staff had completed safeguarding training; they were aware of the different types of abuse and told us what they would do if they suspected abuse or had concerns.” from the report
Respectful interactions
Inspectors saw staff respond to people's needs and treat them respectfully. They also saw medicines being given without rushing.
“We saw staff interacting pleasantly with people and responding to their needs.” from the report
Early management action
The new manager had started making changes, including improving handovers and giving some people's care to the home's own staff for more consistent oversight.
“Since arriving at the home, the manager had made improvements in response to incidents and accidents.” from the report
People were put at risk
seriousRisk assessments did not clearly set out how risks would be reduced. An untrained staff member helped with a hoist transfer and the person slipped out, creating a risk of serious injury.
“New staff had not completed moving and handling training which meant they should not support people to move, for example, using a hoist.” from the report
Medicines were not always safe
seriousPeople did not always receive the prescribed dose. Stock records were incomplete, including a missed dose and an occasion when a full seizure-prevention dose was not given.
“People had not always received their medicines as prescribed, which put them at risk.” from the report
Staffing and recruitment
seriousThe home relied on agency staff, and staff said people sometimes waited too long for morning personal care. Recruitment files also lacked some required employment information.
“However, we found there was only one nurse on duty for the whole home on nine days.” from the report
Incomplete records
needs fixingFluid, food, bowel and equipment records were not always complete or accurate. An unlocked cupboard also contained old medicines and continence records until inspectors raised the issue again.
“Some records were not accurate or complete and some were not kept securely.” from the report
Weak quality oversight
needs fixingMonthly audits had not been kept up, and the home had not properly asked people, relatives, staff or professionals for feedback or acted on it.
“Feedback on the provision of care had not been sought from people, their relatives, staff or professionals this year.” from the report
- 01What has been done to ensure every person's risks are clearly assessed, with clear instructions that staff follow?
- 02How do you now check that all staff supporting hoist transfers and specialist equipment are trained and competent?
- 03What checks ensure medicines are counted, recorded and given in the correct prescribed doses?
- 04How have staffing levels and agency staff oversight changed, especially on shifts that previously had only one nurse?
- 05How are records, monthly audits and feedback from residents and relatives now being completed, reviewed and acted on?
This was a targeted inspection that became focused on Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 13 January 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 South Haven Lodge Care Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Requires improvementstayed Requires improvementSafe: InadequateWell-led: Requires improvement
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2020Goodstayed GoodSafe: GoodWell-led: Good
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- January 2011
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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