CQC report explained · a residential care home
What the CQC found at Whitehall Lodge Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People felt safe, staff understood safeguarding, risks were assessed, and medicines were managed safely. There were mixed views about staffing levels and response times.
- Effective?
- Requires improvement
- Mental capacity assessments had not been completed properly, including for a person subject to DoLS. Staff otherwise received training and support, and people's food and healthcare needs were generally addressed.
- Caring?
- Good
- People described staff positively. Inspectors saw staff treating people with kindness, respecting privacy and dignity, asking permission, and supporting independence.
- Responsive?
- Good
- Care was planned around people's needs and preferences, and activities were tailored to their interests. Some care records needed more detail about mental health needs.
- Well-led?
- Requires improvement
- There was a clear leadership structure and people and staff were positive about the manager. However, audits were not regular enough, action plans lacked detail, and the provider carried out no audits.
What inspectors found, May 2019
Rated Requires Improvement; inspectors found safe, caring and responsive care, but consent records and provider oversight were not good enough.
This was an unannounced inspection on 05 March 2019. Inspectors reviewed care and staff records, documents about running the home, and spoke with people living there, a relative, staff, the manager and a health professional.
The home was rated Good for Safe, Caring and Responsive. People generally felt safe and treated with kindness and dignity. Staff managed medicines safely, understood safeguarding, supported activities and involved people in choices about their care.
The home was rated Requires Improvement for Effective and Well-led. Mental capacity assessments were missing or incomplete, and staff did not have a consistent understanding of people's capacity needs. Checks by the manager were not regular enough, and the provider did not carry out its own audits.
The overall rating was Requires Improvement, the same as at the previous inspection in January 2018. The report says action had resolved earlier breaches about safety risks and provider oversight, but a new breach was found about consent.
People felt safe
Staff understood how to protect people from abuse. Individual and environmental risks were identified and managed.
“People felt safe and staff understood how to safeguard people from abuse.” from the report
Safe medicines practice
Medicines were stored securely, given as prescribed and checked through regular audits.
“Medicines were stored securely and checks of people's medicines records showed people were given their medicines as prescribed.” from the report
Kind and respectful care
Staff supported people with patience and respected their privacy, dignity, choices and independence.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Activities and community links
People could join activities in the home and the local community, including a dementia café and visits from children.
“People engaged in activities within their local community.” from the report
Mental capacity records
seriousThe home had not assessed people's capacity for particular decisions consistently. This could affect whether care and treatment decisions were made lawfully and in people's best interests.
“People's capacity had not been assessed to determine what decisions they could and could not make for themselves.” from the report
Weak provider oversight
needs fixingThe provider did not carry out audits, while the manager's audits were not always regular and did not identify the missing capacity assessments.
“The provider did not carry out any audits, therefore did not have an oversight of the service.” from the report
Some care records lacked detail
needs fixingRecords did not always explain people's mental health needs or what behaviour might indicate that someone was becoming unwell.
“People's care records would benefit from more detail, especially around their mental health needs.” from the report
Unkempt garden
minorThe garden was not well maintained at the inspection. The manager said the home was being refurbished.
“The garden was unkempt.” from the report
- 01How do you assess my relative's mental capacity for each important decision, and where will the assessments be recorded?
- 02If my relative lacks capacity for a decision, how do you record the best-interest decision and involve their family or representative?
- 03What checks does the provider now carry out, and how often, to make sure care records and capacity assessments are complete?
- 04What action has been taken to improve the detail in care records about mental health needs and signs that someone is becoming unwell?
- 05How do you make sure there are enough staff at busy times and that call bells are answered promptly?
This was an unannounced, scheduled inspection looking at the overall quality of the care home and all five CQC questions; the previous rating was Requires Improvement in January 2018. This explanation was written from the published report of 10 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.
What inspectors found, January 2018
Whitehall Lodge Residential Home was rated Requires Improvement; inspectors found kind, responsive care but serious concerns about fire safety, stair risks and oversight.
Inspectors visited without warning on 6 November 2017 for one day. They spoke with seven residents and six staff, observed care, meals, activities and medicines, and checked care plans, medicine records, recruitment files and management records. There were 25 residents at the time, and the home could accommodate 29.
The home was rated Good for Effective, Caring and Responsive. Staff knew residents well, treated them kindly, supported their choices, met their health and nutritional needs, and provided activities and links with the local community. Medicines were managed safely and there were enough staff to provide timely care.
Safe and Well-led were rated Requires Improvement. Inspectors found that risks from steep, open stairs and fire safety arrangements had not been properly assessed or controlled. Audits did not always identify risks or clearly record what action had been taken. The provider breached Regulation 12 and Regulation 17, and received a warning notice for the fire and stair safety concerns.
Enough staff
Inspectors found enough staff to meet residents' needs promptly. Staff were visible, knew residents well and answered call bells quickly.
“There were enough staff to meet people's needs safely.” from the report
Safe medicines
Inspectors observed medicines being given correctly and found suitable storage, stock checks, protocols and staff competence checks.
“At this inspection, we did not identify any concerns and people's medicines were managed in a safe way.” from the report
Kind and respectful care
Staff supported privacy, dignity, independence and personal choices. They explained care and involved residents in decisions.
“Staff had a caring and compassionate nature and spoke with people in a kind way and showed tolerance in their attitude.” from the report
Activities and community links
Residents had group and individual activities, including music, quizzes and links with parents, babies and local schools.
“The service employed a skilled activity coordinator who offered both planned and spontaneous activities, both group and individual.” from the report
Steep open stairs
seriousThe home had steep stairs with only one handrail and no barrier to prevent someone falling. Inspectors could not see records showing that the risks had been properly assessed for people living upstairs.
“We found the stairs very steep and only had a rail on one side.” from the report
Fire evacuation arrangements
seriousFire safety work was still needed. Evacuation equipment was available, but staff had not practised using it, and a fire door bolt could slow evacuation.
“Evacuation sledges were seen on the first floors, stairs were very steep and staff had not been trained or practiced using these chairs in an emergency.” from the report
Weak management audits
seriousAudits were carried out but did not always show how evidence was gathered, what risks were found or when actions had been completed. This meant the provider did not have enough oversight of safety and residents' experience.
“Audits lacked specific detail for example medication audits were carried out regularly but had not identified any issues.” from the report
Incomplete staff support records
needs fixingThe manager said staff were supported, but could not show that everyone received regular formal supervision. There was also no recorded induction for new agency staff.
“They were unable to show that all staff had regular formal supervision of their practice.” from the report
- 01What changes have been made to protect residents from the steep open staircase, and how are residents' individual stair risks now recorded?
- 02Has the fire door bolt been replaced, and have all staff been trained and practised using the evacuation equipment?
- 03How do you now check that safety and maintenance actions are completed and recorded?
- 04How often will staff receive formal supervision, and how is induction recorded for agency staff?
- 05How would nursing needs be provided by the community district nursing team if a resident needed them?
This was an unannounced one-day inspection of the overall service, covering all five CQC questions and reviewing care, observations, records, staffing, premises and management systems. This explanation was written from the published report of 26 January 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 Whitehall Lodge Residential Home
3 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- May 2019Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Whitehall Lodge Residential Home →
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Whitehall Lodge Residential Home →
- October 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 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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