CQC report explained · a residential care home
What the CQC found at Vaughan Lee House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2023
Vaughan Lee House is rated Requires Improvement; inspectors found kind care, but risks, training, consent checks and management oversight were not reliable.
This was an unannounced inspection on 4 and 5 July 2023. Two inspectors spoke with people, staff, relatives and a visiting professional. They observed care and checked care records, medicines records, recruitment files and management records.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Care records and risk assessments were incomplete or out of date. Medicines records were not always reliable. Staff training and supervision were not sufficient, and the home could not always show that legal consent and liberty safeguards were being followed.
Inspectors found no evidence that people had been harmed, but said the gaps increased the risk of avoidable harm. People and relatives described staff as kind and caring, and inspectors saw compassionate interactions. The provider accepted the concerns and started taking action, but CQC required an action plan and will continue to monitor progress.
Kind and compassionate care
People and relatives spoke positively about the staff. Inspectors observed kind, relaxed and respectful interactions.
“Throughout the inspection we observed kind, relaxed, compassionate, and caring interactions between people and staff.” from the report
People felt safe
People told inspectors they felt safe. Staff had training about recognising and reporting abuse and knew what to do.
“Staff knew people well, had training on how to recognise and report abuse and knew how to apply it.” from the report
Clean and comfortable surroundings
Inspectors were assured about infection control arrangements, and the premises were described as comfortable and suitable for people's needs.
“We were assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Links with health professionals
The home worked with healthcare professionals, including GPs and district nurses. A visiting professional said staff listened and acted on advice.
“The staff are helpful, they ask questions whilst we are here, listen to what we say and apply it, and call us when they need us.” from the report
Incomplete risk and care records
seriousTen people did not have a care plan. Some risks were not assessed, and care plans were not always accurate, reviewed or followed.
“People were at risk of avoidable harm. Risk assessments were not in place for all identified risks to people” from the report
Medicines records
needs fixingRecords did not always show that topical creams had been given. Guidance for medicines taken when needed was also missing in some cases.
“Records around the application of medicinal creams were inconsistent and we could not be certain people had received them as prescribed.” from the report
Staff training and supervision
seriousSome required training was incomplete or overdue. Staff did not always receive regular supervision or training specific to people's health needs.
“Staff did not receive effective and sufficient supervision and training to enable them to carry out their roles.” from the report
Consent and liberty safeguards
seriousThe home had not always completed decision-specific capacity assessments or made DoLS applications when required.
“The provider had not ensured appropriate DoLS applications were submitted to the local authority.” from the report
Weak management checks
seriousAudits and quality checks had not found several of the problems identified by inspectors. There was no improvement plan covering all the required actions at the time of the inspection.
“Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service.” from the report
- 01Which care plans and risk assessments have now been completed, reviewed and updated, and how do you check that staff follow them?
- 02How do you record topical creams and medicines taken when needed, and who checks these records?
- 03What training and refresher training has each member of staff now completed, especially in falls, diabetes, the Mental Capacity Act and DoLS?
- 04Have all required mental capacity assessments and DoLS applications now been completed, and how are relatives involved in best-interest decisions?
- 05What improvement plan is now in place, and how does the provider check that each action has been completed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 17 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, May 2019
Vaughan Lee House was rated Good overall; inspectors found safe, kind and personalised care, with only minor concerns about choice and care-plan involvement.
This was an unannounced inspection visit on 8 March 2019. One inspector and an Expert by Experience visited the home. They spoke with 12 people, two visitors, three staff members and the management team. They also reviewed care plans, medicine records, staff files, rotas, training records, complaints and safety checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable staff checks and detailed risk assessments. People received care that was kind, respectful and tailored to their needs.
Inspectors also found good training, support with food and healthcare, and a varied activities programme. People were involved in decisions about their care, activities and the home. The provider had systems to monitor quality, respond to complaints and learn from mistakes.
The home was already rated Good at the previous inspection, published in September 2016, and remained Good overall.
Safe staffing and recruitment
The home had enough staff to meet people's needs, and new staff were thoroughly checked before starting work.
“Before commencing work all new staff were thoroughly checked to make sure they were suitable to work with vulnerable people.” from the report
Kind and respectful care
Inspectors saw staff treating people warmly and respectfully. Staff understood people's individual needs and protected their privacy and dignity.
“We observed people were treated with kindness and care by staff.” from the report
Personalised support and activities
Care plans recorded people's likes, dislikes and communication needs. The home offered a wide range of activities and links with local groups.
“People participated in a range of activities that met their individual needs, hobbies and interests.” from the report
Good leadership and improvement
Management was described as approachable and open. Quality checks were used to identify shortfalls, arrange training and improve the service.
“There were effective quality assurance systems to monitor care and plans for on-going improvements.” from the report
Food choice and variety
minorMost people liked the food, but one person said the choice and variety could be better. The home had sought residents' views and made some menu changes.
“Not bad could be better choice and variety.” from the report
Some people were not aware of their care plan
minorMost people said they had been involved in their care plans, but some people did not know about them. They were nevertheless happy with the care they received.
“Some people told us they had been involved in developing their care plan, whilst others said they did not know about their care plan but were happy with their care and support.” from the report
Confidence in raising concerns
minorPeople knew who they could speak to about complaints, but one person said they would keep a concern to themselves and tell their son. Families may wish to check how the home makes sure everyone feels able to complain.
“However, another person said, "I would keep it to my self and tell my son.” from the report
- 01How will you involve my relative in creating and reviewing their care plan?
- 02What food choices and menu changes are available if my relative dislikes the usual options?
- 03How do you make sure people feel confident raising concerns or complaints?
- 04Which activities and community visits would match my relative's hobbies and interests?
- 05How many staff are usually available at different times of day, and how is this adjusted when people's needs change?
This was an unannounced, planned inspection covering all five CQC areas, including the premises and the care provided. This explanation was written from the published report of 18 May 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.
Every inspection of Vaughan Lee House
5 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2014Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 10 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.
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Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
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