CQC report explained · a residential care home
What the CQC found at St Denis Lodge Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2021
Inspected but not rated; inspectors found strong infection control, visiting arrangements and support for wellbeing.
This was an announced, targeted inspection on 2 February 2021. It focused on infection prevention and control during the coronavirus pandemic.
Inspectors found the home had controlled visiting arrangements, regular testing, social distancing, safe use of protective equipment and detailed infection control policies. They said the home was visibly clean and uncluttered.
The home was supporting people's mental wellbeing through individual activities and support for staff. People living there were reported to be free from Covid-19 at the time of the visit.
The service was inspected but not rated. This report does not give a new overall quality rating.
Controlled visits
Visits were arranged in advance, limited in time and supported by screening and a designated area with a full-height screen.
“Visits were by appointment and were time limited to reduce infection risks and enable thorough cleaning in between.” from the report
Clean environment
The home was clean and uncluttered. Cleaning included frequently touched areas, with management checks on infection control.
“The home was visibly clean throughout and uncluttered.” from the report
Testing and admissions
Residents and staff were tested regularly. New admissions and people staying for short periods were supported to isolate for 14 days.
“The home was regularly testing residents and staff in line with the government's testing programme.” from the report
Wellbeing support
Activities staff provided individual sessions in people's rooms, and staff were encouraged to seek help if they were struggling.
“Activities staff provided one to one sessions in people's rooms to ensure they had regular stimulation.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visits currently arranged, and what infection control checks are used before visitors enter?
- 02How often are residents and staff tested now, and what happens after a positive result?
- 03How would a new resident be supported to isolate safely?
- 04What activities and individual support are available for residents who cannot join group activities?
- 05How are high-touch areas such as handrails, door handles and light switches cleaned and checked?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide ratings for the other four questions or a new overall rating. This explanation was written from the published report of 12 February 2021 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 2020
Rated Good overall; inspectors found kind, safe care, but the home still needed improvement in how it was led.
This was an unannounced inspection on 5 and 6 December 2019. One inspector spoke with people living at the home, visitors, staff and a health professional. They also reviewed care records, medicines, staff files, training, policies and quality checks.
People said they were happy and felt safe. Inspectors found enough staff during the inspection, safe medicines management, kind staff, personalised support and good links with health professionals. People were supported to make choices and maintain their independence.
The main weakness was leadership and oversight. Some care plans, risk assessments and records about capacity and consent were still incomplete or not fully updated. The new manager had identified many of these issues and was making changes, but it was not yet clear whether the improvements would last.
The overall rating was Good. Safe, Effective, Caring and Responsive were each rated Good. Well-led remained Requires Improvement. The previous overall rating was Requires Improvement, so the overall service had improved, but the report said further improvement was needed.
Kind and respectful staff
Inspectors saw caring interactions. Staff knew people well, respected their dignity and supported them to make choices.
“People were supported by kind and caring staff who treated them equally and with respect.” from the report
Medicines managed safely
People received medicines on time and as required. Storage temperatures were checked, and guidance was available for medicines given when needed and for creams.
“People received their medicines on time and in line with their requirements.” from the report
Good health support
The home worked with health and social care professionals. Staff contacted professionals promptly when people's health declined and followed their guidance.
“Guidance from health professionals was followed by staff. Contact was always made promptly when a person's health declined.” from the report
Personal end of life planning
Although nobody was receiving end of life care during the inspection, people's wishes had been discussed and recorded in personal plans.
“End of life care plan information was personal and included what people wanted if they were very ill and what they wanted to happen after their death.” from the report
Improvements not yet proven to last
needs fixingThe provider's oversight had not identified some problems until recently. Inspectors could not yet be sure that the manager's planned and completed changes would continue.
“However, it was not yet clear whether changes already implemented or planned were sustainable.” from the report
Incomplete capacity and consent records
needs fixingSome records for people who lacked capacity did not show that decisions had been made in line with the law. Staff also had limited understanding of this area.
“Limited improvements were found at this inspection in relation to records for people who lacked capacity having decisions made in line with legislation.” from the report
One risk assessment was missing
seriousInspectors found that a heater provided to one person had not been covered by a risk assessment. The manager had identified the issue and was taking action.
“There was no risk assessment to mitigate risks the person could be harmed.” from the report
Some bathroom arrangements could affect privacy
minorSome en-suite bathroom doors faced bedroom doors. Inspectors said this could cause embarrassment if the doors were left open.
“However, some people's en-suite bathroom doors were opposite their bedroom doors which could lead to embarrassing situations if they forgot to shut the doors.” from the report
Activities were not fully inclusive
minorPeople had access to activities, but views differed about how inclusive some were. The new manager planned to adapt activities to people's changing needs.
“There were mixed opinions about how inclusive some activities were.” from the report
- 01What has been done since the inspection to complete and regularly review every person's care plan?
- 02How do you now record capacity and consent decisions, and what training have staff received about this?
- 03How are risks such as heaters and other equipment assessed and reviewed for each person?
- 04How do you check that the improvements made by the new manager are continuing?
- 05How have activities been changed to make sure they meet everyone's needs and wishes?
This was a planned, unannounced inspection based on the previous rating and covered all five CQC questions, including the premises and care provided. This explanation was written from the published report of 18 January 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.
Every inspection of St Denis Lodge Residential Home
4 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at St Denis Lodge Residential Home →
- January 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at St Denis Lodge Residential Home →
- December 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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