CQC report explained · a nursing home
What the CQC found at West Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2023
West Lodge Care Home was rated Requires Improvement; inspectors found risks in care records, safety, consent and management.
Inspectors visited on 27 July and 9 August 2022. They spoke with people and staff, observed care, and checked care records, medicines, recruitment files and management records.
The home was not always keeping people safe. Inspectors found unlocked medicines and cleaning chemicals, incomplete risk information, missed repositioning, unsafe fire evacuation arrangements and gaps in monitoring records. Responses to changing needs were sometimes slow.
People were not always supported in line with the Mental Capacity Act. Some capacity assessments and best-interest decisions were missing, and tables were used to restrict some people's movement. Mealtimes, activities and communication also did not always meet people's needs.
The overall rating was Requires Improvement, as were Safe, Effective and Well-led. This means inspectors found important shortfalls and only limited assurance that people were consistently safe and well supported.
Staffing and recruitment
The home used a dependency tool to plan staffing and followed safer recruitment checks. People were supported by regular staff who knew them well.
“People were supported by regular staff who knew them well.” from the report
Staff training
Staff had training relevant to people's needs, including checks of their ability to carry out specific tasks. Training was updated regularly.
“Staff completed training that was relevant to people's needs.” from the report
Medicines administration
People received medicines as prescribed, and trained staff understood what medicines were for. Medicine audits had led to some improvements.
“People were supported to receive their medicines as prescribed.” from the report
Access to healthcare
The home made referrals to specialist services when people's needs changed, including speech and language therapy and dietetic support.
“People were supported to access healthcare services.” from the report
Safeguarding reporting
Staff knew how to report safeguarding concerns, and records showed concerns had been reported to the local authority and CQC as required.
“Records showed that all safeguarding concerns had been reported to the local authority and the Care Quality Commission in line with guidance.” from the report
Safety risks
seriousSome sluice rooms and cupboards containing chemicals were unlocked. The medicine room was also unlocked, with medicines outside locked cupboards.
“Several doors that had signs to keep shut or locked were found to be open.” from the report
Care records and changing needs
seriousRecords did not always describe people's current risks or the care they needed. Monitoring of food intake and weight loss was incomplete, and responses to changing needs could be slow.
“People's care records did not contain enough information to monitor emerging risk when they were losing weight.” from the report
Pressure sore and falls prevention
seriousSome people at risk of pressure sores were not repositioned as required. Personal alarm sensors for people at risk of falls were not always switched on.
“People who were at high risk of developing pressure sores were not repositioned as required to protect the integrity of their skin.” from the report
Fire safety
seriousEmergency evacuation plans lacked important details, fire drills had not been carried out and staff had no evacuation training.
“We could not be assured that people could be safely evacuated in the event of a fire.” from the report
Consent and restrictions
seriousMental capacity assessments and best-interest decisions were not always completed properly. Tables were placed in front of five people, restricting their movement, although they were moved after inspectors raised this.
“Tables were used to restrict people's movements.” from the report
Limited activities and mealtime support
needs fixingPeople had little stimulation and were often passive. Mealtimes could feel rushed, and staff did not have a reliable process to record who had eaten or been offered food.
“We observed people sitting in the same chairs all day with no stimulation.” from the report
- 01How will you keep medicines and cleaning chemicals locked and check that this is happening every shift?
- 02How will you make sure care plans and food and weight records are updated quickly when someone's needs change?
- 03What fire evacuation training, drills and personal evacuation plans are now in place?
- 04How do you assess capacity, record best-interest decisions and make sure restrictions are necessary and lawful?
- 05What has changed to improve activities, mealtimes and recording whether people have eaten?
The report gives ratings for Safe, Effective and Well-led; Caring and Responsive are not separately rated in this report and the overall rating used previous ratings where questions were not inspected. This explanation was written from the published report of 14 March 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 2021
Rated Requires Improvement; inspectors found kind care and safe medicines, but risks, training, consent and management systems needed urgent improvement.
Inspectors visited the home without warning on 26 May 2021. They observed care, spoke with people, relatives and staff, and checked care records, medicines, staff files and management records.
They found people were treated kindly, supported with food and healthcare, and given medicines safely. However, some safety risks were not managed properly. These included cleaning chemicals within people's reach, unsafe furniture, poor infection control and missed repositioning for people at risk of pressure sores.
The home was rated Requires Improvement overall. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. Caring was rated Good. The overall rating had fallen from Good at the previous inspection, published on 19 February 2019.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff responding compassionately and treating people politely.
“People and relatives spoke highly of the caring nature and kindness of the staff.” from the report
Medicines managed safely
Medicines were stored and disposed of securely. Records were up to date and staff had regular checks of their medicines competence.
“Medicines were managed safely. Medicines were stored and disposed of securely.” from the report
Enough staff
Inspectors found staffing levels were safe. Staff said they had enough time to support people, and care was observed to be calm and unhurried.
“Staff told us they had enough time to support people and we observed staff supporting people in a calm and unhurried way.” from the report
Food and healthcare
People received food and drinks suited to their needs and cultural preferences. Staff made timely referrals and helped people access healthcare when needed.
“People were provided with food and drinks which met their needs and cultural preferences.” from the report
Unsafe environmental risks
seriousCleaning chemicals were stored where people could reach them, and bedroom wardrobes were not secured to walls. Inspectors said this placed people at risk of harm.
“Hazardous substances such as cleaning chemicals (COSHH) stored in a communal area and within people's reach.” from the report
Pressure sore risks not managed
seriousTwo people who had developed pressure sores were not always repositioned as set out in their care plans. This increased their risk of further harm.
“The people were not always being supported with repositioning as per their care plans” from the report
Infection control shortfalls
seriousSome staff did not wear masks correctly or change protective equipment between people. A shared commode was rusty and could not be cleaned effectively.
“Some of the staff did not wear their face mask correctly and they did not ensure the mask covered both nose, mouth and chin.” from the report
Missing best-interest decisions
needs fixingBest-interest decisions had not been recorded for two people receiving end-of-life care in a shared bedroom. Inspectors could not be sure the arrangement protected their privacy and dignity.
“However, the provider did not always complete a Best Interests decision.” from the report
Gaps in staff training
needs fixingStaff had not completed some training needed for people's health needs, including diabetes, epilepsy, skin integrity and catheter care. Some staff using cleaning chemicals also lacked up-to-date training.
“care staff appeared not to have undertaken diabetes, epilepsy, skin integrity and catheter care training, despite providing care and support to people with those needs.” from the report
Weak management checks
seriousAudits did not identify several problems found during the inspection, including poor cleanliness, infection control shortfalls, training gaps and missed repositioning.
“The provider had failed to implement a robust system of quality assurance or to identify and address the shortfalls in the service.” from the report
- 01How have you secured cleaning chemicals and bedroom wardrobes since the inspection?
- 02How do you now check that people are repositioned at the times set out in their care plans?
- 03What changes have you made to mask use, changing protective equipment and cleaning shared equipment?
- 04Which staff have completed training in diabetes, epilepsy, skin integrity, catheter care and safe use of cleaning chemicals?
- 05How do you record and review best-interest decisions, especially for people receiving end-of-life care in shared bedrooms?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control measures and the premises as well as care. This explanation was written from the published report of 6 August 2021 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 West Lodge Care Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2021Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2020
Registered with the Care Quality Commission on 1 October 2020.
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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