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The Lodge Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 June 2021

About the service

The Lodge Care Home is a residential home registered to provide accommodation and personal care for up to 45 older people, some who may be living with dementia. At the time of our inspection there were 34 people using the service.

The home is built over four floors, with a number of communal and dining areas on the ground floor.

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

Staff used risk assessment tools to assess if people were at risk of pressure ulcers, falls, malnutrition and skin integrity. Care plans were developed to ensure measures were in place to mitigate these risks. Risk assessment tools were not always completed correctly, therefore there was a risk that measures in place were not always as effective as they could have been.

Governance systems, audits and analysis of accidents and incidents had not led to improvements. The information recorded by staff was not always consistent, in enough detail and not always submitted to the registered manager. As a result, some safeguarding incidents were not reported to the local safeguarding authority for investigation.

Medicine administration and management was not always done safely or following best practice guidance. People were not always receiving their medicines as intended by the prescriber.

When things went wrong, lessons were not always learnt and staff practices were not changed to improve the quality and safety of the care provided.

Staff told us they were aware of people’s needs, however there was not enough staff to meet people’s needs safely and effectively. We observed people left waiting for staff, sitting in wheelchairs without pressure relieving cushions in place, although care plans detailed they had to sit on those. This increased the risk of people’s skin breaking down.

People felt safe in the home and told us they liked living there. Relatives were complimentary about staff and management and told us they felt the staff team provided care and support to people in a safe way.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 14 December 2018).

Why we inspected

We received concerns in relation to the management of medicines, people’s personal hygiene needs not being met and lack of accurate records kept about people’s care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, safeguarding and governance systems at this inspection.

Full information about CQC’s regulatory response to th

Inspection areas


Requires improvement

Updated 10 June 2021

The service was not always safe.

Details are in our safe findings below.



Updated 10 June 2021



Updated 10 June 2021



Updated 10 June 2021


Requires improvement

Updated 10 June 2021

The service was not always well-led.

Details are in our well-led findings below.