CQC report explained · a residential care home
What the CQC found at Syston Lodge Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks were not always assessed or clearly recorded, and some care plans lacked enough guidance for staff. Inspectors also found that medicines were generally administered safely, with a problem noted about occasional fridge temperature readings.
- Effective?
- Good
- This question was not inspected during this focused visit. The report says the ratings for questions not inspected were carried forward from the last inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. The report says the ratings for questions not inspected were carried forward from the last inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. The report says the ratings for questions not inspected were carried forward from the last inspection.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify missing risk assessments, conflicting care plan information or gaps in staff records. The report says this failure was a breach of the good governance regulation.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found safe staffing and medicines support, but care records, risk assessments and oversight were not reliable enough.
This was an unannounced focused inspection on 13 September 2022. Inspectors reviewed Safe and Well-led because concerns had been raised about medicines management and a serious injury. They spoke with people, a relative, staff and a health professional, and checked care records, medicines records, recruitment files and management records.
People generally felt safe. Staff knew people well, there were enough staff, safeguarding procedures were understood, medicines were mostly managed safely and infection control measures were in place. However, risk assessments and care records were not always complete or consistent. This meant staff did not always have clear written guidance about people's needs and risks.
The home was rated Requires Improvement overall. Safe changed from Good to Requires Improvement, while Well-led remained Requires Improvement. The other three question ratings were not inspected during this visit and were carried forward from the previous inspection. The regulator required an action plan and said it would continue to monitor the service.
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding responsibilities and referrals had been made when needed.
“People felt safe living at Syston Lodge and staff understood their responsibilities in safeguarding people from the risk of abuse.” from the report
Enough regular staff
There were enough staff to meet people's needs. Many staff had worked at the home for a long time and knew people well.
“People were supported by regular staff who knew them well.” from the report
Medicines support
Medicines were administered by trained staff who understood what they were for. The provider had also made improvements after a recent incident.
“Medicines were administered by trained staff. Staff had good knowledge of what medicines were for and why people were taking them.” from the report
Person-centred culture
Inspectors found that staff supported people in an enabling and inclusive way, including during distress and end of life care.
“The registered manager promoted a culture which was person centred and empowering.” from the report
Incomplete risk assessments
seriousSome risks were not assessed or did not have clear instructions for staff. One care plan did not give robust guidance about how to respond when a person became distressed.
“Risks were not consistently assessed and measures to reduce risks were not always clearly recorded in people's care plans.” from the report
Weak quality checks
seriousThe home's audits did not find important gaps in risk assessments, care plans and care records. This was the subject of a regulatory breach.
“The failure to have a robust approach to monitoring the quality of care was a breach of regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Inconsistent care records
needs fixingRecords sometimes conflicted or did not show clearly what care and treatment a person was receiving. Staff recordings were also not consistent.
“Care records were not consistently completed by staff which meant there was no clear audit trail on the care and treatment the person was currently receiving.” from the report
Medicine fridge temperatures
needs fixingSome recorded fridge temperatures went above the maximum required for medicines to remain safe and effective. Inspectors asked the registered manager to review this.
“Temperature monitoring records showed occasional variations in fridge temperatures that exceeded the maximum temperature required to ensure medicines remained safe and effective.” from the report
- 01What actions are in the current improvement plan to fix incomplete or conflicting care records?
- 02How do you make sure risk assessments are updated and give staff clear instructions when someone becomes distressed or has a known risk?
- 03How are medicine fridge temperatures checked now, and what happens if a reading is outside the required range?
- 04How do you check that your audits identify gaps in care plans, risk assessments and staff recordings?
- 05What changes have been made since the recent medicines incident, and how do you know those changes are working?
This was a focused inspection of Safe and Well-led only; the other three question ratings were carried forward from the previous inspection. This explanation was written from the published report of 27 October 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.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection control, visiting arrangements and support during COVID-19 pressures.
This was a targeted inspection on 26 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected people.
Inspectors were assured that the home was using protective equipment safely, arranging testing, following distancing and shielding rules, and managing visits. They also found checks for visitors and staff when they arrived.
The home was inspected but not rated. This means the visit did not provide an overall Good, Requires improvement or Inadequate rating.
Infection control
Inspectors were assured that the home had measures covering visitors, distancing, protective equipment, testing, hygiene and outbreak management.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Safe visiting
The home followed current guidance for visits and carried out checks on visitors and staff when they arrived.
“We were assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Keeping people connected
People could stay in touch with friends and relatives through visits, video calls, phone calls, letters and messages sent through an application.
“Syston Lodge Residential Home supported people who lived there to remain connected with friends and relatives through visits, video calls, phone calls and letters.” from the report
Support from primary care
The home reported regular visits and good support from its GP practice.
“Syston Lodge Residential Home felt well supported by their GP practice who visited the home regularly.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now, including testing, protective equipment and outbreak management?
- 02How are visitors checked and supported to visit residents safely?
- 03How would COVID-19-related staff shortages affect staffing levels and people’s care?
- 04How can residents keep in touch with relatives if visiting becomes difficult?
- 05How often does the GP practice visit, and how is medical information shared with families?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other areas of care. This explanation was written from the published report of 12 February 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 Syston Lodge Residential Home
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Syston Lodge Residential Home →
- February 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Syston Lodge Residential Home →
- July 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 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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