CQC report explained · a residential care home
What the CQC found at Suffolk Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- The building safety work identified through inspections and risk assessments had been completed. Medicines were stored and administered safely, staff recruitment checks were in place, and people were protected from identified care risks.
- Effective?
- Good
- The environment had been improved to support people living with dementia and help them stay independent. Staff training and supervision were up to date, and people received support with food, drink and healthcare.
- Caring?
- Good
- Inspectors saw caring, friendly and respectful interactions. Staff knew people's wishes and preferences, and people's privacy, dignity, confidentiality and independence were supported.
- Responsive?
- Good
- Care was personalised and reviewed when people's needs changed. The home offered varied activities, supported contact with families and dealt with complaints promptly.
- Well-led?
- Good
- New audits and monitoring systems were found to be effective. Staff said they were supported by management, and actions identified through checks were dealt with promptly.
What inspectors found, September 2018
Suffolk Lodge was rated Good; inspectors found safe, kind and personalised care, with improvements made since the previous inspection.
The inspection was unannounced and took place on 4 and 5 September 2018. Inspectors spoke with people living at the home, a relative, staff and health and social care professionals. They observed care, activities and mealtimes, and checked care plans, medicines, recruitment records, training and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that earlier problems with building safety, medicine storage, dementia-friendly features and quality monitoring had been addressed.
People said they felt safe and staff knew them well. Inspectors found respectful care, personalised support, varied activities, suitable training and effective checks on the quality and safety of the home.
Building safety
Extensive work had been completed to address safety concerns involving the building, fire arrangements, lighting, doors and legionella risks.
“Extensive work had been completed on the safety of the building to complete all work identified in internal and external audits.” from the report
Dementia-friendly environment
The home had added clearer signs, improved lighting, better colour contrast and themed units. People helped decide how their living areas should look.
“The findings from the audit had been implemented, resulting in an environment that enhanced people's wellbeing and aided their independence.” from the report
Kind and respectful care
Inspectors saw staff treating people with kindness and respect. Staff understood people's preferences and supported their dignity and independence.
“People's wellbeing was protected and all interactions observed between staff and people living at the service were caring, friendly and respectful.” from the report
Activities and personal interests
There was a varied programme of activities, with choices for people who wanted group activities and one-to-one time for those who did not.
“People could choose what they wanted to do and were also able to try out new activities when identified.” from the report
Quality monitoring
The home had introduced audits and action plans covering areas such as medicines, care plans, cleanliness and health and safety.
“Various different checks and audits had been introduced and were effective in monitoring the quality of the service provision.” from the report
Some environmental work remained
minorThe dementia-friendly improvements were continuing. One unit still needed its themed decoration completed, and further bedroom and window dressing work was planned.
“The registered manager explained the work was ongoing with one unit still to complete their themed decoration.” from the report
- 01Has the themed decoration in the remaining unit now been completed?
- 02How are each person's communication needs recorded and shared with staff?
- 03How are medicine storage temperatures checked and what happens if they are outside the recommended range?
- 04How are care plans reviewed when a person's needs or preferences change?
- 05What activities are available for someone who does not want to join group activities?
This was an unannounced inspection of the overall service, including the premises and care, and all five CQC key questions were rated. This explanation was written from the published report of 22 September 2018 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, September 2017
Rated Requires Improvement; inspectors found kind, personalised care, but safety, the dementia-friendly environment and oversight were not good enough.
The inspection was unannounced and took place on 22 and 23 August 2017. Inspectors spoke with people, relatives, staff and health professionals. They observed care, meals and activities, and checked care plans, medicines, recruitment files, training records and safety documents.
The home was caring and responsive. Staff knew people well, treated them kindly, respected their privacy and supported personal choices. People received health care when needed, had food and drink choices, and relatives knew how to raise concerns.
The home was not always safe or well managed. Inspectors found delays in dealing with fire safety, building, garden and water-system risks. Medicines were generally given safely, but their storage temperatures were not monitored. The environment did not do enough to help people living with dementia find their way around or remain independent.
The overall rating Requires Improvement means the home was not consistently meeting the required standards at the time of this inspection. Three regulations were breached. The report says the provider had to send details of the action it would take, which CQC would check.
Kind and respectful staff
Inspectors saw friendly and respectful interactions. Staff protected privacy and dignity and asked before providing care.
“All interactions observed between staff and people living at the service were respectful and friendly.” from the report
Personalised care
Staff knew people's histories, preferences and abilities. Care plans were individual and updated when needs changed.
“People received care and support that was personalised to meet their individual needs.” from the report
Staff skills and support
Training, induction and supervision were in place. Staff said they had the support and knowledge needed to care for people.
“People received care and support from staff who knew them well and were well trained.” from the report
Food and health support
People could choose meals and snacks, and health professionals were involved when needed. Inspectors saw people enjoying their meals.
“People were able to choose their meals, which they chose a day in advance with staff support.” from the report
Fire and building safety
seriousFire safety work was incomplete. The report also describes a dangerous greenhouse, outstanding property work and a water-system risk that had not been dealt with.
“A Fire Safety Inspecting Officer visited the service in June 2017 and wrote to the provider in August 2017 stating that they were of the opinion that some people were at risk in case of fire.” from the report
Medicine storage
seriousMedicines were usually administered correctly, but the home did not monitor storage temperatures. This could affect whether medicines worked as intended.
“There was no system in place for monitoring the temperature that medicines were being stored at.” from the report
Dementia-friendly environment
seriousThe building did not provide enough help with orientation, sensory loss or independence. Problems included dim lighting, unclear signs, out-of-date noticeboards and limited access to gardens for people on the first floor.
“The environment did not help people maintain their independence.” from the report
Staff identification
minorStaff were not wearing name badges. Inspectors recommended looking at best practice because readable badges can help people living with dementia.
“We recommend the provider explores best practice guidelines on the use of name badges for staff working with people living with dementia.” from the report
- 01Have all the fire safety concerns identified by the Fire Safety Inspecting Officer now been completed, including fire detection in the loft and the fire doors?
- 02How do you now monitor medicine storage temperatures during hot weather and when heating is on?
- 03What changes have been made to improve lighting, signs, clocks, noticeboards and other dementia-friendly features?
- 04How do you make sure risks found in audits, including water-system and building risks, are followed up by a clear deadline?
- 05Has the manager's application to register with CQC been completed, and who has legal responsibility for managing the home now?
This was an unannounced inspection covering all five CQC questions, with observations, discussions and checks of care, medicines, staffing, training, records and safety documents. This explanation was written from the published report of 27 September 2017 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 Suffolk Lodge
4 rated inspections over 3 years: the service has held its Good rating throughout.
- September 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016Goodstayed GoodEffective: Good
- September 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 6 June 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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