22 and 24 July 2015
During a routine inspection
This inspection took place on 22 and 24 July 2015. The visit on 22 July was unannounced and we told the provider we would return on 24 July to conclude the inspection.
We last inspected the service in August 2013 when we found no breaches of the regulations.
Gordon Lodge Nursing Home provides accommodation for people who require nursing or personal care. When we inspected there were nine older people using the service. People using the service had general nursing care needs and some people were living with dementia.
The registered provider, Mrs Andall, is also the registered manager of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found four breaches of the regulations. The provider did not always follow systems for protecting people who used the service. The provider did not always assess the risks to people using the service and did not always act on assessments of possible risks. Staff did not always follow systems to ensure that people consistently received their medicines safely and as prescribed. Checks and audits the provider / manager carried out did not identify issues that they needed to address.
You can see what action we told the provider to take at the back of the full version of the report.
People told us they were well cared for by staff who understood their needs.
The provider ensured staff completed the training they needed to work with people using the service.
Where people were not able to make decisions about the care and treatment they received, the provider acted within the law in people’s best interests.
People told us the nurses and care staff working in the home were caring and during the inspection, we saw staff treated people with kindness and patience.
There was no evidence of analysis or learning from accidents and incidents involving people using the service.
The provider had systems in place to monitor the day to day operation of the service but these were not always effective and there was a lack of clarity about the management of the home.