CQC report explained · a residential care home
What the CQC found at Mar Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicine management, effective risk planning and a clean environment.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- The home had effective checks and audits, clear responsibilities and an open management culture. People and relatives spoke highly of the service.
What inspectors found, February 2024
Rated Good; inspectors found safe, person-centred care, with better safety since the last inspection but a conservatory temperature issue still to address.
Inspectors visited on 28 December 2023 and 15 January 2024. They spoke with staff, relatives and people living at the home, observed care and reviewed care, medicine and management records.
The home was safe and well-led. Staff knew people well, supported their independence and understood how to manage risks, medicines and safeguarding. The home was clean, and there were enough staff.
Safety improved from Requires Improvement at the previous inspection to Good. Well-led remained Good. The inspection only checked Safe and Well-led, so the other ratings carried over from the previous inspection.
Inspectors recommended improving temperature control in the conservatory so people can use it throughout the year. They will continue to monitor information about the home.
People’s independence
People were supported to make choices, follow their goals and stay connected with friends and family. Staff used the least restrictive approach possible.
“People were supported to be as independent as possible and to maintain positive relationships with the people they cared about.” from the report
Knowledgeable staff
Staff understood people’s communication needs and knew how to support them safely. Many staff had worked at the home for several years.
“Staff knew people well and explained how changes of behaviour and mood may indicate something was wrong.” from the report
Safe care systems
Risk plans, safeguarding processes and medicine checks were in place. Inspectors found medicine records accurate and up to date.
“People's medicines were managed in a safe way. Staff had training and had their competency assessed.” from the report
Listening to people
People helped shape their support plans, goals, menus and activities. The home used meetings and accessible information to gather views.
“Changes were made in response to what people said, for example, changes to the menu and where to go for trips out.” from the report
Clean environment
The home was visibly clean and staff followed cleaning schedules and infection control guidance.
“The service was visibly clean and fresh throughout.” from the report
Conservatory temperature
needs fixingInspectors recommended action so people can use the conservatory comfortably throughout the year. This was a shortfall rather than a breach.
“We recommended the provider take action to improve temperature control in the conservatory so people can access this living space as required at all times of the year.” from the report
Steps inside the building
minorThere were several steps that could create a trip or fall risk. The provider had reduced the risk with brighter lighting, adaptations and individual support.
“There were a number of steps within the building which may present a trip or fall hazard” from the report
- 01What action has been taken to control the temperature in the conservatory throughout the year?
- 02How are the steps in the building assessed and managed for each person’s risk of falling?
- 03How will you maintain the improvements that led Safe to move from Requires Improvement to Good?
- 04How are people involved in setting their goals, support plans, menus and activities?
- 05What were the previous ratings for Effective, Caring and Responsive, which were not checked in this inspection?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection published on 12 December 2018. This explanation was written from the published report of 7 February 2024 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, December 2018
Mar Lodge was rated Good overall, but Safe Requires Improvement because parts of the kitchen, laundry and bathroom created safety or infection risks.
This was an unannounced comprehensive inspection on 14 November 2018. One inspector spoke with people, staff, managers and relatives. They checked a care record, medicines, health and safety records, and meeting records.
The overall rating stayed Good, as it had at the previous inspection. Inspectors found enough staff, safe medicines practice, suitable training, kind care and strong support for people's choices, independence, activities and relationships.
Safe was rated Requires Improvement. Cracked kitchen tiles, uneven worktops, a cooker beside a doorway and damaged flooring in the laundry created potential safety or infection risks. The communal bathroom was also difficult for a person with sight loss to use independently. The provider had identified these issues and said work was due to start in 2019.
Kind and respectful care
People were treated with kindness, dignity and privacy. Staff developed positive relationships and understood what mattered to each person.
“People were treated with dignity. For example, one person was seen wearing a top which staff thought had shrunk in the last wash.” from the report
Support for independence
Staff encouraged people to do more for themselves and supported them to take part in work, hobbies and activities in the community.
“People were supported by a staff group who had an excellent understanding of their needs and how to provide support in a way which encouraged people's independence.” from the report
Accessible communication
The home used easy-read information and communication dictionaries to help people understand information and help staff understand how people communicated.
“The service was excellent at ensuring information was communicated in an appropriate format for people.” from the report
Good management checks
Managers monitored medicines, care records and health and safety. They also acted on accidents and incidents and worked with other agencies.
“The provider had a range of checks to ensure the quality of care at the home was maintained.” from the report
Kitchen and laundry risks
seriousCracked tiles and uneven worktops made the kitchen harder to clean. The cooker was close to a doorway, and flooring in the laundry created an infection risk.
“The kitchen had cracked tiles, and the worktop surfaces were not always aligned.” from the report
Bathroom access
needs fixingThe shower had a 24cm step, and the bath was small and low without grab rails. This reduced independence, particularly for the person with sight loss.
“This meant it was difficult for the person with the sight impairment to access independently.” from the report
End of life training
needs fixingPeople's end of life preferences were recorded, but the deputy manager was still arranging access to end of life training for all staff.
“The deputy manager was in the process of ensuring all staff had access to end of life training.” from the report
- 01What work was completed in 2019 to repair the cracked kitchen tiles and uneven worktops?
- 02Has the cooker been made safer in relation to the nearby doorway?
- 03Has the laundry flooring been replaced or repaired to reduce the infection risk?
- 04Has the communal bathroom been changed to provide a walk-in shower and suitable grab rails?
- 05Have all staff now received end of life care training?
This was an unannounced comprehensive inspection covering all five key questions, and the overall rating remained Good from the previous inspection. This explanation was written from the published report of 12 December 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 Mar Lodge
3 rated inspections over 8 years: the service has held its Good rating throughout.
- February 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2018Goodstayed GoodSafe: Requires improvementWell-led: Good
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 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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