Gordon Lodge care home in Westgate placed in special measures

The Care Quality Commission (CQC) has told Gordon Lodge Rest Home in Westgate to make immediate improvements after being rated as inadequate and placed in special measures.

Gordon Lodge, run by Fleming Care Homes Limited, is a residential care home that provides support for up to 33 older people.

An inspection in September was prompted to check on the progress of improvements they were told to make following previous enforcement action.

Following this inspection, Gordon Lodge  has dropped from requires improvement to being rated inadequate overall, as have the ratings for safe and well-led. The ratings for responsive, effective and caring were not inspected and retain their previous ratings of good.

The home has been placed in special measures, which means it will be kept under close review while improvements are made, and CQC is also using its regulatory powers further.

‘Decline in care’

Serena Coleman, CQC deputy director of operations in the south, said: “We were concerned to find a decline in the level of care being provided and the culture at Gordon Lodge Rest Home, which put people at an increased risk of coming to harm.

“The poor workplace culture directly affected the quality of care. Staff left their jobs due to lack of support and involvement in service improvements, leading to understaffing and inconsistent care.

“People living in the home felt unable to speak up about problems. This created an environment where neither staff nor residents felt empowered to highlight issues that needed addressing.

“People’s right to dignity and privacy wasn’t always respected. We were made aware of occasions when one resident would enter other people’s rooms while they were receiving care. Staff addressed this by locking the door of the person they were giving personal care to.  However, no other action had been taken to manage the risks this resident posed to people at other times.

“We were told this risk had been removed because the person had since left the service and leaders advised hadn’t taken any further action. Instead, a healthcare professional had reported the incidents to the local authority safeguarding team.

“The service managed medicines poorly. Staff applied one resident’s pain relief patch a day late, causing potential unnecessary pain, and failed to investigate or prevent future incidents.

“One person’s record detailed they should take a strong pain killer before they received treatment, but records showed this hadn’t been administered for several days. When we asked why staff said it had been stopped by health care professionals and they hadn’t updated the person’s care plan. This meant people were at risk of receiving medicines they were no longer prescribed.

“We have told Gordon Lodge Rest Home where we expect to see rapid and widespread improvements and it has been placed into special measures while these changes are made. “We will return to re-inspect the home and won’t hesitate to use our regulatory powers further if people aren’t receiving the care they have a right to expect.”

‘Key improvements implemented’

A spokesperson for Gordon Lodge said they were disappointed with the CQC report but added that measures have been taken to implement improvements.

They said: “We are disappointed with the outcome of the latest CQC assessment which took place in September 2024. While we do not agree with all the aspects of CQC’s description of the home,  we accept that there are areas where improvements are required. We are working closely with external partners and a nationally recognised consultancy expert in care quality to make these improvements, to ensure we continue to deliver high standards of care to our residents.

“Since the assessment we have already implemented several key improvements. For example, we have strengthened our auditing systems so we can better demonstrate actions taken to mitigate risks, made upgrades to the building and implemented more robust systems for the management of medications. Most recently a new manager has been appointed who will continue with implementing our improvement plan and embedding the changes already made.

“We would like to thank residents, their family and friends and our loyal caring staff for the support shown during this time.  The health, safety and welfare of our resident is our upmost priority. We are committed to providing a good quality service to all our residents and continue to make planned improvements at the home to ensure this is maintained at all times.”

Inspectors say:

• There were not always enough staff to meet people’s needs and keep them safe.
• Leaders had not identified or addressed all infection control risks, such as broken furniture. Cleaning records had been recently introduced and staff noted when they had cleaned areas of the service, but this system had not been effective in improving the cleanliness of the home.
• People were not always supported to move safely between services. One person’s relative said that their loved one had been waiting to see a health professional for several weeks.
• Staff understood their responsibility to report safeguarding concerns but had not always taken action to protect people from the risk of abuse.
• There was no formal process in place to induct agency staff. Agency staff said they were not introduced to people before they provided their care. Also, they supported people to get up, washed and dressed on their own without being told what people could do for themselves or what their preferences were. They had not been told about fire safety on arrival and said they were shown a fire exit later on in the shift.

The inspection also found staff had not been supported to complete training in relation to catheter and stoma care. Some staff had not completed training updates in relation to day to day care, including health and safety or moving and handling. Seven staff had not completed training in infection control.

Staff said they were not clear about their roles and responsibilities. One staff member said: “There are blurred lines around responsibilities. For example, the deputy manager covered for the head of care when they were off but the head of care did not cover for the deputy manager”.

Staff said they did not feel supported by the provider, with one saying: “The provider will not accept responsibility. They will throw us under the bus.”

Positive view of some residents and families

However, residents and their families did express that they were happy with their care.

The report notes: “People and their loved ones told us staff managed risks and they felt safe and protected.

“People told us staff supported them in the way they preferred, and we observed this during our visit to the service. People and families were happy with the standard of cleanliness within the service.

“People were supported to do the things they enjoyed such as gardening, they had access to healthcare professionals. While the people we spoke with expressed they were generally happy with their care, our assessment found elements of care continued not to meet the expected standards.”

The report added: “We observed staff talking with people, reassuring them and treating them kindly.”

The full report with detailed findings will be published on CQC’s website in the next few days.