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North Lodge Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 23 January 2020

About the service

North Lodge Care Home is a residential care home providing personal and nursing care to 19 people aged 65 and over at the time of the inspection. The service can support up to 21 people.

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

Risks to people were not always assessed to help ensure they were safely managed. 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. However, the registered manager had not always submitted applications where needed to deprive people of their liberty under the deprivation of liberty safeguards (DoLS). This meant some people’s freedoms were restricted without lawful authority.

Staff received support in their roles through an induction, training and supervision. However, improvement was required to ensure staff received refresher training in areas relevant to people’s needs, in line with the provider’s training requirements. Improvement was also required to ensure the provider’s quality assurance systems were robust in identifying issues and driving service improvements.

We have made a recommendation about using nationally recognised assessment tools when assessing people’s needs.

People told us they felt safe living at the home. They were protected from the risk of abuse because staff knew to follow the provider’s safeguarding and whistle blowing procedures, should the need to do so. There were enough staff working on each shift to meet people’s needs. The provider followed safe recruitment practices. Staff were aware of the action to take to reduce the risk of infection. They knew to report and record the details of any accidents or incidents which occurred at the home. The registered manager reviewed accident and incident information for learning and to reduce the risk of repeat occurrence.

Medicines were safely stored, administered and administration was accurately recorded. People had access to a range of healthcare services when needed and staff worked to ensure people received consistent and effective support when moving between different services. People were supported to maintain a balanced diet. The home had been adapted to meet people’s needs.

Staff treated people with kindness and compassion. People were involved in making decisions about the support they received. Staff treated people with dignity and respected their privacy. People had care plans in place which reflected their individual needs and preferences. They were supported to take part in activities which they enjoyed and to maintain the relationships that were important to them.

People and staff spoke positively about the working culture and management of the service. The registered manager sought people’s views on the service through regular meetings and an annual survey. They sought to make improvements based on people’s feedback. The provider had a complaints procedure in place and people told us they knew how to complain. The expressed confidence that any issues they raised would be addressed to their satisfaction.

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 good (published 13 May 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to the failure to comprehensively assess and manage areas of risk to people and the failure to ensure lawful authorisation had been given to deprive people of their liberty under DoLS, where this was in their best interests.

Please see the action we have told the provider to take at the end of this report.

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


Requires improvement

Updated 23 January 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 23 January 2020

The service was not always effective.

Details are in our effective findings below.



Updated 23 January 2020

The service was caring.

Details are in our caring findings below.



Updated 23 January 2020

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 23 January 2020

The service was not always well-led.

Details are in our well-Led findings below.