Etherley Lodge

Social Care Org · North East

Overall Rating
Inadequate Last inspected 21 October 2014
Domain Ratings
Safe
Inadequate
Effective
Inadequate
Caring
Inadequate
Responsive
Inadequate
Well-led
Inadequate

View Full CQC Report

16 must-do actions

Must-Do Actions (16)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must ensure that information provided by other health and care professionals is included in people’s care plans to enable staff to care for people appropriately and to protect people's health and welfare.
Regulation 11 (Safeguarding service users from abuse)
Information provided by other health and care professionals was not included in people’s care plans to enable staff to care for people appropriately. ... We made a safeguarding alert to Durham County Council during the inspection as we were concerned about the provider failing to protect this person’s health.
Must Do
Safe
The provider must ensure that comprehensive care information is in place which describes how people are to be cared for, including appropriate risk assessments for identified risks such as falls, and that these are analysed and addressed.
Regulation 9 (Care and welfare of service users)
We found the provider did not have in place care information which described how people were to be cared for. ... There was no analysis of the fall by the provider to ensure the person was safe and there was no risk assessment in place to address their needs.
Must Do
Safe
The provider must ensure that staff are safely recruited, including carrying out appropriate checks and risk assessments for staff with previous convictions, to ensure they are suitable and safe to work with vulnerable people.
Regulation 21 (Requirements relating to workers)
We found staff had not been safely recruited and where some staff had committed offences these were not risk assessed to see if they were safe to work with vulnerable people. ... The provider had not carried out appropriate checks to see if prospective staff members were safe to work …
Must Do
Safe
The provider must ensure the home is sufficiently clean to reduce the risk of the spread of infection, including proper segregation of dirty and clean washing in the laundry area and maintaining cleanliness in the kitchen.
Regulation 12 (Safe care and treatment)
We found the home was insufficiently clean to reduce the risk of the spread of infection. ... The laundry area was cluttered; there was no segregation of dirty and clean washing. ... The kitchen was not sufficiently clean to reduce the risk of infections.
Must Do
Safe
The provider must ensure that premises and equipment are properly maintained and safe, including implementing fire safety control measures, having personal evacuation plans, robust maintenance mechanisms, and ensuring electrical items are tested and damp issues are addressed.
Regulation 15 (Premises and equipment)
We found the control measures identified by the provider to reduce the risk of fire had not been put in place. ... We found there were no personal evacuation plans in place. ... The provider didn't have in place a robust mechanism for managing the maintenance of the premises. ... …
Must Do
Safe
The provider must ensure that risk assessments are in place for the safe use of equipment such as wheelchairs, and that these are regularly assessed and monitored.
Regulation 16 (Assessing and monitoring the quality of service provision)
We asked the registered manager if we could see risk assessments for the use of the wheelchairs to make sure they could be used safely, she told us there were no risk assessments in place.
Must Do
Effective
The provider must ensure that care records accurately reflect the care provided and that staff have access to comprehensive information describing people’s needs to enable them to provide appropriate care.
Regulation 9 (Care and welfare of service users)
Day staff had not routinely recorded what actions they had taken in relation to the tasks; this meant we were unable to evidence if people had received care. ... We found staff did not have the information required to be able to care for people. ... The information on the …
Must Do
Effective
The provider must ensure that care plans and risk assessments are in place for people’s nutrition, including specific dietary requirements and choices, to protect people from risks of inadequate nutrition and related health problems.
Regulation 14 (Meeting nutritional needs)
We found the provider did not have in place care plans and risk assessments about people’s nutrition. ... Kitchen staff were not aware of one person’s specific dietary requirements. ... The menu did not offer people choices nor ensured people on special diets were catered for. ... This meant people …
Must Do
Effective
The provider must ensure that staff receive appropriate training, such as in the use of wheelchairs and moving and handling, to protect people from harm and abuse.
Regulation 11 (Safeguarding service users from abuse)
There was no staff training recorded for the use of wheelchairs. Only one member of staff was trained in moving and handling. This meant people were put at risk as staff had not been trained in the use of wheelchairs.
Must Do
Effective
The provider must ensure that staff receive effective support through supervision, and that all staff receive mandatory training and training specific to the needs of people at the home, such as mental health and diabetes care, to ensure adequate staffing levels with appropriate skills.
Regulation 23 (Staffing)
The provider was unable to produce any evidence of discussion which may include the staff member’s personal development, their training needs or discussions about their concerns. This meant we were unable to ensure staff received effective support. ... Staff had not received the mandatory training as set out in the …
Must Do
Effective
The provider must ensure that mental capacity assessments are carried out for all people in accordance with the Mental Capacity Act 2005, and that decisions made on behalf of people without their consent have a clear legal basis and are documented.
Regulation 18 (Consent to care and treatment)
We found no provider records as to the capacity of any of the 28 people at Etherley Lodge to make specific decisions in accordance with the Mental Capacity Act 2005. ... It was also unclear whether any capacity or best interest’s assessments had been carried out at all. As a …
Must Do
Caring
The provider must ensure that people’s dignity is respected and that they are involved in their care, including when carrying out personal care tasks such as weighing, by ensuring privacy.
Regulation 17 (Respecting and involving service users)
During our inspection we observed staff asking people to come into the hallway to be weighed in front of other people. We asked the registered provider about people’s dignity being compromised by weighing them in front of everyone.
Must Do
Responsive
The provider must ensure that care is person-centred, that staff have sufficient information to respond to people’s changing health needs, and that people’s individual needs and preferences are incorporated into their care plans and acted upon.
Regulation 9 (Care and welfare of service users)
We found there was a lack of person centred information in people’s electronic records. ... We found staff were given insufficient information to be able to respond to the changes in a person’s blood sugar levels. ... We found the provider was not responding to the needs of people in …
Must Do
Well-led
The provider must ensure effective systems are in place for assessing and monitoring the quality of service provision, including addressing cleaning issues, assessing health risks in the kitchen, and routinely gathering feedback from people and visitors to inform improvements.
Regulation 10 (Assessing and monitoring the quality of service provision)
We found the provider had failed to address the lack of cleaning. ... We found the provider had not assessed the risks to people’s health in the kitchen. ... We found the provider did not have in place a mechanism for routinely gathering the views and opinions of people who …
Must Do
Well-led
The provider must ensure that all risks relating to the health, welfare, and safety of people are identified, assessed, and managed, including risks associated with individual behaviours, to prevent harm.
Regulation 9 (Care and welfare of service users)
We found the provider had failed to identify, assess and manage risks relating to the health, welfare and safety of people. ... The provider had not instigated risk assessments to demonstrate the person’s behaviours did not put other people at risk. This meant the provider had failed to assess if …
Must Do
Well-led
The provider must ensure that record-keeping arrangements are in place which protect people, including maintaining accurate, fit-for-purpose, and securely stored personal and staff records, and ensuring staff supervision records are comprehensive and accessible.
Regulation 20 (Records)
We found the provider didn’t have in place record keeping arrangements which protected people. People’s personal records were not accurate and fit for purpose. ... The information was not securely stored. ... Staff supervision records were not fit for purpose. ... Staff records were stored in box files on open …
Location Details
CQC ID: 1-106220488
Local Authority: County Durham
Region: North East
Inspection Report
Type: Comprehensive inspection
Date: 21 October 2014
Rating: Inadequate
Actions: 16 must-do
AI-extracted 17 Feb 2026