27 July 2022
During an inspection looking at part of the service
West Lodge is a care home providing accommodation for people who require nursing or personal care in one adapted building. The service provides support to adults over 65 years who may have dementia or physical disabilities. The service can accommodate a maximum of 27 service users. At the time of our inspection there were 18 people using the service.
People’s experience of using this service and what we found
There was a lack of consistency in how the service was managed and led. There were no clear roles and responsibilities for staff who were managing the service.
People were not always protected against avoidable harm. When people’s needs changed, responses were slow in ensuring people had appropriate support. Some care records did not accurately reflect risks to people or how these were managed.
People were not supported to have maximum choice and control of their lives. The systems in place did not always mean people were supported in the least restrictive way and in their best interests.
People had access to health care professionals. The management team were building relationships with local health professionals and where necessary, made referrals for additional advice and support.
Staff were recruited safely, and staffing levels were sufficient to support people's needs. Staff had received training that was appropriate to their role.
Following our feedback, the provider began to address our concerns demonstrating their commitment to improving the standard of care delivered to people.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 6 August 2021).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to safe care and treatment, consent and good governance at this inspection.
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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.