CQC report explained · a residential care home
What the CQC found at Tomswood Lodge Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments did not cover all the risks people faced. Medicines records had errors, although inspectors found no unexplained gaps on medicine administration records.
- Effective?
- Requires improvement
- The premises had maintenance problems and the lift had not worked for about six weeks. Staff training and appraisals had improved, but regular supervision had not been provided consistently.
- Caring?
- Requires improvement
- People were generally described and observed as relaxed and happy with staff. However, care was not always fully person-centred, and privacy was affected by a lounge without curtains or blinds.
- Responsive?
- Requires improvement
- People had activities, visitors and support with relationships and communication. However, care plans were not sufficiently detailed or personalised and did not fully cover independent living, equality or diversity needs.
- Well-led?
- Inadequate
- There was poor communication between senior leaders and quality checks did not identify known problems. The provider had not put an earlier action plan into effect, and CQC issued a Warning Notice.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found unsafe systems for medicines, care planning, premises and leadership, with well-led rated Inadequate.
This was an unannounced inspection on 9 June 2023. Inspectors spoke with people living in the home, relatives and staff. They reviewed care and medicines records, policies and management records.
The home supported eight people with learning disabilities or autism. Inspectors found enough staff at the time of the visit, suitable recruitment checks, infection control measures and support with healthcare, food, activities and relationships.
There were important shortfalls. Risk assessments and care plans were incomplete, medicines were not always managed safely, and parts of the building were poorly maintained. Leadership and quality checks were not effective. The home was rated Requires Improvement overall, with Inadequate for well-led.
The overall rating has fallen from Good at the previous inspection, published in September 2018. The provider must send an action plan. CQC issued a Warning Notice about governance and will monitor progress.
Staffing and recruitment
Inspectors found enough staff on duty during the visit. Recruitment checks included criminal records checks, identity checks and employment references.
“Staff told us there were enough staff on duty and they had enough time to carry out their duties.” from the report
People felt safe
People and relatives told inspectors they felt safe in the home. Staff had safeguarding training and understood their reporting responsibilities.
“People told us they felt safe, one person said, "[There are] changes in staff all the time but I feel safe.” from the report
Health and activities
People had access to healthcare professionals and were supported to attend appointments. They also took part in activities at home and in the community.
“People were able to engage in a variety of activities both in the home and in the community.” from the report
Choice and dignity
Staff supported people to make choices and to do as much as possible for themselves. Inspectors found staff understood the importance of privacy and dignity.
“People were supported to make choices about their care, and staff understood how to support them with this.” from the report
Food and nutrition
People were offered choices and inspectors saw plentiful food, including fresh fruit and vegetables. People and relatives said they were happy with the food.
“we saw evidence of amply supplies of food including fresh fruit and vegetables.” from the report
Incomplete risk assessments
seriousRisk assessments did not cover all risks. This included risks from using the stairs while the lift was broken and staff using physical restraint.
“The provider had not carried out a comprehensive assessment of the risks people faced. This placed people at risk of harm.” from the report
Medicines records
seriousA medicine was kept in an unlocked container in the kitchen fridge. Records did not always show how much medicine was held or how many tablets had been given.
“Records were not maintained of the amounts of medicines held at the service.” from the report
Poorly maintained premises
seriousInspectors found broken cupboards, cracked kitchen surfaces, unsuitable chairs and a lift that had been out of use for about six weeks. An electrical safety certificate was also missing.
“The premises were not properly maintained. This was a breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Care plans not personalised
seriousCare plans were not detailed enough and some plans were identical despite different needs. They did not fully cover independent living skills or equality and diversity.
“The provider had failed to carry out a comprehensive assessment and develop care plans for people.” from the report
Weak leadership and checks
seriousSenior leaders did not communicate well, and audits failed to find problems with care plans, medicines, the kitchen and people's money. The registered manager had not received formal supervision since starting in May 2022.
“There was a lack of coherent leadership at the service.” from the report
Irregular staff supervision
needs fixingStaff had received supervision after a local authority visit, but supervision before that had been sporadic and did not follow the provider's policy.
“This meant that staff did not always have the guidance and support they needed to make sure they were providing good care.” from the report
- 01What has been done to make sure every person has a complete risk assessment, including risks linked to mobility and any physical restraint?
- 02How are medicines now stored, counted and recorded, and who checks the medicine records?
- 03Has the lift been repaired, and have the broken cupboards, cracked surfaces, missing curtains or blinds and unsuitable chairs been replaced or fixed?
- 04How have care plans been rewritten to cover each person's independent living goals, communication, religion, ethnicity and other personal needs?
- 05What changes have been made to communication between senior managers, staff supervision and quality audits since the Warning Notice?
This was an unannounced inspection covering all five key questions, including the care provided and the premises; inspectors spoke with three people, six relatives and four staff and reviewed care, medicines and management records. This explanation was written from the published report of 16 August 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, September 2018
Rated Good; inspectors found safe, caring and well-managed support, and confirmed that an earlier food-storage problem had been fixed.
This was an unannounced inspection on 30 August 2018. One inspector spoke with two people using the home, observed staff, spoke with staff and managers, and checked care plans, medicines, staff records, quality checks and health and safety records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable safeguarding arrangements and personalised risk assessments.
People were supported to make choices, access health professionals, maintain independence and take part in activities. At the previous inspection in April 2016, Safe had needed improvement because food was not always stored safely. Inspectors found this issue had been addressed.
Safe staffing and medicines
Inspectors found enough staff to respond promptly and found medicines records complete and up to date.
“There were enough staff working at the service to support people safely.” from the report
Respectful care
Staff supported people in a calm and respectful way, including protecting privacy and dignity.
“We observed staff interacting with people in a caring way.” from the report
Personalised activities
People took part in activities they enjoyed, both in the home and in the community. Their choices were respected if they preferred to stay at home.
“People were supported to engage in various activities, both in house and in the community.” from the report
Open management
Staff described an approachable manager and an inclusive team. The home held meetings and surveys to gather views.
“Staff praised the registered manager and said they fostered an open and inclusive culture at the service.” from the report
Health Action Plans
minorAt the inspection, two people did not have Health Action Plans. The manager prepared them and sent them to CQC four days after the inspection.
“These were not in place for the other two people.” from the report
- 01Have the refurbishment works mentioned in the report now been completed, including the new bedroom facilities and garden ramp?
- 02How are Health Action Plans kept up to date for every person living in the home?
- 03How will you assess whether my relative's needs can be met before they move in?
- 04What activities and community outings would be available for my relative, and how would their choices be respected?
- 05How can my relative or family raise a complaint, and how will it be followed up?
This was an unannounced inspection covering all five key questions and the overall quality of the home; three people were using the service at the time. This explanation was written from the published report of 19 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.
Every inspection of Tomswood Lodge Limited
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 13 April 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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