CQC report explained · a residential care home
What the CQC found at The Lawns Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People generally received medicines as prescribed and risks were assessed and managed. However, some guidance and records for medicines and creams were incomplete or unclear.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous comprehensive inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous comprehensive inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous comprehensive inspection.
- Well-led?
- Good
- Management oversight and quality systems had improved, and the culture was more positive. Audits had not identified every issue, so medicine and care-record checks needed further development.
What inspectors found, October 2022
Rated Good overall; inspectors found major improvements, but safe care still Requires Improvement because some medicine records were incomplete.
This was an unannounced focused inspection. Inspectors visited on 17 August 2022 and spoke with people living in the home, relatives, staff and professionals. They also checked care records, medicine records, recruitment files and management documents.
The home had improved greatly since the previous inspection. People were supported by enough staff, risks were managed, infection control had improved and people told inspectors they felt safe. The atmosphere was more positive, and relatives and professionals spoke positively about the management.
Safe care was rated Requires Improvement. Medicines were generally managed safely, but guidance and records for creams, 'when required' medicines and variable-dose medicines were not always clear or complete. The home was given recommendations about medicine records and quality audits.
Well-led was rated Good. The overall rating changed from Inadequate to Good, and the home was no longer in Special Measures. However, this inspection only checked Safe and Well-led. The other key-question ratings used for the overall rating came from the previous comprehensive inspection.
Improved safety
Risks were assessed and monitored. Staff had current information through risk assessments and daily handovers, and fire safety procedures had improved.
“Staff appropriately assessed, monitored and managed risks to people.” from the report
Enough staff
Inspectors found enough staff to provide safe care. Recruitment checks were in place, although the home was still recruiting permanent staff and using some agency staff.
“There were enough staff to provide safe care to people.” from the report
Cleaner environment
The home had made significant improvements to infection prevention, cleanliness and maintenance. Inspectors were assured that infection risks were being managed.
“An effective infection control system was in place. Significant improvements had been made in this area.” from the report
More positive culture
Staff morale and the atmosphere had improved. Relatives, staff and professionals described the manager as approachable, supportive and responsive.
“The provider and manager had worked hard to change the culture within the service and had created a positive, welcoming and friendly atmosphere.” from the report
Good communication
Relatives were kept informed, people took part in meetings and the home worked more effectively with healthcare professionals.
“Relatives told us communication was good and they were kept informed.” from the report
Medicine records
needs fixingRecords for creams and lotions were not always complete. Guidance for medicines taken when needed and medicines with a variable dose was sometimes inconsistent or lacked detail.
“Some further improvements were needed within the guidance and records around the administration of creams, 'when required' medicines, and medicines with a variable dose.” from the report
Quality checks
needs fixingAudits did not identify all the issues inspectors found. The home needed to improve its checks of care records and medicine records.
“Audits had identified some, but not all, of the concerns we found.” from the report
Understanding high-calorie drinks
needs fixingSome care workers did not clearly understand how to provide high-calorie drinks. The manager addressed this immediately after inspectors raised it.
“Some care workers did not have a clear understanding about providing high calorie drinks to people throughout the day.” from the report
- 01How do you now check that records for creams, 'when required' medicines and variable-dose medicines are complete and clear?
- 02How often are care records and medicine records audited, and how do you make sure audit findings lead to action?
- 03How do you keep care plans up to date when a person's needs or risks change?
- 04What training and checks do staff receive about providing high-calorie drinks?
- 05How much agency staff are currently being used, and what is the plan for recruiting permanent staff?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key-question ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 6 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, April 2022
The Lawns Care Home was rated Inadequate and placed in special measures after inspectors found serious problems with medicines, risks, staffing and leadership.
This was an unannounced focused inspection on 16 and 17 February 2022. Inspectors looked at Safe and Well-led because of concerns about medicines, cleanliness and safeguarding. They spoke with people, relatives and staff, and checked care records, medicine records, recruitment files and management documents.
The inspectors found that medicines were not safely managed or always given as prescribed. Risks, nutrition and hydration were not managed well. Some areas were dirty, staffing was not always suitable, and checks on agency staff were incomplete. Care records were not always accurate or up to date, and the provider's quality checks had failed to identify or resolve problems.
The service was rated Inadequate overall, with Safe and Well-led both rated Inadequate. This was a fall from the previous overall rating of Good. The other three key questions were not inspected during this visit, so their previous ratings were used in calculating the overall rating.
The provider put an action plan in place immediately after the inspection and arranged extra support for the service. However, the report says the home was in special measures and would be re-inspected to check for significant improvement.
Kind staff
People said they felt safe and liked the staff. Relatives also gave positive feedback about the care and staff attitude.
“I like the staff. They are kind and caring” from the report
Action after inspection
The provider and acting manager responded quickly to the inspectors' feedback and put an action plan in place. Extra management support was arranged.
“The provider immediately prepared and implemented a robust action plan.” from the report
Infection precautions
Visitors were screened, PPE was available, and people and staff took part in regular COVID-19 testing. Visiting arrangements followed government guidance.
“Visitors to the service were appropriately screened for COVID-19.” from the report
Medicines
seriousTablets were found on floors, medicines were not always stored correctly, and some medicines were not available or were not given as prescribed. This created a risk of harm.
“Medicines were not safely managed and were not administered as prescribed.” from the report
Risks and nutrition
seriousSome health risks, dietary needs and fluid intake were not properly recorded or managed. Staff did not always know people's current needs, and action was not taken when people did not drink enough.
“Nutrition and hydration were not safely managed. This placed people at risk of harm.” from the report
Staffing and recruitment
seriousStaff were not always present where they should have been, and people, relatives and staff said there were not enough care workers. Agency staff records, training records and DBS checks were incomplete.
“Staffing was not always suitable to support people's needs.” from the report
Cleanliness
seriousSeveral areas needed deep cleaning, carpets and flooring were damaged, and cleaning schedules had significant gaps. Extra cleaning was arranged after inspectors raised the concern.
“The service was not clean.” from the report
Weak oversight
seriousAudits missed problems or did not ensure they were fixed. Care records were sometimes inaccurate or out of date, and the provider's oversight was not effective.
“The provider did not have appropriate or effective oversight of the service.” from the report
Delayed professional referrals
needs fixingHealthcare professionals were not always contacted promptly. The report gives an example involving multiple falls and delayed support.
“Referrals to healthcare professionals were not always made in a timely manner.” from the report
- 01What evidence can you show that medicines are now stored, recorded and given safely, including 'when required' medicines?
- 02How do you now monitor people's food, drinks and special diets, and what action is taken if someone does not meet their fluid target?
- 03How many care workers will be on duty in each unit, and how do you make sure no unit is left without staff?
- 04How do you check that agency staff have completed required training and have suitable DBS checks before working here?
- 05What changes have been made to audits, care records and management oversight since the inspection?
This was an unannounced focused inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous inspection. This explanation was written from the published report of 14 April 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 The Lawns Care Home
4 rated inspections over 5 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2022InadequateSafe: InadequateWell-led: Inadequate
- November 2020Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: Requires improvementWell-led: Good
- June 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 23 May 2016.
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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