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Conifer Lodge Residential Home Inadequate

Inspection Summary

Overall summary & rating


Updated 15 January 2020

About the service

Conifer Lodge residential care home providing personal care and accommodation for up to 20 older people. There were 17 people living at the service at the time of our inspection.

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

People could not be assured they would receive safe care. Measures were not in place to protect people from falls from height, scalds and falling furniture. Incidents that occurred within the service were not always reported to the appropriate authorities including the Care Quality Commission.

People’s safety and well-being were at risk. The provider and registered manager failed to make the required environmental improvements identified during our previous inspection. They failed to identify further risks to people from the environment that were found during this inspection.

The provider and registered manager did not have effective systems and process in place to safely monitor the service.

People’s care needs were not always assessed and risks to their health were not always safely monitored.

People were at risk of infection and medicines were not managed safely.

Staff did not receive effective support and guidance from the provider or registered manager.

People and their relatives were provided with little opportunity to share their views of the service. People’s personal information was not securely stored.

Staff were kind and considerate to people and treated them with 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.

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

Rating at last inspection and update: The last rating for this service was requires improvement (published 22 November 2018) and there were two breaches of regulation. 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 not enough improvement had been made and the provider remained in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to the safety, security and suitability of the environment, managing people’s medicines, and assessing and reviewing people’s care needs.

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

Follow up

We will request an action plan for 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.

Inspection areas



Updated 15 January 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 15 January 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 15 January 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 15 January 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 15 January 2020

The service was not well-led.

Details are in our well-Led findings below.