CQC report explained · a residential care home
What the CQC found at Stokeleigh Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found improved infection control, enough staff, safe medicines systems and risk assessments, although one staff member was not wearing a mask with their visor.
- Effective?
- Good
- This key question was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Quality checks and provider oversight had improved. Inspectors found an open culture, regular feedback from people and staff, and an action plan to address shortfalls.
What inspectors found, August 2021
Rated Good; inspectors found major improvements in safety, staffing and management, with one PPE shortfall corrected during the visit.
This was an announced focused inspection on 6 July 2021. One inspector spoke with people, staff and managers, observed care, and checked medicines, risk assessments, maintenance and quality records.
The home was rated Good overall. Safe and Well-led were also rated Good. Inspectors found better infection control, more staff, safer medicines systems and stronger checks on the quality of care.
The inspection followed a Requires Improvement rating and legal breaches found in February 2021. Inspectors said the home had made the required improvements and was no longer in breach.
This inspection only checked Safe and Well-led. The other key question ratings were carried forward from the earlier comprehensive inspection.
Improved infection control
Cleaning, PPE storage, laundry arrangements and visiting procedures had been improved. Inspectors said the risk of cross-contamination had been reduced.
“The risks from cross contamination had been reduced due to the effective changes that had been put in place.” from the report
More staffing
Staffing levels had increased, including domestic, catering and evening care support. People and staff said this had reduced pressure and provided enough staff to meet needs.
“Since the last inspection the provider had increased staffing levels at the home. This helped to ease the pressure on the care staff.” from the report
Medicines managed safely
People received medicines as prescribed. Inspectors saw staff following medicines records, and records were complete.
“We observed staff administering medicines to people in line with their medicine's records.” from the report
Stronger management checks
Audits had become more detailed and actions were recorded to deal with shortfalls. The provider was visiting and checking the home more regularly.
“Since the last inspection quality assurance monitoring and audits had improved with shortfalls identified addressed.” from the report
People involved
People could give feedback through meetings and care reviews. The home was also involving people in decisions about a garden project.
“The home actively engaged people to ensure they had a say in the running of the home.” from the report
PPE was not fully correct
needs fixingInspectors saw one staff member wearing a visor but not a mask. Managers acted promptly when this was raised, but the report said the provider was only somewhat assured that PPE was being used safely.
“We were somewhat assured that the provider was using PPE effectively and safely. This was because we observed one staff member wearing a visor and not a mask.” from the report
Building work was still planned
minorThe hallway needed redecorating and its carpets needed replacing. The report said this work was planned for the end of summer, but it does not confirm whether it was completed.
“An example of this includes that it had been identified the hallway was in need of redecoration and carpets replacing.” from the report
- 01How do you check that all staff use masks and other PPE correctly?
- 02Have the hallway redecoration and carpet replacement been completed, and if not, when will they be done?
- 03How are the increased staffing levels being maintained?
- 04What changes have been made to care records to make them more focused on people's outcomes?
- 05How can relatives receive feedback from care reviews and residents' meetings?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 21 August 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, March 2021
Requires Improvement; inspectors found serious infection control and staffing shortfalls, although medicines and safeguarding were managed safely.
This was an unannounced inspection on 15 February 2021. Two inspectors observed care, spoke with staff and the registered manager, and reviewed records and policies. A video meeting took place afterwards to gather more evidence.
The home was not consistently safe. Inspectors found problems with infection control, cleaning, repairs, laundry arrangements and the storage of protective equipment. They were also not satisfied that there were enough staff to keep people safe and support their choices.
Medicines were managed safely, staff recruitment checks were completed, and safeguarding processes were in place. However, quality checks had not identified or dealt with important problems. The overall rating fell from Good at the previous inspection in February 2018 to Requires Improvement.
Medicines
Medicines were managed safely. Staff administering medicines had completed competency checks and received regular updates.
“Policies, procedures, records and practices demonstrated medicines were managed safely.” from the report
Safeguarding
Staff understood how to raise concerns about possible abuse and knew which agencies might need to be notified.
“Staff understood the processes to follow to safeguard people in their care.” from the report
Teamwork
Inspectors found good relationships and a staff group that worked well together. Managers were described as caring, kind and respectful.
“They were a good, cohesive group who worked well as a team.” from the report
Emergency planning
People had individual fire risk assessments and emergency plans were up to date.
“Up to date emergency plans were in place to ensure people were supported in the event of a fire.” from the report
Infection control
seriousProtective equipment was not stored safely, some furnishings and equipment could not be cleaned effectively, and laundry arrangements increased the risk of cross-infection. These problems meant people were not consistently protected from infection.
“We could not be satisfied that people were protected by the home's infection prevention and control measures.” from the report
Staffing levels
seriousCare staff were also expected to clean and do laundry. Inspectors were not satisfied that staffing levels were enough to meet people's needs, support their choices or respond to people who became seriously unwell.
“We could not be satisfied people were supported by enough staff.” from the report
Quality monitoring
seriousThe home's audits and oversight had not identified obvious shortfalls or dealt with some required actions promptly, including problems with the environment.
“Systems for monitoring the quality of the service and ensuring people and staff were kept safe were not always robust and had not identified obvious short falls in practice.” from the report
Cleanliness and repairs
needs fixingSome equipment and fixtures were damaged and could not be cleaned properly. Rust was exposed where plastic coating had peeled away.
“In some areas the interior fixtures, fittings and furnishings were not in good physical repair and could not be effectively cleaned.” from the report
- 01What has been changed about the storage of PPE, visiting arrangements and laundry facilities since the inspection?
- 02How many care staff and domestic staff are on duty at different times, and how is this adjusted when residents' needs increase?
- 03What repairs have been completed to equipment and furnishings that inspectors said could not be cleaned effectively?
- 04What actions were included in the provider's action plan, and which have now been completed?
- 05How are audits now checking infection control, staffing levels and the cleanliness and repair of the home?
This was a focused inspection of Safe and Well-led, mainly examining infection control and staffing concerns; the other key question ratings were not given in this report. This explanation was written from the published report of 20 March 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.
Every inspection of Stokeleigh Lodge
4 rated inspections over 6 years: the service has held its Good rating throughout.
- August 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2018Goodstayed GoodSafe: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 10 May 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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