CQC report explained · a residential care home, run by The Lodge Trust CIO
The Lodge
Main Street, Market Overton, Oakham, LE15 7PL
Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Safeguarding concerns were not always identified, investigated or reported to the relevant agencies. Some health risk assessments and care plans were missing, although the registered manager said these had been put in place after the inspection.
- Effective?
- Good
- This question was not inspected in this report.
- Caring?
- Good
- This question was not inspected in this report. Inspectors did report that staff were caring, respected people's dignity and involved people in decisions.
- Responsive?
- Good
- This question was not inspected in this report. Inspectors found that people were supported with activities, interests, choices and community links.
- Well-led?
- Requires improvement
- Management oversight and quality checks did not reliably identify problems. Some required notifications were not sent to CQC, and governance systems were not consistently applied.
What inspectors found, December 2023
The Lodge rated Requires Improvement; inspectors found caring support, but safeguarding and management systems were not reliable enough.
Inspectors visited on 24 and 25 October and 1 November 2023. The first visit was unannounced. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, staff files and policies.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found that some safeguarding incidents were not identified, investigated or reported properly. Some health risk assessments and care plans were missing, and not all staff had completed required learning disability and autism training.
People were described as receiving warm, respectful and person-centred care. They were supported to make choices, take part in activities and use community facilities. Medicines were given as prescribed, but medicines audits did not always check enough areas to find possible problems.
The overall rating fell from Good at the previous inspection, published in 2017. The report says the home started an action plan and made some changes during and after the inspection, but CQC will monitor progress and meet the provider to discuss further improvements.
Kind and respectful care
Inspectors found that staff understood people well and supported them with warmth, compassion and dignity.
“Staff were caring and provided support to people with warmth, compassion and preserved their dignity.” from the report
People had a voice
People were involved in decisions about their lives and could raise views and concerns through regular meetings.
“People were listened to. Monthly 'Our Voice' meetings took place where people could share their wishes and concerns.” from the report
Community and activities
People were supported to pursue interests and take part in community life, including local clubs, churches and other activities.
“People living at the service were engaged in local community life, and enjoyed attending local churches, the bowls club and the village pub.” from the report
Medicines generally given correctly
Inspectors found no medicine errors and saw that records, storage and arrangements for some complex medicines were in place.
“Whilst there were no medicine errors identified, the audit in place did not always cover all areas” from the report
Safeguarding referrals
seriousNot all safeguarding matters were identified, investigated or reported to the right agencies. This meant chances to review safety and reduce risk were missed.
“Safeguarding referrals were not always completed. Whilst policies and processes were in place these were not sufficiently embedded into staff practice.” from the report
Weak management oversight
seriousThe provider's checks did not reliably find problems with care plans, risk assessments and reporting. This was a breach of the governance regulation.
“Systems and processes were not effectively established to provide oversight and drive improvements required. This placed people at risk of harm.” from the report
Training gaps
needs fixingSome staff had not completed mandatory training about learning disabilities and autism.
“We reviewed the training matrix and found some staff had not completed mandatory training on learning disabilities and autism.” from the report
Medicines audit gaps
needs fixingMedicines were given as prescribed, but the audit did not always cover enough areas to identify possible issues quickly.
“This meant opportunity to identify errors and prevent recurrence could be missed.” from the report
Recruitment records
needs fixingIn three of the four staff files checked, gaps in employment history had not always been explored at interview.
“We reviewed 4 staff files and in 3 found gaps in employment were not always explored at interview.” from the report
- 01What changes have you made to ensure every safeguarding incident is identified, investigated and reported to the correct agency?
- 02How do you now check that each person's health conditions, including mental health needs, have a current risk assessment and care plan?
- 03What checks are now included in medicines audits, and how do you know that possible errors would be found quickly?
- 04Have all staff completed mandatory learning disability and autism training, and how is outstanding training monitored?
- 05What has changed in the provider's quality assurance system since the inspection, and can you show the latest audit or action plan?
This was a focused inspection of Safe and Well-led; the other key question ratings were not inspected and the overall rating used previous ratings for those areas. This explanation was written from the published report of 9 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.
Every inspection of The Lodge
2 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017GoodSafe: GoodWell-led: Good
- August 2016
Registered with the Care Quality Commission on 29 August 2016.
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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