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

Cepen Lodge

West Cepen Way, Chippenham, SN14 6UZ

Goodpublished 7 December 2023, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found improved risk plans, safe medicines management, suitable infection control and enough staff overall. They raised concerns about intermittent evening supervision in the dementia household and missing checks that medicine patches remained in place.
Effective?
Good
This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
Caring?
Good
This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
Responsive?
Good
This question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
Well-led?
Good
Inspectors found that quality checks were embedded, improvement actions were followed up and the management team was approachable and responsive to feedback.
The latest report, explained

What inspectors found, December 2023

Cepen Lodge is rated Good; inspectors found safe, kind care, but evening supervision and checks on medicine patches needed attention.

This was an unannounced focused inspection in response to concerns about staffing and their effect on care. Inspectors visited over three days, spoke with people, relatives, staff and healthcare professionals, and reviewed care, medicines, recruitment and quality records.

The home was rated Good for Safe and Well-led. Inspectors found enough staff overall, improved risk assessments, safe medicines management, good infection control and regular checks on quality and safety. People and relatives described people as safe and staff as kind and caring.

There were two areas for improvement. People living in the dementia household had intermittent supervision when staffing reduced to night levels in the evening. There was also no recorded check between applications to confirm that medicine patches stayed in place.

The overall rating improved from Requires Improvement to Good. However, this was a focused inspection of Safe and Well-led only. The ratings for the other three questions were carried forward from the previous inspection.

What inspectors praised
  • Improved risk planning

    Risk assessments were reviewed monthly and updated when people's needs changed. Staff had detailed guidance for risks such as falls, skin problems and pressure ulcers.

    Risk management plans were available to give staff guidance on how to support people safely.from the report
  • Kind relationships

    People and relatives said staff were kind and caring. Inspectors also saw warm interactions and staff who knew people well.

    We observed during our inspection warm interactions between people and staff, and it was clear staff knew people very well.from the report
  • Stronger management checks

    The home had regular quality checks by managers and other staff. Actions for improvement were recorded, shared and followed up.

    At this inspection we found systems were embedded and quality monitoring was regularly taking place.from the report
  • Improved medicines management

    Inspectors found that people received medicines as prescribed. Staff had medicines training and their competence was checked.

    At this inspection, this had improved, and people had their medicines as prescribed.from the report
What inspectors were concerned about
  • Evening supervision

    needs fixing

    When staffing reduced to night levels at 8pm, people in the dementia household were sometimes left with intermittent supervision. Inspectors recommended reviewing evening staffing through observations and feedback from people.

    This meant people had intermittent staff supervision in the dementia household.from the report
  • Medicine patch checks

    needs fixing

    The home recorded when patches were applied and changed, but did not record checks between applications to confirm they were still in place. The manager introduced a checking procedure, which inspectors recommended monitoring.

    We found there was no documented monitoring that the patches remained in place.from the report
Questions to ask them, based on this report
  1. 01What staffing arrangements are now in place in the dementia household after 8pm?
  2. 02How do you observe evening care and gather people's feedback when deciding staffing levels?
  3. 03How often are medicine patches checked between applications, and where is this recorded?
  4. 04What ratings for Effective, Caring and Responsive were carried forward from the previous inspection?

This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 7 December 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 Cepen Lodge

6 rated inspections over 9 years: the service has improved, from Requires improvement to Good.

  1. December 2023Goodcurrent ratingup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Cepen Lodge

  2. March 2022Requires improvementdown from Good
    Safe: Requires improvementWell-led: Requires improvement

    We are reading this report · the original is on cqc.org.uk

  3. May 2021Goodstayed Good
    Safe: Requires improvementWell-led: Good

    Read this report on cqc.org.uk

  4. December 2017Goodup from Requires improvement
    Safe: Requires improvementWell-led: Good

    Read this report on cqc.org.uk

  5. January 2017Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good

    Read this report on cqc.org.uk

  6. December 2014Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  7. February 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. January 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. October 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. October 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  11. September 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  12. December 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  13. February 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  14. November 2010

    Registered with the Care Quality Commission on 30 November 2010.

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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