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.
What inspectors found, November 2022
Manor Lodge rated Requires Improvement; inspectors found kind and personalised care, but medicines records, staffing and management checks were not reliable enough.
This was an unannounced follow-up inspection on 17 October 2022. One inspector and an Expert by Experience spoke with people, a relative, staff and managers. They observed care and reviewed care plans, medicines records, training and infection control documents.
The home had improved since the previous inspection. People were treated with dignity, their care was more personalised, and their consent and health needs were better recorded. Food, healthcare support, activities and communication were also generally good.
There were still important concerns. Medicines were not always recorded against the correct dates, staffing could be short at times, and the home's checks had not found these problems. The home remained in breach of Regulation 17 on good governance.
The overall rating was Requires Improvement. Safe and well-led were also Requires Improvement, while effective, caring and responsive were Good. The report says the home had this overall rating at its last two inspections.
Improved consent
The home had improved how it assessed and recorded people's ability to consent. Staff understood the Mental Capacity Act and people's choices were respected.
“The service followed the principles of the MCA. People's ability to consent to decisions made about their care was assessed and recorded in their care plans.” from the report
Respectful care
Inspectors saw an improvement in the way staff treated people. Staff were attentive and usually kind and respectful.
“There was an improvement at this inspection. Staff were attentive to people and treated them with respect.” from the report
More personalised care
Care plans gave a clearer picture of people's lives, preferences, health needs and desired outcomes. They were reviewed every month.
“Care plans were reviewed monthly and updated with any changes to people's preferences or health conditions.” from the report
Better mealtime experience
The lunchtime service had improved since the previous inspection. Staff interacted more with people, and people appeared to enjoy the meal and each other's company.
“There were improvements to the lunchtime experience at this inspection. Staff were more interactive and people seemed to enjoy their meal and each other's company.” from the report
Medicines records
seriousMedicines were given against incorrect dates on administration records for most people. This meant inspectors could not always be sure that medicines had been given on the correct days and times.
“Medicines were not always managed safely. The administration of people's medicines was not always being recorded accurately.” from the report
Staffing pressure
needs fixingStaffing was sometimes reduced, and senior staff might have had to take on extra duties. Inspectors were concerned this could leave staff without enough time to support people.
“We recommend the provider follows best practice guidance for adequate staffing levels for homes of this size to ensure people receive the support they need at all times.” from the report
Weak management checks
seriousAudits did not identify the medicines recording errors. Some daily care records were incomplete, and the provider had not yet resolved staffing plans raised at the previous inspection.
“We did not find evidence people had been harmed but management systems were not robust to ensure there was a good standard of safe care in the home.” from the report
Limited morning activities
minorThere was little for people to do in the morning, although staff offered more activities in the afternoon.
“At this inspection, there were some improvements, although there was little for people to do in the morning.” from the report
- 01What has been done to correct the medicines administration records, and how are the records now checked before errors can affect people?
- 02How many staff are now planned for each shift, and what happens when someone is away or more than one person wants to go out?
- 03Has an additional member of staff been recruited to help prepare meals and reduce pressure on care staff?
- 04How are audits now checking medicines, staffing and daily care records?
- 05What regular morning activities are now available for people who want to take part?
This was an unannounced follow-up inspection after the previous rating, covering all five key questions and infection prevention and control under Safe. This explanation was written from the published report of 26 November 2022 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, October 2021
Rated Requires Improvement; inspectors found risks, consent, dignity, care planning and management systems that needed urgent improvement.
This was an unannounced inspection on 23 August 2021. Inspectors spoke with people, relatives, staff and health professionals. They observed care and reviewed care records, risk assessments, medicines records, maintenance records and management information.
The home was not always safe. Most windows did not have restrictors, despite a known risk that one person might climb or fall through them. Risk assessments did not always give staff enough guidance. Medicines were administered correctly, but checks on staff competence were not recorded.
People did not always receive personalised care or have their consent properly recorded. Inspectors also found examples where privacy, dignity and respectful communication were not maintained. Activities were limited and meal times were rushed.
All five areas were rated Requires Improvement. The overall rating had fallen from Good at the previous inspection, published on 28 February 2019. The provider was required to send an action plan, and the CQC said it would monitor progress and return to inspect.
Staffing
Inspectors found the correct number of staff on duty. People received help promptly, and recruitment checks were completed.
“We saw there were the correct the numbers of staff on duty.” from the report
Infection control
Most infection prevention arrangements were in place, including safe use of protective equipment, testing and visiting arrangements. One entry temperature check was missed.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff training and support
Staff had induction, refresher training and supervision. Relatives told inspectors staff were trained and knew what they were doing.
“Training information showed all staff had received refresher training in essential topics including safeguarding adults, medicines, autism and learning disabilities, infection control and equality and human rights awareness.” from the report
Health support
The home worked with GPs and other health professionals. People attended appointments, and hospital passports contained important health and communication information.
“The home worked with the local medical centre and there were checks on people's health.” from the report
Safeguarding and incidents
The provider had improved its safeguarding process after earlier delays. Accidents and incidents were recorded and reviewed to help prevent them happening again.
“Accidents and incidents in the home were logged and staff took the necessary actions to ensure people remained safe.” from the report
Uncontrolled window risk
seriousMost windows did not have restrictors, despite a known risk that a person could climb or fall through them. The provider said restrictors were installed shortly after the inspection.
“This meant there was a high risk of the person coming to avoidable harm should they access one of the windows.” from the report
Consent and legal safeguards
seriousRecords did not show how people consented to care or how best-interest decisions were made. Some Deprivation of Liberty Safeguards applications were still in progress after earlier authorisations had expired.
“This meant the provider did not ensure people in the home and those acting on their behalf had given their consent to any care or treatment.” from the report
Privacy and dignity
seriousInspectors saw personal care being provided with a person's door open and the person uncovered. They also saw communication that was abrupt and care records that used disrespectful language.
“There was no consideration of their dignity or right to privacy.” from the report
Person-centred care
seriousCare plans did not consistently reflect people's own views, interests and preferences. Reviews were sometimes identical and did not describe progress or achievements.
“Person-centred care planning was not effective to ensure people's needs were being met.” from the report
Limited activities and rushed meals
needs fixingPeople had few meaningful activities and often spent much of the day watching television. Inspectors also found the lunchtime service rushed and dietary information was not available in the kitchen.
“This meant people were not being supported with activities that were meaningful and socially or culturally relevant to them.” from the report
Weak quality checks
seriousThe provider's audits did not reliably identify or manage risks. Medicines competency checks were not recorded, and some building safety issues were still awaiting repair.
“The provider's systems to assess, monitor and improve the quality and safety of the service provided were not effective or robust.” from the report
- 01Have window restrictors now been fitted throughout the home, and how are individual risks of absconding or climbing managed?
- 02How do you record consent, capacity assessments and best-interest decisions for each person?
- 03What has changed in care plans and reviews to make them personal to each person's interests, choices, health and achievements?
- 04How are staff medicines competencies checked and recorded, including their understanding of controlled drugs?
- 05What meaningful activities and improvements to meal times are now available for people living in the home?
This was an unannounced inspection of the care home covering all five CQC key questions, including infection prevention and control; the report compares all five ratings with the previous inspection. This explanation was written from the published report of 14 October 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.
Every inspection of Manor Lodge
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Registered with the Care Quality Commission on 18 August 2014.
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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