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Archived: Queens Lodge Good

Inspection Summary

Overall summary & rating


Updated 30 June 2015

The inspection took place on the 11 May 2015 and was unannounced. Queens Lodge provides care and accommodation for up to 6 persons who have a Learning Disability. There were a total of five people living at the service at the time of our inspection.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Systems were in place which guided staff on how to manage risks and safeguard people who used the service. There were clear procedures in place to ensure peoples safety and there were checks undertaken on the environment as well as assessments on how to minimise risks. There were some issues about storage which presented some risks which had not been fully considered.

Staff could recognise signs of harm or potential abuse but we found some barriers to reporting which meant that people may not be as open as they could be.

Staff turnover was high but efforts were made to ensure consistency by using regular agency staff. Staffing levels were regularly reviewed in consultation with other professionals and adjusted to meet the needs of the people using the service. Recruitment processes ensured that the staff who were appointed were safe to work in this setting.

Medication systems were safe but the guidance directing staff on the use of “as required” medication was not clear. This means that medicines may not be given consistently and when needed.

Staff received induction and training which gave them the knowledge they needed to carry out their role. Staff were regularly supervised and their competency monitored to ensure that they could meet people’s needs effectively.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. The Act, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals.

Staff were proactive in their contacts with healthcare agencies and acted on their guidance, in people’s best interests.

People were involved in the developing of the menu and in meal preparation. The quality of the meals we observed were good however the monitoring of food and fluid for individuals, identified as at risk would benefit from greater oversight.

Interactions between people using the service and staff were warm and friendly. Staff knew people they were caring for and what their care preferences were. Care plans were detailed and informative and reflected people’s needs. Where people’s needs changed, advice was sought and the plan evaluated. People were involved in planning their care and this endured that people were provided with care in a way that they wanted to be supported.

People were enabled to access person centred activities and were encouraged to maintain hobbies and interests. Staff supported people to maintain relationships which were important to them.

The registered manager demonstrated clear leadership and was described as approachable and helpful.

The provider had systems in place to assess and monitor the quality of the service, which included sampling of documentation and visits. Action plans were in place to address areas identified by the audit.

Inspection areas


Requires improvement

Updated 30 June 2015

The service was not always safe.

The mechanisms for reporting abuse were not always clear.

Risks were identified and plans put into place to manage them.

Staffing levels were adequate to meet people’s needs.

Medication procedures did not always ensure that people received their medication when needed.



Updated 30 June 2015

The service was effective.

The Deprivation of liberty Safeguards (DOLS) were understood by staff and appropriately implemented.

Staff had been provided with training and supervision which gave them the knowledge to meet people’s needs.

People were provided with a balanced diet but the recording should be strengthened for those individuals identified as at risk.

People had good access to health care support.



Updated 30 June 2015

The service was caring.

Staff had developed positive relationships with people who used the service.

People were supported to express their view and make decisions about their care.

People had their privacy and dignity respected.



Updated 30 June 2015

The service was responsive.

Care plans were detailed and informative and provided clear guidance about how to meet people’s needs.

Complaints were investigated and responded to.



Updated 30 June 2015

The service was well led.

There were systems in place to monitor the quality of the service.

The manager was approachable and visible.