CQC report explained · a residential care home
What the CQC found at Spencers Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2020
Rated Requires Improvement overall; inspectors found safe and well-led care, with improvements since the last inspection.
This was a focused inspection over three days in September 2020. The inspector spoke with six people, three relatives, three staff members and the registered manager. Records about care, medicines, incidents and how the home was managed were also checked.
The home was rated Good for Safe and Good for Well-led. Inspectors found better systems for recording and learning from incidents, safe medicines arrangements, enough staff and suitable infection control during the Covid-19 pandemic. People and relatives said they felt safe and supported.
The overall rating stayed Requires Improvement because this inspection only looked at Safe and Well-led. Ratings for the other areas came from the previous comprehensive inspection. The home had improved since the last inspection and was no longer in breach of regulations.
People felt safe
People and relatives told inspectors that the home was safe. Staff understood how to recognise and report possible abuse.
“People who lived at Spencers Lodge told us they felt safe living there.” from the report
Better incident systems
The home had improved how it recorded and reviewed incidents. The manager used this information to reduce the chance of similar events happening again.
“The registered manager regularly analysed incident records.” from the report
Safe medicines support
Medicines records showed that medicines and homely remedies were managed safely. People said they received medicines when they were due and in their preferred ways.
“Medicine administration records showed homely remedies were now managed in an appropriate and safe way.” from the report
Good involvement
People and relatives were involved in care planning and reviews. People said staff listened to their concerns and wishes.
“People and their relatives were involved with planning and reviewing their support.” from the report
Campus setting
minorThe home is larger than recommended by best practice guidance and is on a campus with other services. Inspectors said the provider had taken steps to reduce the possible effect on person-centred care.
“The service is larger than recommended by best practice guidance and is situated on a campus style setting with four other homes and the provider's adult skills service.” from the report
Further person-centred work
needs fixingThe home's action plan still included work to develop person-centred approaches to care and support. Ask what progress has been made since the inspection.
“One action point was to further develop person-centred approaches to care and support.” from the report
- 01What are the current ratings for Effective, Caring and Responsive, which were not assessed in this inspection?
- 02What actions have been completed to further develop person-centred approaches to care and support?
- 03How do people have control, choice and independence while living in the campus setting?
- 04How are incidents reviewed now, and how do you show that lessons have been put into practice?
- 05What infection control arrangements remain in place, and how are people supported to understand them?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 2 October 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, October 2019
Rated Requires Improvement; inspectors found kind staff and positive activities, but gaps in safety, dignity, care records and management.
Inspectors visited on 3 September 2019 and spoke with people living at the home, relatives and staff. They reviewed care records, medicine records, staff files and management records.
People generally said they felt safe and that staff were kind. Staff supported people with health care, activities, education, work opportunities and personal relationships. However, inspectors found that accidents and incidents were not always properly recorded, investigated or reviewed.
Care plans did not always reflect people's current needs. Some people did not receive all their additional one-to-one support hours. Inspectors also found concerns about dignity, complaints, infection control, nutrition and the condition of the building.
All five areas were rated Requires Improvement. This means care and management were inconsistent, and inspectors had limited assurance that people were always safe and well supported. The rating had fallen from Good at the previous inspection in 2016.
People felt safe
People using the service and relatives generally said they felt safe at the home. Staff had safeguarding training and understood their responsibilities.
“People who used the service felt safe. Staff received safeguarding training and understood their responsibilities around this.” from the report
Kind relationships
Inspectors saw positive interactions between staff and people. People and relatives described staff as kind, caring and helpful.
“We observed positive interaction between staff and people who used the service.” from the report
Health support
Staff worked with health and social care professionals. Records showed people's health appointments and support were recorded in medical action plans.
“People who used the service had been supported to access on going health.” from the report
Activities and opportunities
People had access to education, work experience, holidays, trips and personal interests. Several people attended courses on the campus.
“People were encouraged to seek education opportunities.” from the report
Accessible communication
The home used easy-read information, pictures and larger print. Staff also used Makaton with one person to support communication and choice.
“The service provided people with easy read versions of policies and information guides to enable them to have access to organisation information.” from the report
Accidents and safeguarding were not reliably reviewed
seriousSome incidents were only recorded in daily notes, so the manager could not identify patterns or take action. Staff did not always recognise safeguarding concerns, creating an increased risk of harm.
“The registered persons had failed to record, investigate and analyse accidents and incidents to enable them to minimise the risk of them happening again.” from the report
Risks were not fully documented
seriousPeople were supported to take positive risks, but care plans did not always explain how those risks were managed. There were also no clear checks that one person had returned safely after going out alone.
“However, these risks were not fully documented in people's care plans and so we could not be sure that people's safety was maintained.” from the report
Care plans and support hours
needs fixingCare plans did not always contain enough information about current needs. People who had been allocated extra one-to-one hours did not always receive them.
“People allocated additional support hours on a one to one basis, did not always receive the full hours.” from the report
Dignity and privacy
needs fixingInspectors saw one person's dignity was not protected while they walked from the shower room to their bedroom. The position of the bathroom also meant people could pass large windows and glass doors after bathing.
“During inspection, we observed one person's dignity not being protected.” from the report
Complaints were not always resolved
needs fixingThe complaints process was available in easy-read form, but it was not always followed for relatives' complaints. Inspectors did not see action plans showing how complaints would improve care.
“However, complaints had been received from relatives and we found that the organisation's complaints policy and procedures had not always been followed.” from the report
Weak quality checks
seriousInternal audits identified problems, but similar problems remained after actions were marked complete. Weekly checks were not completed consistently, and some events were not reported to CQC.
“We found systems and processes were not effective at identifying concerns and driving improvement in the service.” from the report
- 01What changes have you made to record, investigate and analyse accidents, incidents and safeguarding concerns?
- 02How do you now make sure each person's care plan reflects their current needs and risk arrangements?
- 03How do you record and monitor people's additional one-to-one support hours to ensure they receive them?
- 04How are relatives' complaints now investigated, answered and turned into action plans?
- 05What checks are now in place to make sure audits identify problems and that completed actions have really fixed them?
This was a planned inspection covering all five CQC questions; all five ratings had fallen from Good at the previous inspection in 2016. This explanation was written from the published report of 23 October 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 Spencers Lodge
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- October 2020Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- October 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 15 November 2010.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.