CQC report explained · a residential care home
What the CQC found at Ummah Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that medicines were stored, recorded and audited safely. There were risk assessments, enough staff, safe recruitment checks and systems for safeguarding and learning from incidents.
- Effective?
- Requires improvement
- The building needed repairs and decoration, with missing bathroom tiles, worn carpets, cracks, an out-of-use toilet and other areas needing attention. Staff training, supervision, support, food choices and healthcare arrangements were otherwise in place.
- Caring?
- Good
- Staff were observed to be caring and compassionate. They promoted privacy, dignity, equality, choice and independence, and advocates were available when needed.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with activities inside and outside the home, communication needs and complaints.
- Well-led?
- Good
- A registered manager was in place and regular audits covered areas such as medicines, care plans and infection control. Feedback about the manager was mixed, including one concern about accessibility.
What inspectors found, March 2019
Ummah Lodge is rated Good overall, but inspectors found the premises needed improvement and rated Effective Requires Improvement.
Inspectors visited the home on 5 February 2019 after giving 24 hours' notice. One inspector looked at records, staff files, medicines, care plans and how people were supported. They also spoke with staff, the manager, an advocate, a relative and care professionals. People using the service were not able to communicate with the inspector, so inspectors observed their care instead.
The home was rated Good for Safe, Caring, Responsive and Well-led. Inspectors found safe medicines systems, enough staff, suitable recruitment checks, personalised care plans, kind support and activities that matched people's interests. Staff understood people's needs and supported their choices, health and independence.
The Effective rating was Requires Improvement. Parts of the building had missing tiles, stained carpets, cracks, poor decoration and an unusable toilet. The manager was asked to improve these areas. Staff had training and regular supervision, but formal yearly appraisals had not yet been introduced.
The overall Good rating means inspectors found the service met the relevant standards overall at this visit. The previous overall rating was Requires Improvement in July 2017, so the home had improved and there were no breaches of regulations at this inspection.
Safer medicines
Staff who administered medicines had training and their competence was checked. Records showed medicines were administered as prescribed and audited.
“We saw that medicine administration record sheets (MARS) were completed and signed by staff to confirm medicines were administered as prescribed.” from the report
Kind and respectful care
Inspectors observed caring relationships. Staff supported people's dignity, privacy, choices and independence.
“We observed that staff had caring relationships with people and demonstrated a compassionate approach and understanding of their needs.” from the report
Personalised support
Care plans described people's needs, preferences and goals. Staff knew how to respond to people's communication and behaviour.
“Care plans were regularly reviewed and updated to ensure people's needs were met.” from the report
Activities and community life
People took part in activities such as swimming, walks, shopping, restaurants, sensory sessions and helping with meals.
“Records showed that people participated on different activities in the community and within the service.” from the report
Improved management
The home had a registered manager and regular audits. This was an improvement from the previous inspection, when there was no registered manager.
“At this inspection, we noted that the service had a registered manager in place.” from the report
Condition of the building
needs fixingParts of the premises were in poor condition. Inspectors recommended improvements to missing tiles, worn carpets, cracks, decoration and an out-of-use toilet.
“During our tour of the premises we noted missing tiles in bathrooms, stained and worn out carpets, walls that needed painting and out of use toilets.” from the report
No formal yearly appraisals
minorStaff had training and regular supervision, but formal annual appraisals had not yet been introduced. The manager said these would include objectives and training plans.
“However, the registered manager was yet to implement a formal staff annual appraisal.” from the report
Mixed views about manager access
minorOne relative said the manager was not always accessible, although professionals and staff gave positive feedback. The concern was raised with the manager.
“A relative said the registered manager was not always accessible.” from the report
- 01Which missing tiles, stained carpets, cracks and decoration issues have been repaired since the inspection?
- 02What arrangements are now in place for the out-of-use toilet and the safety concerns around showers and stairs?
- 03How are staff appraisals now carried out, and how are objectives and training needs recorded?
- 04How can relatives contact the registered manager, and what is the expected response time?
- 05How are medicines, care plans and incidents checked and reviewed now?
This was an announced inspection covering all five key questions, but inspectors did not speak directly with people using the service because they were unable to communicate with them. This explanation was written from the published report of 2 March 2019 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 2017
Ummah Lodge is rated Requires Improvement; inspectors found kind, personalised care but serious medicines and management weaknesses.
The inspection took place on 10 July 2017 and was announced. It checked whether improvements had been made since the February 2017 inspection, when the home was rated Inadequate and had seven legal breaches.
Inspectors found improvements in recruitment, risk assessments, staff training, care plans, activities and quality checks. People were treated with dignity, had personalised support and had their complaints dealt with.
However, staff competency in managing medicines had not been checked, and medicines instructions were not clearly recorded. Staff also could not show a suitable understanding of the Mental Capacity Act, and there was still no registered manager.
The overall rating was Requires Improvement. Caring and Responsive were rated Good. Safe, Effective and Well-led were rated Requires Improvement. The home had one breach of legal requirements.
Kind and respectful care
Inspectors found that staff treated people with dignity and communicated with them in a friendly way.
“Staff were kind, respectful and treated people with dignity.” from the report
Personalised support
Care plans included people's preferences, communication methods, activities and guidance for responding to their needs.
“The support plans included pertinent information for staff, so they knew how to support the person according to their needs, preferences and wishes.” from the report
Improved risk planning
Risk assessments had been added to support plans, with guidance for staff on reducing specific risks.
“At this inspection we found that risk assessments were part of support plans.” from the report
Safer recruitment
The records checked showed that relevant employment checks, including DBS checks, references and proof of identity, had been completed.
“We found that the provider had followed the principles of safe recruitment.” from the report
Staff understanding of legal decisions
needs fixingAlthough staff had completed Mental Capacity Act training, they could not show that they understood how to apply it appropriately.
“Although staff had been trained in MCA, during our discussion, they remained unable to demonstrate appropriate knowledge and understanding of the Act.” from the report
No registered manager
needs fixingThe home did not have a registered manager in overall charge. Inspectors were concerned that this made it difficult to know whether improvements would last.
“The provider did not have a registered manager in overall charge of the service.” from the report
Quality checks still developing
needs fixingThe home had introduced audits, checks and feedback surveys, but inspectors said these systems needed more development.
“This was work in progress which required further development.” from the report
- 01How are staff now assessed and recorded as competent to administer medicines safely?
- 02Are medicines now supplied through the monitored dosage system mentioned after the inspection?
- 03Has a registered manager been appointed and accepted by CQC?
- 04How do staff demonstrate that they understand and apply the Mental Capacity Act?
- 05How are the new quality checks and feedback surveys used to make sure improvements continue?
This was an announced follow-up inspection after the February 2017 comprehensive inspection; inspectors could not speak directly with people using the service, and daytime personal assistants were outside the inspection's scope. This explanation was written from the published report of 31 August 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 Ummah Lodge
3 rated inspections over 2 years: the service has improved, from Inadequate to Good.
- March 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2014
Registered with the Care Quality Commission on 11 December 2014.
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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