CQC report explained · a residential care home
What the CQC found at The Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm. Fire safety, risk management, staffing, infection control and medicines administration had improved, although some medicines records were incomplete.
- Effective?
- Requires improvement
- This area was not inspected during this focused visit. The previous rating was used to calculate the overall rating.
- Caring?
- Requires improvement
- This area was not inspected during this focused visit. The previous rating was used to calculate the overall rating.
- Responsive?
- Requires improvement
- This area was not inspected during this focused visit. The previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found stronger management oversight, better monitoring and a positive, caring culture. They recommended regular reviews of quality checks because the audit had missed medicines issues.
What inspectors found, February 2023
Rated Requires Improvement; inspectors found safer, kinder care and stronger leadership, but medicines records and quality checks still needed attention.
This was an unannounced focused inspection on 24 and 27 January 2023. One inspector spoke with people, relatives and staff, observed care, looked around the home, and checked care, medicines, staffing and management records.
The inspectors found improvements in safety and leadership. Fire safety work had been completed, risks were better managed, staffing was sufficient, and people were protected from abuse. Medicines were usually given safely, but some records and instructions were not fully accurate.
The home had a caring culture and people, relatives and professionals gave positive feedback about the new management team. Systems for checking quality had improved, although they did not identify the medicines problems before the inspection.
The overall rating stayed Requires Improvement. Safe and well-led were rated Good. The other three areas were not inspected, so their previous ratings were used in calculating the overall rating.
Improved safety
Fire safety work had been completed and systems were in place to manage risks to people's safety and wellbeing.
“The provider ensured the safety of the building and equipment through the completion of required fire safety work, regular maintenance and servicing.” from the report
Caring culture
Inspectors found a person-centred culture, with staff described as caring and passionate. Relatives also reported positive experiences.
“There was a person-centred, caring culture which had a beneficial impact on people's wellbeing.” from the report
Enough staff
The inspectors found enough staff to keep people safe and meet their needs on time. Staff had induction and regular training.
“There were sufficient numbers of staff to keep people safe and to meet their needs in a timely manner.” from the report
Stronger management
The new management team had improved oversight and used an action plan to address problems.
“The provider had improved their oversight of the service through changes to the management team and increased monitoring which had helped to improve the safety and quality of the service provided.” from the report
Medicine records
needs fixingControlled Drugs records were not always complete. One person's prescribed cream was also used more often than prescribed on a couple of occasions, although the GP confirmed there was no harm.
“Records for Controlled Drugs were not always fully completed.” from the report
Quality checks missed medicine issues
needs fixingThe home's audit system had improved but did not identify the medicines problems found by inspectors. The provider was asked to review its quality assurance systems regularly.
“However, it had not identified the issues we found with medicines.” from the report
No registered manager in post
minorA manager was in place and had started the registration process, but the home did not have a registered manager at the time of inspection.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are Controlled Drugs records checked to make sure they are complete?
- 02What changes have been made to prevent prescribed creams or other medicines being given more often than directed?
- 03How do your quality audits now make sure they identify medicines problems promptly?
- 04Has the manager completed the registration process with the CQC?
- 05What were the previous ratings for Effective, Caring and Responsive, which were not inspected during this visit?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 25 February 2023 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, August 2022
Rated Requires Improvement; inspectors found unsafe medicines and risk controls, and rated leadership Inadequate.
This was an unannounced focused inspection on 23 and 31 May 2022. Inspectors looked mainly at safety and leadership. They spoke with people, relatives and staff, observed care, checked the home and reviewed care, medicine, recruitment and management records.
The home was not always safe. Fire safety actions were overdue, some personal emergency evacuation plans were missing, care risk records were not always current, infection control was inconsistent and medicines were not always given safely or as prescribed. Inspectors found no evidence that anyone had been harmed, but they said people were at risk.
Leadership was rated Inadequate. Quality checks had repeatedly failed to find or correct problems with safety, medicines, infection control and records. The overall rating remains Requires Improvement, and the service had not reached Good in its last seven consecutive inspections.
Safe recruitment and staffing
Recruitment checks were completed and staffing levels were monitored. Staff supported people promptly.
“The provider's recruitment processes were safe. Recruitment checks and regular staff checks helped to ensure only suitable staff were employed at the service.” from the report
Kind staff
Inspectors saw positive interactions. People and relatives mostly gave positive feedback about the care.
“Staff were kind and caring and interacted positively with people.” from the report
Safeguarding awareness
Staff understood how to recognise and report abuse. Concerns had been shared with the local authority safeguarding team.
“Staff understood how to recognise signs of abuse and knew how to report concerns internally and externally.” from the report
Respect for choice
Inspectors found that the home was working within the principles of the Mental Capacity Act, with appropriate legal authorisations where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Fire and care risks
seriousSome fire safety actions had not been completed promptly. Missing evacuation plans and out-of-date care records meant people might not receive the right support in an emergency or with health risks.
“Personal emergency evacuation plans (PEEPs) were not always in place which placed people at risk of not receiving appropriate support in an emergency.” from the report
Medicines
seriousSome medicines were out of date, given late or not administered according to their instructions. Storage and records were also not always safe or complete.
“People's medicines were not always administered as prescribed. One person was prescribed a pain relief patch which was to be changed every 72 hours.” from the report
Infection control
seriousSome areas and equipment were dirty. Inspectors also saw incorrect mask use, poor hand hygiene and missing hand-washing supplies.
“Staff did not always wear personal protective equipment (PPE) effectively. On both days of the inspection we observed several staff not wearing face masks appropriately.” from the report
Weak leadership and checks
seriousThe provider's checks did not identify or fix repeated problems. Important records were incomplete, and the provider had not sent the required improvement action plan.
“Quality assurance systems had not identified or addressed all the shortfalls found during the inspection which included fire safety, infection control, medicines and records.” from the report
Missed CQC notifications
needs fixingSeveral incidents involving allegations of abuse had not been reported to the CQC as required.
“We found several incidents which related to allegations of abuse had not been reported to CQC.” from the report
- 01Have all fire safety actions and missing personal emergency evacuation plans now been completed and checked?
- 02How do you make sure medicines are given at the prescribed time, stored correctly and recorded accurately?
- 03What checks now confirm that care plans and daily records accurately reflect people's risks and care needs?
- 04What has changed in cleaning, hand hygiene and personal protective equipment practice since the inspection?
- 05Who is currently responsible for leadership and quality checks, and how are you proving that problems are found and fixed promptly?
This was a focused inspection of Safe and Well-led; the ratings for Effective, Caring and Responsive were carried over from the last comprehensive inspection. This explanation was written from the published report of 26 August 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 Lodge
9 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- August 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- August 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- April 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- June 2019Inadequatedown from Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 December 2010.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
37 live-in carers within about an hour of York
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,270 a week. 32 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.