Davigdor Lodge Rest Home

Updated 31 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was undertaken by an inspector and an assistant inspector.

Service and service type

Davigdor Lodge Rest Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Davigdor Lodge Rest Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service and 5 relatives about their experience of the care provided. We spoke with 7 members of staff including care workers, the registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service

We reviewed a range of records. This included 4 people's care records and numerous medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 31 May 2023

About the service

Davigdor Lodge Rest Home is a residential care home providing personal care to up to 25 people. The service provides support to adults, many of whom were living with mental health conditions. At the time of our inspection there were 23 people using the service.

People’s experience of using this service and what we found

People were not always kept safe using the service. Risk assessments were not always completed for known risks to people or were not detailed to guide staff to support people safely. We discussed our concerns with the registered manager during the inspection who acted immediately to investigate the concerns raised and reduce the risk.

Auditing systems were not robust or effective to ensure management had oversight on identifying risk and acting on lessons learnt. The concerns found during this inspection had not been identified through internal quality assurance processes.

People medicines were managed safely and regular audits including competency checks of staff were undertaken. There were enough suitably trained staff to meet people’s needs and keep them safe. Robust recruitment processes were in place to ensure staff employed were safe to work with the people living at Davigdor Lodge.

Staff were caring in their approach towards people. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff demonstrated a good knowledge of the mental capacity act, and it was clear its principles were applied throughout everyday practices. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People, relatives and staff spoke positively about the open culture at the service. They described a registered manager who was approachable and expressed confidence that any concerns raised would be dealt with appropriately.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 27 March 2019).

Why we inspected

The inspection was prompted in part due to concerns received about risk management, staffing levels and information not being shared with appropriate external agencies. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Davigdor Lodge Rest Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to risk management, including fire safety and oversight of quality assurance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.