Ravensworth Lodge

Updated 16 February 2023

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector and an Expert by Experience. 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

Ravensworth Lodge 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. Ravensworth Lodge 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

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. 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 used all this information to plan our inspection.

During the inspection

We spoke with 7 people using the service and with 11 staff members; including 8 care staff, a maintenance person, a cook, a domestic staff, and a consultant. We reviewed 3 paper copy care plans, 3 electronic care plans, and 4 staff files. We observed mealtime arrangements, the medication round and looked at records associated with accidents, incidents, risk and quality assurance processes used to check the service.

Updated 16 February 2023

About the service

Ravensworth Lodge is a residential care home providing regulated activity of personal care to up to 24 people. The service provides support to older people. At the time of our inspection there were 21 people using the service.

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

People did not always receive care and support to meet their assessed needs in a timely manner. Staff were working without sufficient support and guidance due to a lack of appropriate management support. Processes to ensure enough suitably trained staff were always on duty were not effective. Due to a lack of appropriate management of the service, staff did not receive appropriate checks, support and supervision to carry out their roles effectively.

The provider did not have oversight to ensure staff and health professionals had access to complete care records and up to date policies and procedures. There was no manager oversight to ensure new electronic care recording processes in place for staff to use remained effective, putting people at risk from harm. Information used to manage the risks was not robustly completed. For example, checks to keep people safe during a fire were not completed as required.

People were at risk from otherwise avoidable harm. Staff told us they were not confident in the processes in place to raise any concerns internally for further investigation. There was no clear process for staff to follow to ensure accidents, incidents and safeguarding concerns were recorded and reported as required to keep people safe. We were unable to check all required actions had been completed as the provider had failed to ensure all notifications had been submitted to the CQC as required.

There was no clear strategy in place at provider level to manage the service and no operational plan that ensured the service remained legally compliant with required regulation. The provider had failed to display CQC performance ratings both in the home and on their website. Provider oversight had failed to ensure appropriate checks were completed or reviewed to ensure systems and processes remained effective. We found a range of quality assurance audits had not been completed to check the service since January 2022.

Processes in place to ensure people lived in a clean environment and were protected from the risks of air born viruses were not robust. Where people were incontinent, insufficient numbers of staff meant people were not always assisted in a timely way as required. Deep cleaning of 3people’s carpeted rooms failed to ensure they remained free from the smell of urine and there was no plan in place to implement remedial actions for improvement.

People told us they received their medicines safely. However, checks were not completed that ensured the safe management of medicines followed best practice guidance.

People told us they felt safe and were happy with their care. Staff were knowledgeable and skilled. People received support from a range of health professionals when required. Observations and feedback confirmed the failings we found had a low impact on people at the time of the inspection, but people were at risk if continued.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update

The last rating for this service was good (published 21 March 2019).

At our last inspection we recommended the provider developed more robust systems to record and analyse accidents and incidents and improved their policy regarding medicines administration. At this inspection we found further improvements were required.

Why we inspected

We received concerns in relation to the management of the home, provider oversight, management of risks and staffing. 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 from good to requires improvement based on the findings of this inspection.

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

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to the management of the service, provider oversight (including risk management and governance checks), quality assurance, staffing and recruitment.

We have made recommendations for the provider to review and improve their policy and practice for infection prevention and medicines control and the reporting of accidents incidents and safeguarding.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.