Nene Lodge Retirement Home

Updated 1 December 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

One inspector and an Expert by Experience completed the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Nene Lodge Retirement Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Nene Lodge Retirement Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service.

During the inspection

We spoke with 6 people who used the service and 2 relatives for their experience of the service. We also observed staff interaction with people to help us understand people’s experience. We sought feedback from staff and spoke with the registered manager, the provider, assistant manager, 2 care workers, cook and relief cook and 2 domestic staff. We spoke with 3 visiting health care professionals.

We reviewed the care records of 5 people and multiple people’s medicine records. We reviewed 3 staff files and a variety of records relating to the management of the service, including policies and procedures, audits and checks, staff deployment, dependency tool, meeting records and staff training.

Updated 1 December 2022

About the service

Nene Lodge Retirement Home is registered to provide accommodation and support for up to 52 older people. At the time of our inspection, there were 28 people living at the service.

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

Guidance for staff about how to meet people’s individual care needs and mitigate known risks, had not been consistently reviewed, kept up to date or made available.

The provider used a dependency tool to determine staffing levels required. However, this did not consider the layout of the building and the staff rota showed occasions when care staff levels were below what was expected.

People spoke positively about the service they received and highly of the management and staff team. However, examples were given of long wait times for calls for assistance and how staff were constantly busy and lacked time to spend with people.

Medicines management did not consistently follow expected best practice guidance. However, no person had come to harm.

The service was found to be clean and hygienic. Staff had access to personal protective equipment. Clinical waste was not disposed of as required. We discussed this with the provider who agreed to take action.

People’s experience of visiting arrangements differed, with some people raising concerns about restrictions. The provider confirmed there were no restrictions and agreed to notify people and visitors of this.

Systems and processes that monitored quality and safety were not fully effective. Audits and checks were not always recorded to confirm checks had been completed and what the outcome was. This impacted on opportunities to continually develop and improve the service.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). At the time of the inspection, no person had a DoLS. However, we were concerned a DoLS was required for a person and asked the provider to submit an application.

Following the recent pandemic, resident and relative meetings had stopped. However, the provider was planning to introduce these again. People and relatives were confident they could raise any issues or concerns with the management team. Quality assurance procedures included an annual feedback survey for people and relatives to share their experience.

Safeguarding information was available to people. Staff had received training and understood their role and responsibility to protect people from abuse and avoidable harm.

Staff were positive about working at the service and the support they received. Visiting professionals gave positive feedback about their experience of working with staff to support people in their ongoing care needs.

For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

Rating at last inspection

The last rating for the service was good (published 21 February 2020).

Why we inspected

We received concerns in relation risk management and staffing levels. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 changed good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nene Lodge Retirement Home on our website at www.cqc.org.uk.

We have identified two breaches in relation to the provider’s governance systems and processes and staffing at this inspection.

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 from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.