During an assessment under our new approach
About the service
Courtlands Lodge is a care home. There were 17 people using the service at the time of the assessment.
Who the service is for
Courtlands Lodge is a care home providing accommodation, personal care and nursing care for older and younger adults. The service supports people living with dementia and people with a range of mental health needs.
Our view of the service
We carried out this assessment on 20, 25 August and 1 September 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.
People were protected from avoidable harm by staff who understood individual risks and safeguarding responsibilities. Staff demonstrated an understanding of least restrictive practice and adapted their approach to meet people's needs. However, risk assessments and care plans did not always provide sufficient guidance on responding to refusals of care. The registered manager recognised these areas for improvement and undertook a review of care plans and associated documentation.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives.
Learning was discussed and shared through supervision and staff meetings. However, more consistent management oversight of incidents was needed to ensure learning and any actions taken were regularly reviewed and clearly evidenced.
Medicines were managed safely, and staff followed appropriate processes for their storage, administration and recording. Staff were recruited safely and received regular training, supervision and support.
The environment was clean and well maintained, with regular safety checks and ongoing improvements.
People's needs had been assessed, and staff demonstrated a good understanding of people's support requirements. Staff were able to describe personalised approaches to supporting people, including providing reassurance, repeating information where required, allowing people time and adapting support to individual preferences. Staff worked effectively with healthcare professionals and monitored people's health and wellbeing to support positive outcomes. Staff understood the importance of gaining consent and described using explanation, reassurance and revisiting people at a later time if support was initially declined. However, records did not always clearly demonstrate how best interest decisions should be implemented in practice or provide enough detailed guidance regarding responses to refusals of care. Following discussions during the assessment, the registered manager reviewed care documentation and involved relevant health and social care professionals to review some decisions where people lacked capacity.
People were supported to maintain their independence and make choices about how they spent their time. We observed people accessing the community and leaving the service independently or with support from companions. Staff understood the importance of promoting people's independence and encouraging participation in activities and social opportunities. Whilst people experienced different levels of engagement depending on their individual needs and abilities, the registered manager had recognised that some people were at risk of social isolation and had started exploring additional ways to promote engagement and meaningful occupation.
People received support from staff who knew them well and understood their individual needs and routines. Care plans contained personalised information and reflected their views and individual choices. Staff demonstrated a good understanding of people's communication needs and how to support them to be involved in day-to-day decisions. Resident meetings took place and provided opportunities for people to share feedback. The service recognised the importance of supporting people to maintain relationships and contact with those who were important to them.
Staff spoke positively about the leadership of the service and described managers as approachable, supportive and willing to listen. Staff told us they felt able to raise concerns and were confident these would be addressed.
The registered manager demonstrated a clear understanding of the culture they wanted to promote and explained how they worked alongside staff to ensure they understood the values and standards of the service. Staff described good teamwork and communication and said they received regular supervision and support in their roles. This helped promote a positive culture and shared understanding of expectations across the service.
However, governance systems had not always been effective in ensuring care plans and associated records provided enough detail regarding responses to refusals of care and best interest decisions. Management oversight was not always sufficiently robust to identify and address areas for improvement within records and incident management. We found examples of subjective language within records which was not always reflective of person-centred recording. Incident records did not always demonstrate enough effective review, analysis and learning from events. Despite this, the registered manager demonstrated a commitment to continuous improvement through ongoing service reviews and action plans. They welcomed feedback, took prompt action where improvements were identified and fostered a culture where staff felt able to raise concerns and share ideas.