CQC report explained · a residential care home
What the CQC found at Worstead Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found unsafe medicines management, missing or incomplete care records, weak safeguarding systems and ineffective staff deployment. Maintenance checks, emergency plans and infection control systems were in place, although some flats and bungalows were not clean.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward, but the report does not state that rating in the text provided.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward, but the report does not state that rating in the text provided.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward, but the report does not state that rating in the text provided.
- Well-led?
- Requires improvement
- Inspectors found weak management oversight, inaccurate audits, missing records and poor involvement of people, relatives and staff. A new management team had begun an action plan and new systems, but these were not yet fully implemented.
What inspectors found, February 2024
Worstead Lodge is rated Requires Improvement; inspectors found unsafe medicines and staffing systems, although new managers had started making changes.
This was a focused inspection after concerns about safeguarding, staffing, medicines and management. Inspectors visited on 5, 11 and 12 January 2024. They spoke with people, relatives, staff and managers, observed care, and checked records, medicines, staffing and safety systems.
The home was not always safe. Some care records had been destroyed or did not reflect people's needs. Medicines records had gaps and medicines were not always given safely. People were also at risk from weak systems for preventing financial abuse, and staff were not always deployed effectively.
The home was not well-led. A closed culture had developed after changes in ownership and management. People, relatives and staff said they felt unsettled and not listened to. A new management team had started work, but the new systems had not been fully tested by the inspection.
The overall rating fell from Good at the previous inspection to Requires Improvement. Only Safe and Well-led were inspected at this visit. The other ratings were carried forward from the previous inspection.
Kind staff
Staff were described as kind and caring. People were comfortable with staff who knew them well.
“Staff were kind and caring in their interactions with people and people were comfortable with the staff they knew well.” from the report
Safer recruitment
The home checked staff before they started work, including references, employment history and DBS checks.
“The provider operated a safer recruitment system. Staff were appropriately checked before they started work” from the report
Emergency planning
People had up-to-date emergency evacuation plans. Fire drills took place at different times of day and night.
“People had comprehensive, up-to-date personal emergency evacuation plans in place and fire drills were undertaken regularly, at different times of the day and night.” from the report
New improvement work
The new management team had introduced audits, an action plan and extra management support. It also acted quickly on some medicines concerns during the inspection.
“The new management team had implemented a more robust incident and accident reporting system.” from the report
Choice and rights
The report said people were supported to make choices and staff used the least restrictive approach. Staff had training in the Mental Capacity Act and related safeguards.
“People were supported to have maximum choice and control of their lives” from the report
Medicines were not always safe
seriousMedicine records were missing or inconsistent. Staff were interrupted while giving medicines, and one person's medicines were regularly put into another container.
“Medicines had not been managed safely. Records were missing and there were discrepancies and gaps in people’s medicine administration records (MARs).” from the report
Risk information was missing
seriousSome care and support records had been destroyed or did not reflect people's needs. This left unfamiliar and agency staff without the guidance needed to support people safely.
“Although risks relating to most people's support had been assessed, many records were not available to guide the support staff provided to people.” from the report
Financial abuse safeguards were weak
seriousThe provider did not have effective systems to protect people from financial abuse. The previous manager had also failed to refer some incidents properly.
“The provider had not operated effective systems to ensure people were safeguarded from the risk of abuse.” from the report
Staffing was inconsistent
seriousStaff were not always deployed effectively. Vacancies, agency workers and staff turnover meant that some staff did not know people's needs well, and some daily support was missed.
“Staff were not always deployed effectively to ensure people's needs were met and their rights protected.” from the report
Weak management oversight
needs fixingAudits did not accurately show how the home was operating. People, relatives and staff said they were not listened to or involved enough.
“Management oversight of the operation of the service had not been comprehensive or robust.” from the report
- 01How have you checked that every person's care and risk records are complete, accurate and available to all staff, including agency staff?
- 02What changes have you made to medicines administration, recording, disposal and prescriber reviews since the inspection?
- 03How are you protecting people from financial abuse, and how do you investigate and report concerns now?
- 04How many permanent and agency staff are currently working, and how do you make sure staff know each person's needs?
- 05What evidence can you show that the new audits, meetings and action plan are improving the home?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 23 February 2024 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, December 2021
Worstead Lodge is rated Good; inspectors found safe, personalised care and stronger records, with minor issues around notifications and night-time fire drills.
This was an unannounced focused inspection on 24 November and 2 December 2021. Inspectors spoke with 12 people, three relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good overall and Good for Safe and Well-led. People were supported to make choices, manage medicines where safe, and stay as independent as possible. Inspectors also found suitable infection control measures and a stable staff team.
The previous inspection in April 2019 rated the home Requires Improvement and found a breach about good governance. Inspectors found that the provider had completed its action plan, improved records and audits, and was no longer in breach.
Personalised support
People were supported to make choices about their lives, activities and where they spent their time. Staff worked with people to promote independence and manage positive risks.
“People received personalised care and support, tailored to their individual needs and wishes.” from the report
Medicine independence
People were assessed to manage their own medicines where this was safe. Staff were trained and had their medicine-giving skills checked regularly.
“People were assessed to manage their own medicines independently wherever safe to do so.” from the report
Stable staff team
Inspectors found a stable staff team who knew people's needs, preferences and wishes. Relatives said low staff turnover helped staff know their family member well.
“The service had a stable staff team.” from the report
Improved leadership and records
The provider had acted on the previous inspection findings. Records were more consistent and quality audits were in place.
“The provider had implemented changes since the last inspection.” from the report
Support during the pandemic
The home changed its environment and activities to reduce isolation when community access was restricted. Inspectors found appropriate use of personal protective equipment and infection control measures.
“Changes to the care environment such as installing a running track and opening up a pop-up café prevented people feeling socially isolated” from the report
CQC notifications
needs fixingInspectors found some incidents that should also have been notified to CQC. The provider said it was changing its paperwork to address this.
“We did identify some examples of where notifications should also have been submitted to CQC” from the report
Night-time evacuation checks
needs fixingThere was one sleeping staff member at night. Inspectors suggested carrying out night-time fire drills to check that staffing was enough for an evacuation.
“We suggested for the provider to complete night time fire drills to ensure one staff member was enough” from the report
- 01How do you now make sure all incidents that need reporting to CQC are notified promptly?
- 02What were the results of your night-time fire drills, and is one sleeping staff member still the planned night-time arrangement?
- 03How do you check that improvements to care records and quality audits have been maintained?
- 04How will you support my relative to manage medicines independently while making sure they remain safe?
- 05What activities and community access are currently available to reduce the risk of social isolation?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 21 December 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 Worstead Lodge
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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