CQC report explained · a nursing home
What the CQC found at Western Mount Lodge Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found staff had infection prevention training and that the home used protective equipment safely, supported safe admissions and visits, and kept its infection control policy up to date.
- Effective?
- Good
- People's needs and risks were assessed and reviewed. Staff received induction, training and support, and people were supported with healthcare, food, drink and decisions about their care.
- Caring?
- Good
- The report does not give a separate Caring rating. Inspectors found people were involved in their care and that staff respected their choices, routines and preferences.
- Responsive?
- Good
- Care plans were personalised and staff knew how people liked to be supported. People could follow their preferred routines, choose keyworkers and raise concerns in meetings.
- Well-led?
- Good
- The home had a registered manager, regular meetings and audits. The management team used audit findings to improve medicine ordering and reduce delays.
What inspectors found, July 2022
Rated Good overall; inspectors found effective, responsive and well-led care, while Safe was inspected but not rated.
The inspection was unannounced and took place on 22 June 2022. One inspector observed care, spoke with five people and staff, checked two people's care records, and reviewed records about how the home was managed.
Inspectors found that people's care needs, risks, food choices and communication needs were assessed and reviewed. Staff had training and support. People were involved in their care, daily routines, activities and menu choices. Infection prevention measures, including the use of protective equipment, were also checked and found to be in place.
The overall rating was Good. Effective and Responsive improved from Requires Improvement at the previous inspection, while Well-led remained Good. Safe was inspected for infection prevention and control but was not given a rating.
Up-to-date care planning
Inspectors found that health and care needs were assessed and that care plans and risk assessments were kept under review.
“People's health and care needs were assessed, and care plans and risk assessments were kept up to date.” from the report
Personalised support
Support plans reflected people's individual needs. Staff respected people's preferred routines, interests and choices.
“Each person was treated as an individual and their support plans provided information tailored to their individual needs.” from the report
People involved in decisions
People helped plan their care, choose keyworkers, decide how to spend their day and choose meals.
“People were involved in planning their care.” from the report
Training and partnership working
Staff received induction, ongoing training, supervision and appraisal. Other health and social care professionals were involved when needed.
“Staff confirmed that they completed the providers induction training and received a range of training which helped them to effectively support people.” from the report
Positive atmosphere
People said they were happy living at the home, and staff said they worked well together and felt supported by management.
“The atmosphere at the home was warm and friendly. People told us they were happy living at the home.” from the report
End-of-life wishes not yet discussed with two people
minorTwo people did not want to discuss their end-of-life preferences at the time of the inspection. Staff said they would continue to explore this in future discussions.
“The nominated individual confirmed that two people did not wish to discuss to their wishes.” from the report
- 01How will you continue discussing end-of-life wishes with people who have not yet wanted to discuss them?
- 02What changes were made after the medicine audit, and how do you check that medicine ordering delays have stopped?
- 03How are my relative's mental health needs, risks and preferred routines recorded and reviewed?
- 04What training and supervision will staff supporting my relative receive, including training on mental capacity and least restrictive care?
- 05How will my relative be involved in choosing their keyworker, daily routine, activities and meals?
This was an unannounced inspection that checked infection prevention and control under Safe and assessed Effective, Responsive and Well-led; Safe was not rated, and the other ratings were not all reassessed. This explanation was written from the published report of 21 July 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.
What inspectors found, August 2019
Rated Requires Improvement; inspectors found safe, kind care, but weaknesses in consent, personalised records and end-of-life planning.
This was an unannounced inspection on 10 and 12 June 2019. One inspector spoke with six people, the provider, managers and care staff. They reviewed care records, medicines records, accident records and staff recruitment files.
The home was rated Good for Safe, Caring and Well-led. People felt safe, there were enough staff, medicines records had no gaps, and people described staff as kind and caring.
The home was rated Requires Improvement for Effective and Responsive. Staff did not all understand their responsibilities under the Mental Capacity Act, consent was not always sought, care plans lacked some personal history, and complaints and end-of-life wishes were not recorded fully. The overall rating fell from Good at the previous inspection in November 2016.
Enough staff
Inspectors found staffing levels were enough to meet people's needs and keep them safe.
“There were enough staff to meet people's needs. People said staff were always available to support them.” from the report
Kind and respectful care
People said staff were caring, listened to them and respected their privacy, dignity and choices.
“People said that staff were kind and caring.” from the report
Safe medicines systems
Medicines records showed people received their prescribed medicines, with no gaps in the records checked.
“There were no gaps in records. This indicated medicines had been supplied to people as prescribed.” from the report
Management oversight
The home used audits and acted quickly when inspectors identified problems.
“The registered manager took immediate action to address issues found on this inspection.” from the report
Consent and legal safeguards
needs fixingStaff did not always seek consent before providing care. A restriction on e-cigarette use had no recorded best-interest decision.
“However, we saw a staff member moving a person without seeking consent first.” from the report
Incomplete personal information
needs fixingCare plans included some preferences but did not fully describe people's life histories, likes and dislikes. This could make it harder for staff to provide fully individual care.
“Care plans had some information about people's preferences, though this did not fully cover their life histories and likes and dislikes.” from the report
Complaints records
minorComplaints were investigated and verbally answered, but people did not receive written responses. The complaints procedure also lacked some information about outside organisations.
“These had been investigated and a verbal response provided to the complainant, though there was no written response to the complainant.” from the report
End-of-life planning
needs fixingThe home did not have a system to record people's end-of-life wishes and not all staff had received end-of-life care training.
“End of life care and support had been supplied although there was no system in place to record people's wishes and preferences.” from the report
Specialist staff training
needs fixingStaff had not received specialist training about people's health conditions, including mental health conditions, although qualified nurses were available for advice.
“Staff had not received specialist training in people's health conditions, though the service had qualified registered nurses to provide expert advice.” from the report
- 01How do you now make sure staff understand the Mental Capacity Act and seek consent before providing personal care?
- 02How are best-interest decisions recorded when a person's lifestyle is restricted, such as limits on e-cigarette use?
- 03How do you record each person's life history, likes, dislikes and personal preferences in their care plan?
- 04Will complaints now receive a written response, and does the complaints procedure explain how to contact outside organisations?
- 05How are people's end-of-life wishes recorded, and have all relevant staff received end-of-life care training?
This was an unannounced planned inspection covering all five CQC questions; the previous Good ratings were reassessed, with Effective and Responsive falling to Requires Improvement. This explanation was written from the published report of 10 August 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 Western Mount Lodge Nursing Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Western Mount Lodge Nursing Home →
- August 2019Requires improvementdown from GoodEffective: Requires improvementResponsive: Requires improvementWell-led: Good
Read what inspectors found at Western Mount Lodge Nursing Home →
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014Inspected but not rated
- December 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 5 July 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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