CQC report explained · a residential care home, run by Voyage

Aykroyd Lodge

The Crescent, Reedley, Burnley, BB10 2LX

Requires improvementpublished 25 November 2023, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask

Safe?: Requires improvement; Some risks were not fully assessed or managed, including falls and skin care risks. Medicines were mostly managed safely, but topical cream records and as-needed medicine instructions were not always clear.
Effective?: Good; People's health, nutritional and training needs were generally well supported. However, capacity assessments and consent forms had not been reviewed for a long time, and the environment needed improvement.
Caring?: Good; Staff treated people with dignity and respect, offered choices and encouraged independence. Relatives spoke positively about the care.
Responsive?: Requires improvement; Care plans were not always person-centred or up to date, and some specific health-condition plans were missing. Activities, communication support and community trips were positive.
Well-led?: Requires improvement; Governance systems did not always identify concerns or show that risks were dealt with. Staff and relatives were positive about the manager, and staff meetings and supervision were taking place.

The latest report, explained

What inspectors found, November 2023

Rated Requires Improvement; inspectors found kind care and enough staff, but identified serious gaps in risk records and quality checks.

This was an unannounced inspection on 24 and 25 October 2023. One inspector spoke with a resident, a relative and seven staff. They also observed care, toured the building and checked records about medicines, risks, staffing, incidents, maintenance and management.

The home supported three people with learning disabilities and could accommodate up to five. Inspectors found people were treated with dignity, had choices and were supported by enough staff. Food, activities, communication support and access to healthcare were also positive.

However, some safety risks were not properly assessed or recorded. Care plans and consent records were out of date. Medicines records needed improvement, and the home’s checks did not always identify problems or show what action had been taken.

The overall rating changed from Good at the previous inspection, published in January 2018, to Requires Improvement. The home breached regulations about safe care and treatment and good governance. CQC will ask for an action plan and continue to monitor progress.

What inspectors praised

Enough staff
Inspectors saw enough staff to support people without rushing. Recruitment checks were also in place.
“During our inspection, we observed sufficient staff were deployed to meet people's needs and people received support in an unrushed and timely manner.” from the report
Kind and respectful care
People were treated well and staff supported their choices, privacy, dignity and independence.
“People were treated well and their individuality was respected. The manager and staff knew people well.” from the report
Choice and independence
Staff encouraged people to make decisions and do things for themselves where possible.
“People were supported to make their own decisions where possible and staff encouraged independence.” from the report
Activities and community life
People had activities, a sensory room and frequent trips into the community. Staff checked whether people enjoyed these activities.
“Trips out into the community were frequent and the staff assessed whether people enjoyed them.” from the report

What inspectors were concerned about

Risk assessments were missing or out of date
serious
There were no falls or skin care risk assessments despite people being at risk. Existing assessments were not always updated after accidents or changes in need.
“There were no falls risk assessments or skin care risk assessments in place, despite people being at risk in these areas.” from the report
Quality checks did not lead to action
serious
Audits did not always find the problems inspectors identified. When concerns were found, there was limited evidence of action to reduce future risks.
“The provider had failed to operate effective systems to assess, monitor and improve the quality of the service.” from the report
Care plans were not current
needs fixing
Care plans did not always contain enough information about people's current needs, health conditions, goals and preferences.
“Care plans were not always person centred as they did not contain sufficient information to guide staff on people's needs.” from the report
Consent records needed review
needs fixing
Capacity assessments and consent forms had not been reviewed or updated for a long period. This meant the home could not be sure that records reflected people's ability to consent.
“Capacity assessments and consent to care forms had not been reviewed or updated for a long period of time.” from the report
Some medicines guidance was unclear
needs fixing
Topical cream charts were sometimes missing or unclear, and creams were not always dated when opened. Instructions for some as-needed medicines did not give enough detail.
“Topical cream charts were not always in place to guide staff and when they were in place, it was not clear where the creams should be applied.” from the report

Questions to ask them, based on this report

01Have all falls and skin care risk assessments now been completed and reviewed after incidents or changes in need?
02Have every resident's care plan, capacity assessment and consent form been reviewed and updated?
03What changes have been made to topical cream charts and instructions for as-needed medicines?
04How do managers now make sure audits identify problems and record the action taken?
05What improvements have been made to the tired environment and limited signage?

This was an unannounced inspection covering all five CQC questions, including the care provided and the home’s premises. This explanation was written from the published report of 25 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Aykroyd Lodge

3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.

November 2023Requires improvementcurrent ratingdown from Good
Safe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Aykroyd Lodge →
January 2018Goodstayed Good
Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
We are reading this report · the original is on cqc.org.uk
September 2015Good
Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read this report on cqc.org.uk
July 2014
Registered with the Care Quality Commission on 1 July 2014.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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