Background to this inspection
Updated
3 September 2015
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 22 and 24 July 2015. The visit on 22 July was unannounced and we told the provider we would return on 24 July to conclude the inspection.
The inspection team consisted of two inspectors.
Before the inspection, we reviewed the information we hold about the provider. This included the last inspection report and notifications the provider sent us about significant events affecting people using the service.
During the inspection, we spoke with five people using the service, interviewed four members of staff and spoke with the provider / registered manager and deputy manager. We also used the Short Observational Framework for Inspection (SOFI) during lunchtime on the first day of our inspection. SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed the care records for four people using the service and looked at other records, including medicines records, staff recruitment records and records related to the management of the home.
We spoke with a community nurse and a social worker during our visit. Following the inspection, we spoke with two relatives and a tissue viability nurse.
Updated
3 September 2015
This inspection took place on 22 and 24 July 2015. The visit on 22 July was unannounced and we told the provider we would return on 24 July to conclude the inspection.
We last inspected the service in August 2013 when we found no breaches of the regulations.
Gordon Lodge Nursing Home provides accommodation for people who require nursing or personal care. When we inspected there were nine older people using the service. People using the service had general nursing care needs and some people were living with dementia.
The registered provider, Mrs Andall, is also the registered manager of the service. 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.
We found four breaches of the regulations. The provider did not always follow systems for protecting people who used the service. The provider did not always assess the risks to people using the service and did not always act on assessments of possible risks. Staff did not always follow systems to ensure that people consistently received their medicines safely and as prescribed. Checks and audits the provider / manager carried out did not identify issues that they needed to address.
You can see what action we told the provider to take at the back of the full version of the report.
People told us they were well cared for by staff who understood their needs.
The provider ensured staff completed the training they needed to work with people using the service.
Where people were not able to make decisions about the care and treatment they received, the provider acted within the law in people’s best interests.
People told us the nurses and care staff working in the home were caring and during the inspection, we saw staff treated people with kindness and patience.
There was no evidence of analysis or learning from accidents and incidents involving people using the service.
The provider had systems in place to monitor the day to day operation of the service but these were not always effective and there was a lack of clarity about the management of the home.