You are here

Inspection Summary

Overall summary & rating


Updated 5 December 2017

At the last inspection on October 2016 we found breaches of legal requirements. We asked the provider to take action to make improvements on record keeping. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found improvements were made.

Cepen Lodge Care Home provides residential care for up to 63 older people. The first floor is designated for people with a diagnosis of dementia. At the time of the inspection there were 60 people living at the service.

This inspection was unannounced and took place on 25 and 26 October 2017.

A registered manager was in post. 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 that staff were not always signing medicine administration records (MAR) for medicines administered. MAR charts were audited daily but the audit record showed staff were not signing medicines records for medicines administered. Procedures were in place for staff that consistently failed to sign medicines records.

Procedures on the administration of when required medicine (PRN) was not in place for all PRN medicines. For example, a PRN protocol was not in place for the treatment of angina attack. We noted that for some people the instructions for the application of topical creams were not clear.

Care plans were mainly person centred and we found consistent use of terminology which showed a respectful manner. In places the information in the care plans was not cross references and not consistent with the area of need.

People said they felt safe. The staff we spoke with said they had attended safeguarding of abuse training. They knew how to identify abuse and were clear on the procedures for reporting their concerns.

Assessments tools were used to identify risk and action plans were developed on how to minimise the risk to people. The staff were clear on the actions in place to manage the identified risk. For example lowering beds for people at risk of falls. Falls audits included the preventative measures and lesson learnt from the event. We saw from the audit the number of falls had reduced from the preventative actions taken.

Intervention charts in place followed risk assessments and were well completed. 24 hour fluid charts detailed people’s individual fluid intake target and were totalled throughout the day. Where people did not have enough to drink the information was passed to staff during handovers. A member of staff said the introduction of the monitoring fluids had improved people’s health.

Incident and accidents reports were completed. An online incident reporting system was used by staff to record accidents and incidents. The reports were investigated at provider level for patterns and trends and the registered managers received feedback on the analysis of accidents.

The number of staff on duty reflected the duty rota. We saw staff available at all times. Staff took their time with people and care was not observed to be rushed. However, staff said there was staff sickness. Action was being taken by the registered manager to manage sickness and absences.

Staff told us the training was good. There was mandatory training set by the provider which staff said they had attended. There were opportunities for vocational qualifications. Staff said during their one to one supervisions they discussed concerns, the people at the service and performance.

Staff knew the day to day decisions people were able to make. People’s capacity to make decisions about their care and treatment was assessed with accompanying best interest decisions in plac

Inspection areas


Requires improvement

Updated 5 December 2017

The service was not consistently safe.

Medicines records were not always signed for medicines administered and procedures were not always in place for medicines to be taken when required (PRN).

Risks identified were assessed and action plans were developed on minimising the risk. Members of staff were knowledgeable on actions necessary to reduce risks.

There were sufficient staff to support people and we observed that staff were visible and available to people.

People said they felt safe and were able to describe what safe meant to them. Staff knew the types of abuse and the responsibilities placed on them to report abuse.



Updated 5 December 2017

The service was effective.

Staff enabled people to make choices. People�s capacity to make complex decisions were assessed and best interest decisions were taken where people lacked capacity.

Staff had the knowledge and skills needed to carry out their roles. There were arrangements in place to support staff to meet the responsibilities of their role. Staff attended training set by the provider as mandatory and had opportunities for personal development through one to one supervision.

People�s dietary requirements were catered for



Updated 5 December 2017

The service was caring

People were treated with kindness and with compassion. We saw positive interactions between staff and people using the service. Staff knew people�s needs well and there was a calm and friendly atmosphere.

People�s rights were respected and staff explained how these were observed.



Updated 5 December 2017

The service was responsive.

Care plans were mainly person centred support plans but some needed to be cross referenced to ensure information was accurate and up to date.

The registered manager investigated complaints and responded formally on the action to be taken to resolve complaints.



Updated 5 December 2017

The service was well led.

There was strong emphasis on continuous improvement. The views of people using the service were gathered. Quality assurance systems were in place and where shortfalls were identified there were action plans on meeting these standards.

Staff were aware of the values of the organisation. They said the team worked well together.