Courtland Lodge

The inspection was prompted in part by an incident following which a person using the service died and 3 people using the service came to harm. This incident is subject to further investigation by The Care Quality Commission (CQC) as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.

The information shared with CQC about the incident indicated potential concerns about the management of risk for people during heatwaves. This inspection examined those risks.

We visited the service on 28 May 2026 and 2 June 2026. This was an unannounced inspection completed by 2 inspectors, 2 medicines inspectors and 1 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. We received feedback from 19 people living at the home, 10 relatives, 27 staff and 1 professional. We found the service was in breach of the regulation related to good governance.

The provider’s governance and quality assurance systems were not always effective in identifying and addressing concerns; their audits had failed to identify some of the issues found during the inspection. The provider responded promptly to issues raised and demonstrated a commitment to improvement. However, further work was required to strengthen risk management and learning, to ensure people consistently received safe care.

The provider did not always ensure people were protected from avoidable harm. Risks to people were not consistently managed, particularly in relation to hydration, medicines management and environmental safety. People’s records showed people were not always supported to meet their fluid intake targets, placing them at risk of dehydration. Staffing levels were not always sufficient to meet people’s needs promptly.

Staff understood safeguarding responsibilities and concerns were appropriately reported to external agencies. Infection prevention and control measures were effective, and the service was clean and well maintained.

People’s needs were assessed to include their physical and mental health needs. Staff worked effectively with healthcare professionals, involved people and their relatives in care planning and reviews, and supported people to make choices about their care and daily lives.

People received caring, person-centred support from staff who knew them well and treated them with kindness, dignity and respect. Staff supported people with meaningful activities tailored to their interests and encouraged independence.

The provider promoted choice and person-centred care, respected people's rights around consent and had processes to assess mental capacity and make best interest decisions where required. Staff demonstrated an understanding of how to seek consent.