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Archived: Atherton Lodge Inadequate

The provider of this service changed - see new profile

We are carrying out a review of quality at Atherton Lodge. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 30 June 2018

We carried out an inspection on 5 and 7 July 2017. The first day was unannounced.

Atherton Lodge is a privately owned two-storey detached property that has been converted and extended into a care home. It is registered with Care Quality Commission (CQC) to provide accommodation for up to 40 older people who require personal and nursing care. Some people at the service were living with dementia. At the time of the inspection there were 17 people living at the service who required accommodation and personal care only.

There was no registered manager in place. 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. There was a manager in post who had been interviewed by CQC for registration at the service.

At the last comprehensive inspection on the 12 and 13 December 2016 we identified breaches of Regulations 11, 12, 15 and 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014 and found that a number of improvements were required at the service. People were not protected from the risk of unsafe care and treatment and the systems and processes which the registered provider had in place to assess, monitor and improve the quality and safety of care were not effective. Consent to care and treatment was not always sought in line with relevant legislation and the environment was not suitable to meet the needs of people living with dementia. We asked the registered provider to take action to address these areas.

This inspection found continued breaches of Regulations 11, 12, 15 and 17 as well as additional breaches of regulation 10 and 14 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded

Medication was not administered safely. Risk assessments and care plans were not followed for the safe administration of one person’s medicines. Staff failed to protect one person from a known risk of harm putting this person’s health and safety in danger. Instructions provided by a GP for the administration of medication were not followed. Records relating to medicines were not always kept up to date in a timely manner.

We found that parts of the service and equipment in use were not clean. There were ongoing risks identified with regards to infection control. Eight call bell cords were found to be tied up in toilets and communal bathrooms near to people’s bedrooms. This meant people were placed at unnecessary risk as the ability to call for help in an emergency had been restricted. Rooms containing hazardous equipment and substances were not secure. The management of health, safety and infection control was poor.

People were not consistently supported to have maximum choice and control of their lives. People were not always supported in the least restrictive way possible. Bedroom doors were locked at the service and this restricted people from gaining access to their bedrooms and possessions as and when they wished. Policies and systems relating to the Mental Capacity Act and Deprivation of Liberty safeguards in the service were not robustly followed.

The registered provider’s statement of purpose identified that the home is able to support people living with dementia. However, we found that the environment was not dementia friendly and limited adaptions had been made to aid and support people who were living with dementia.

People’s privacy was not ensured as records were not held securely at the service. People’s rights to choice, privacy and dignity were not always respected.

People were not always protected from the risk of malnutrition and dehydration. Where

Inspection areas



Updated 30 June 2018

The service was not safe.

Medication administration was not safe. People were not adequately protected from the risk of harm.

Infection control was poorly managed. The service and equipment used was not clean.

Pull cords to trigger the call bell systems in bathrooms and bedrooms were not always in place or were not in reach for people to use in the event of an emergency.

Accidents and incidents were reviewed on a regular basis at the service. However, the manager failed to identify appropriate actions to be taken minimise risk.

Recruitment procedures were safe. The deployment of staff was proportionate to people's needs and safety.



Updated 30 June 2018

The service was not effective

People�s rights and best interests were not fully protected in line with the Mental Capacity Act 2005. People were restricted from gaining access to their bedrooms and personal belongings.

The environment was not dementia friendly. There were limited adaptations or equipment in place to support people living with dementia.

People had access to health professionals as required. However, advice and guidance was not always followed appropriately.

People were cared for and supported by staff who had received appropriate training and support for their role.


Requires improvement

Updated 30 June 2018

The service was not consistently caring.

People�s privacy, dignity and confidentiality were not always respected.

People were supported by staff they described as kind, friendly and caring.

Family members told us they were free to visit the service when they wished. Observations showed they were welcomed when visiting their relatives.


Requires improvement

Updated 30 June 2018

The service was not always responsive

Care plans varied in detail. Accurate information regarding a person�s care needs was not always recorded. Information in daily records was not always accurate.

Food and fluid charts were not accurately completed, reviewed or analysed. People were not protected from the risk of dehydration and malnutrition.

The registered provider had a complaint policy in place. However, records of verbal complaints were not accurately maintained.

Staff promoted meaningful activities with people which reflected their individual interests.



Updated 30 June 2018

The service was not well led

The manager and registered provider had failed to make the necessary improvements to the service following our last inspection visit.

The registered provider�s quality assurance systems were not effective. Systems did not always identify areas of concern or where improvements to changes were required.

CQC were not notified as required about incidents that had occurred at the service.