Source · CQC inspection

St Paul's Lodge

Type Social Care Org Region Yorkshire & Humberside Last inspected 22 Jul 2015

Overall rating: Inadequate  View full CQC report

Domain ratings

Five CQC key questions
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Inadequate
Well-led
Inadequate

Earlier inspection findings

pre-2024 framework · 10 must-do 1 should-do

Must-do actions (10)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 10
Must do
Safe
The registered person must provide care and treatment in a safe way for service users by assessing the risks to the health and safety of service users and doing all that is reasonably practical to mitigate any such risks.
Regulation: Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
⚠ The registered person had not provided care and treatment in a safe way for service users as they had not assessed the risks to the health and safety of service users or done all that was reasonably practical to mitigate any such risks.
Must-do action 2 of 10
Must do
Safe
The registered person must provide care and treatment in a safe way for service users by ensuring the proper and safe management of medicines.
Regulation: Regulation 12 HSCA(RA) Regulations 2014 Safe care and treatment
⚠ The registered person had not provided care and treatment in a safe way for service users as they had not ensured the proper and safe management of medicines.
Must-do action 3 of 10
Must do
Safe
The registered person must protect service users from abuse or improper treatment by establishing and operating effective systems and processes to prevent abuse of service users.
Regulation: Regulation 13 HSCA(RA) Regulations 2014 Safeguarding service users from abuse and improper treatment
⚠ The registered person had not protected service users from abuse or improper treatment as systems and processes were not established and operated effectively to prevent abuse of service users.
Must-do action 4 of 10
Must do
Effective
The registered person must ensure the nutritional and hydration needs of service users are met by ensuring service users receive suitable and nutritious food and hydration adequate to sustain life and good health and dietary supplements prescribed by a healthcare professional.
Regulation: Regulation 14 HSCA(RA) Regulations 2014 Meeting nutritional and hydration needs
⚠ The registered person had not ensured the nutritional and hydration needs of service users were met as they had not ensured service users received suitable and nutritious food and hydration adequate to sustain life and good health and dietary supplements prescribed by a healthcare professional.
Must-do action 5 of 10
Must do
Safe
The registered person must ensure suitably qualified, skilled and experienced persons are deployed to meet people’s needs.
Regulation: Regulation 18 HSCA(RA) Regulations 2014 Staffing
⚠ The registered person had not ensured suitably qualified, skilled and experienced persons were deployed to meet people’s needs.
Must-do action 6 of 10
Must do
Responsive
The registered person must ensure that the care and treatment of service users is appropriate and meets their needs by assessing service users’ needs and designing care to ensure their needs are met.
Regulation: Regulation 9 HSCA(RA) Regulations 2014 Person-centred care
⚠ The registered person had not ensured that the care and treatment of service users was appropriate and met their needs as they had not assessed service users’ needs or designed care to ensure their needs were met.
Must-do action 7 of 10
Must do
Well-led
The registered person must establish and operate effective systems and processes to assess, monitor and improve the quality of the services provided and to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others whom may be at risk.
Regulation: Regulation 17 HSCA(RA) Regulations 2014 Good governance
⚠ Systems and processes were not established or operated effectively to assess, monitor and improve the quality of the services provided or to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others whom may be at risk.
Must-do action 8 of 10
Must do
Well-led
The registered person must maintain accurate, complete and contemporaneous records in respect of each service user, including a record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided.
Regulation: Regulation 17 HSCA(RA) Regulations 2014 Good governance
⚠ Accurate, complete and contemporaneous records were not maintained in respect of each service user, including a record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided.
Must-do action 9 of 10
Must do
Safe
The registered person must establish and operate effective recruitment procedures to ensure that persons employed for the purposes of carrying on a regulated activity are of good character.
Regulation: Regulation 19 HSCA(RA) Regulations 2014 Fit and proper persons employed
⚠ Recruitment procedures were not established and operated effectively to ensure that persons employed for the purposes of carrying on a regulated activity are of good character.
Must-do action 10 of 10
Must do
Well-led
The registered person must submit notifications to the Commission in relation to people who have sustained serious injuries as required by Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.
Regulation: Regulation 18 of the Care Quality Commission (Registration) Regulations 2009
⚠ Notifications in relation to two people who had sustained serious injuries had not been submitted to the Commission as required.

Should-do actions (1)

Recommended improvements to enhance service quality.

Should-do action 1 of 1
Should do
Effective
We recommend that the service explores published guidance such as the National Institute for Health and Care Excellence (NICE) quality standards for people living with dementia under Quality Standard 30 (QS30: Supporting people to live well with dementia) and Quality Statement 7 (design and adaptation of housing) on how premises can be designed or adapted in a way that helps people with dementia manage their surroundings, retain their independence, and reduce feelings of confusion and anxiety.

Previous inspection

22 April 2015
RatingInadequate
TypeInspection report
Actions 5 must-do
1 resolved 4 repeated

Location details

CQC ID: 1-110528496
Local authority: Bradford
Region: Yorkshire & Humberside

Inspection report

Type: Inspection report
Date: 22 July 2015
Rating: Inadequate
Actions: 10 must-do 1 should-do
AI-extracted 17 Feb 2026