We carried out a review of the data available to us about The Lodge Retirement Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Lodge Retirement Home, you can give feedback on this service.
The Lodge Retirement Home is a residential care home providing personal care for up to 14 people aged 65 and over. At the time of the inspection, 12 people were living in the home. The home provides accommodation over two floors and there is a stair lift available to access the first floor.
People’s experience of using this service and what we found
Improvements had been made and the home was well-led. The registered manager had a robust governance and auditing system in place. Audits were up to date and identified any lessons learnt following incidents and accidents so that they could take action to keep people safe.
The planning and provision of meaningful activities for people had improved. One person told us, “[Staff name] has made all the difference for me with the activities. There is lots to do in the afternoons, we have lots of different projects.” Another commented, “There is enough to do here at the home. They organise things for you.”
People told us they were safe at The Lodge Retirement Home and risks were managed well. A person told us, “I feel safe at the Lodge. I trust the staff here, they are very good, lovely actually, more like family.”
Medicines were managed, stored and administered safely. The home had recently moved medicines into each person’s bedroom. One staff member stated, “Medication being in the room makes it more personalised. You aren’t going around with a trolley and less likely to make an error, the pharmacy supported us to make this change.”
Care plans and risk assessments were person centred. People and relatives told us staff knew them well. Staff supported people in a kind and compassionate way, considering their dignity and respect.
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 of the culture within the home. One person told us, “Staff here are lovely, they are just like your family, you feel as though you can talk to them about anything.” Staff and relatives we spoke with all described the home as a “family”. The registered manager told us, “The Lodge is a hidden gem, you may not know it’s here but once you come in, you’re hooked”.
The home was following up to date government guidance relating to COVID-19 for care homes. Cleaning and infection control procedures followed the relevant COVID-19 guidance to help protect people, visitors and staff from the risk of infection.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk.
Rating at last inspection and update
The last rating for this service was requires improvement (published 6 August 2019).
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last 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 COVID-19 and other infection outbreaks effectively.
The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Lodge Retirement Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
The Lodge Retirement Home is a residential care home providing personal care to up to 14 people aged 65 and over. At the time of the inspection, 13 people were living in the home. The home provides accommodation over two floors and there is a stair lift available to access the first floor.
People’s experience of using this service and what we found
The provider lacked effective governance systems to identify concerns in the service and drive the necessary improvement. At times, there was a lack of detailed records regarding people's support needs and any potential risks posed to them. Records were not always in place to demonstrate effective monitoring of environmental safety systems such as fire and legionella.
The oversight of infection control procedures needed improving and medicines were not always managed safely. People told us there was enough staff to meet their needs but the provider did not use a systematic approach to ensure sufficient staff were deployed to meet people’s needs at all times. We have made a recommendation about this.
Although people told us they were able to make choices about their care, the application of the Mental Capacity Act was not always clear. We have made a recommendation about this.
The planning and provision of meaningful activities for people needed to improve and we have made a recommendation about this.
Despite this, people were happy living at The Lodge Retirement Home and people told us they felt safe. People were positive about the food and were supported to access health care professionals to maintain their health. People were supported by staff who were kind, caring and who understood their likes, dislikes and preferences. There was a dedicated and consistent staff team, most staff had worked at the service for a considerable length of time and they had got to know people well.
The provider was responsive to our concerns and began taking action to make improvements in the service.
Rating at last inspection and update
The last rating for this service was Good (report published 4 October 2016).
The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvement. Please see the Safe, Effective, Responsive and Well-led sections of this full report.
We have identified a breach in relation to the governance of the service. We also identified breaches in relation to the management of medicines and the management of risk.
Please see the action we have told the provider to take at the end of this report.
Why we inspected
This was a planned inspection based on the previous rating.
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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.
People told us they felt safe with the home’s staff. Relatives we spoke with had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of potential harm.
Risk assessments were in place to protect people from any identified risks and help keep them safe. There were also risk assessments in place to help keep people safe in the event of an unforeseen emergency such as fire or flood.
Thorough recruitment processes were in place for newly appointed staff to check they were suitable to work with people. There were sufficient numbers of staff to meet people’s needs safely. People told us there were enough staff on duty and records and staff confirmed this.
People were supported to take their medicines as directed by their GP. Records showed that medicines were obtained, stored, administered and disposed of safely.
The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no-one living at the home was currently subject to DoLS, we found the registered manager understood when an application should be made and how to submit one. We found the provider to be meeting the requirements of DoLS. There were no restrictions imposed on people and they were able to make individual decisions for themselves. The registered manager and staff were guided by the principles of the Mental Capacity Act 2005 (MCA) regarding best interests decisions should anyone be deemed to lack capacity.
Each person had a plan of care which provided the information staff needed to provide effective support to people. Staff received training to help them meet people’s needs. Staff received an induction and regular supervision including monitoring of staff performance. Staff were supported to develop their skills through additional training such as National Vocational Qualification (NVQ) or care diplomas. All staff completed an induction before working unsupervised. People were well supported and relatives said staff were knowledgeable about their family member’s care needs.
People told us the food at the home was good and they were offered a choice at mealtimes.
People’s privacy and dignity were respected. Staff had a caring attitude towards people. We saw staff smiling and laughing with people and offering support. There was a good rapport between people and staff.
People were involved as much as possible in planning their care. The registered manager and staff were flexible and responsive to people's individual preferences and ensured people were supported in accordance with their needs and abilities. People were encouraged to maintain their independence and to participate in activities that interested them.
The registered manager operated an open door policy and welcomed feedback on any aspect of the service. The registered manager and deputy manager monitored the delivery of care.
There was a stable staff team who said that communication in the home was good and they always felt able to make suggestions. They confirmed management were open and approachable.
A system of audits were in place to measure and monitor the quality of the service provided and this helped to ensure care was delivered consistently. Suggestions on improvements to the service were welcomed and people’s feedback was encouraged.
There was a clear complaints policy and people knew how to make a complaint if necessary.
We looked around the home which was clean and free of unpleasant odours. All the room were single occupancy with hand basins and eight rooms had ensuite hand basins and toilets. We saw that individuals had personalised their room with photographs, books, TV's and pictures. There was a chair lift so people could access the first floor.
During our visit we spoke with three people who use the service and four staff including the registered manager. We spent time observing how staff interacted and supported people. We saw staff treat people in a sensitive, respectful and professional manner.
One person told us that they were 'very happy and the food was excellent' and 'that when I first came to the home I was feeling very low'. Other people told us that they had no complaints. People told us that staff would always knock when they entered their room.
We saw that care plans looked at all aspects of people's care needs and that people's assessment looked at their goals and the support required.
We looked at four of people's care records and noted that assessments had been carried out by the home but the care plans did not identify how needs were met or choices of activities. One care staff told us that they did not look at people's care plans because they knew the people at the home and knew what they needed.
Another person we spoke with said that they felt safe in the home and that they would "have no problem" to speak to a member of staff if they felt concerned, the same person added that "I feel safe and happy here."
The people we spoke with about staff having regard to hygiene and infection control measures when they were working told us staff wore gloves and aprons, and "always cleaned up after themselves." There were no concerns raised by the people we spoke to about cleanliness or infection control.
The last care quality commission inspection had identified some minor action regarding having a locked box chained to the wall and the use of a metal box for medication storage which had been implemented.
We saw evidence of residents and relatives meetings, this showed us that the residents and relatives were being informed of changes; a record in the minutes told us that their view on food choices and activities had been sought.