CQC report explained · a residential care home
What the CQC found at Manor Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and reviewed, staffing was considered sufficient, and infection control arrangements were in place. Medicines were generally managed safely, but some medicines care plans and PRN instructions were incomplete.
- Effective?
- Good
- People had detailed assessments and care plans. Staff had suitable training and support, and people were supported with food, health care and consent decisions.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw respectful support, choice, privacy and encouragement for people to remain independent.
- Responsive?
- Good
- Care was personalised and reflected people's communication needs, interests and preferences. People were supported with activities, relationships and complaints.
- Well-led?
- Good
- The home had a consistent staff team, approachable leadership and quality checks. Feedback was gathered and action was taken when improvements were needed.
What inspectors found, December 2021
Manor Lodge is rated Good; inspectors found kind, personalised care, with some medicines care-plan records needing improvement.
Inspectors visited on 2 and 4 November 2021. The first visit was unannounced and the second was announced. They spoke with people, relatives, staff and a social care professional. They also observed care and checked care, medicines, staff and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said staff were kind and looked after them well. Inspectors saw respectful engagement, personalised care and staff who knew people’s needs.
Medicines were generally managed safely, but some medicines care plans and instructions were incomplete. The home dealt with these issues after the inspection. Inspectors also identified some less serious record-keeping and environment improvements.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff supporting people in a friendly and respectful way.
“We saw positive respectful engagement between staff and people.” from the report
Personalised support
Care plans included people's backgrounds, interests, communication needs and preferences. Staff used this information to tailor support.
“People's care plans included very detailed information about people's background, life story and experiences.” from the report
Responsive staffing
Inspectors found staff available when people needed help. Call bells were answered promptly and staffing levels were adjusted to people's needs.
“People told us they did not have to wait for care and assistance.” from the report
Activities and relationships
People could take part in group and one-to-one activities and were helped to keep in touch with relatives and friends.
“We saw people participating in group and one to one activities, which they told us they had enjoyed.” from the report
Medicines records
needs fixingSome medicines instructions and care plans were incomplete. The manager addressed the issues after the inspection, and inspectors made a recommendation to review medicines guidance and practice.
“Two people who were prescribed medicines at specific times did not have this detailed in their medicine care plan.” from the report
Care-plan reviews
needs fixingMonthly review records did not show that people had been asked about their care. The manager said this would be improved.
“Monthly review records of people's care plans did not indicate that people had been asked about their care.” from the report
Some areas looked tired
minorSome corridors and bathrooms lacked colour and needed attention. The home said these areas would be addressed.
“However, there were some areas including corridors and some bathroom facilities that were 'tired' looking and lacked colour.” from the report
Meal feedback records
minorPeople were asked for feedback about meals, but there were no records showing whether criticism had led to action. The cook said this would be recorded.
“There were no records to show whether they had been responsive to any criticism.” from the report
- 01How do you now check that every person's medicines care plan includes clear and current instructions?
- 02How are people involved in their monthly care-plan reviews, and where is this recorded?
- 03What improvements have been made to the corridors and bathroom areas that inspectors described as tired?
- 04How do you record feedback about meals and any action taken in response?
- 05What staffing levels are in place for the current needs of the people living here?
This was a planned inspection covering all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 17 December 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2018
Rated Good; inspectors found safe, kind and personalised care, with improvements needed to building access and dementia-friendly decoration.
This was an unannounced comprehensive inspection on 15 March 2018. The inspector observed care, spoke with people, relatives and staff, and checked care records, staff files, audits and policies.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, medicines were managed safely, staff understood people's needs and care was reviewed when needs changed.
People were generally positive about the care, staff and activities. The report also identified two areas for improvement: access for people with mobility needs, and the design and decoration of the home for older people, including those living with dementia.
The overall rating stayed Good because inspectors found no serious risks or concerns. The report includes recommendations, but does not say that any regulation was breached.
Safe care and medicines
Staff understood safeguarding and risk procedures. Medicines were stored, administered and checked safely.
“Arrangements were in place to manage and administer medicines safely.” from the report
Personalised support
Care plans described people's preferences, routines and needs. Staff knew people well and updated plans when needs changed.
“People's care plans were personalised.” from the report
Kind and respectful staff
Inspectors saw positive interactions. Staff supported privacy, dignity, choice, independence and communication.
“During general observation and SOFI we saw positive interaction between staff and people using the service.” from the report
Activities and family involvement
People took part in activities such as flower arranging, bingo, music, reading and reminiscence. Relatives were asked for views and invited to meetings and open days.
“People were supported to take part in activities.” from the report
Quality monitoring
The manager and senior staff carried out regular checks and acted when they found problems. Staff could raise concerns in meetings or directly with the manager.
“We found that a range of audits were regularly undertaken by the manager and senior care staff as part of the quality assurance and quality improvement process.” from the report
Difficult access
needs fixingThe front ramp was steep and difficult for wheelchair users, and the garden ramp looked worn and had no handrails. The home was recommended to seek advice about improving access.
“The ramp for accessing the front door was not easy to use and not very suitable for meeting the needs of wheelchair users.” from the report
Environment not dementia-friendly enough
needs fixingSome areas and bedrooms looked tired, and the decoration lacked colour and features that could support people living with dementia. The home was recommended to seek advice about improvements.
“The interior of the premises lacked colour and other features that could promote the attractiveness of the environment for people as well as be more suitable for people living with dementia.” from the report
Care review feedback
minorRecords did not show that people or, where appropriate, relatives were asked for feedback during monthly care reviews. The manager said this would be improved.
“Records did not show that people had been asked for their feedback about their care during the monthly review of their needs.” from the report
Some people did not know how to complain
minorAlthough a complaints process was in place, two people did not know how to raise a complaint. The report says there had been no complaints in the previous 12 months.
“However, two people we spoke with were not aware how to raise a complaint.” from the report
- 01What changes have been made to the front and garden ramps since the inspection?
- 02How would you support someone using a wheelchair to enter, leave and access the garden safely?
- 03What improvements have been made to the design and decoration for people living with dementia?
- 04How are residents and relatives now asked for feedback during monthly care reviews?
- 05How are new residents shown how to make a complaint?
This was an unannounced comprehensive inspection covering all five rating areas, and the overall Good rating was unchanged from the previous inspection. This explanation was written from the published report of 1 May 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Manor Lodge
4 rated inspections over 6 years: the service has held its Good rating throughout.
- December 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Goodstayed GoodSafe: Requires improvement
- April 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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