CQC report explained · a residential care home
What the CQC found at Marina Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found blocked fire escape routes, poor cleanliness, problems with PPE disposal and incomplete safety checks. Staff numbers, safeguarding arrangements and individual risk assessments were positive.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward from the 2019 inspection.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward from the 2019 inspection.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward from the 2019 inspection.
- Well-led?
- Requires improvement
- The provider’s audits and governance systems did not identify and address problems promptly. Records did not consistently show people’s goals, and one serious injury had not been reported to the CQC.
What inspectors found, December 2022
Marina Lodge rated Requires Improvement; inspectors found staffing and safeguarding strengths but serious safety, cleanliness, recruitment and oversight shortfalls.
This was an unannounced focused inspection on 10 November 2022. Inspectors looked at Safe and Well-led, including infection prevention and control. They spoke with one person, managers and staff, contacted relatives and reviewed care, medicines, staff and audit records.
The home had enough staff and staff understood safeguarding. People’s individual risks were assessed, and medicines were generally stored and given safely. However, an external fire exit was blocked, some areas were unclean, PPE was not disposed of properly and some medicines records were incomplete.
The home’s checks and audits did not find or fix problems quickly enough. Recruitment records were incomplete and the provider had not always checked whether applicants were suitable. The overall rating fell from Good at the previous inspection to Requires Improvement. The report says the provider breached Regulations 12, 17 and 19.
Enough staff
The home had enough staff to meet people’s needs, including one-to-one support for activities and visits.
“The service had enough staff, including one-to-one support for people to take part in activities and visits how and when they wanted.” from the report
Safeguarding
Staff knew how to recognise and report abuse, and the home worked with other agencies to protect people.
“Staff had training on how to recognise and report abuse and they knew how to apply it.” from the report
Support from professionals
The home contacted other professionals when needed and followed their advice, which helped people’s wellbeing.
“The provider contacted other professionals when needed and followed advice and guidance provided, which helped to improve people's wellbeing.” from the report
People felt safe
The report records that people felt safe living at the home.
“I like it here. It is my home.” from the report
Fire safety and environmental risks
seriousRubble blocked an external fire exit and moss covered part of the fire escape route. Some environmental and window safety checks were also missing or ineffective.
“Rubble was blocking the external fire exit and heavy moss was present on the fire escape route which posed a risk to people in the event of an emergency evacuation.” from the report
Cleanliness and infection control
seriousSome communal areas and bathrooms were unclean. Used PPE did not have suitable disposal arrangements, including a lack of clinical waste bins.
“Areas of the service, such as bathrooms and communal spaces were unhygienic and unclean.” from the report
Recruitment checks
seriousSome recruitment records lacked important information. Previous convictions were not always followed up thoroughly, and gaps in employment and references were not always checked.
“Where DBS checks had highlighted previous convictions, thorough action had not been taken to ensure the applicant was of good character and suitable for working with vulnerable adults.” from the report
Weak quality checks
seriousThe provider’s audits did not cover all relevant areas or check whether care plans were still suitable. This meant problems were not identified and addressed promptly.
“Governance processes were not always effective to hold staff to account, keep people safe, protect people's rights and provide good quality care and support.” from the report
Incomplete medicines records
needs fixingRecords for medicines given when needed did not always say why they were given or whether they worked.
“Records did not always provide sufficient information when people were administered 'when required' medicines.” from the report
- 01Has the external fire exit and fire escape route been checked regularly since the inspection, and what prevents them becoming blocked again?
- 02What changes have been made to cleaning, PPE disposal and clinical waste arrangements?
- 03How are recruitment gaps, references and previous convictions now checked and recorded?
- 04How does management check that care plans, safety audits and environmental checks are complete and up to date?
- 05How are medicines given when needed now recorded, including the reason for giving them and whether they were effective?
This was a focused inspection of Safe and Well-led, including infection control; the Effective, Caring and Responsive ratings were not inspected and were carried forward from 2019. This explanation was written from the published report of 17 December 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, November 2019
Rated Good; inspectors found safe, kind and personalised care, with all five areas rated Good.
This was an unannounced planned inspection on 21 October 2019. One inspector spoke with two people, a relative and three staff members. They also reviewed care, medicines, quality, infection control and building records.
The home supported up to 11 younger people with mental health needs. Seven people were living there during the inspection. People said they felt safe and supported. Inspectors found suitable staffing, safe medicines management, trained staff and a clean, well-maintained home.
People were involved in decisions about their care and were supported to build independence. Staff supported activities, community visits and healthcare appointments. Care plans were kept up to date, and inspectors found staff caring, respectful and responsive.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. The previous rating was also Good, published in April 2017.
People felt safe
People said they felt safe and trusted the staff supporting them. Inspectors found robust recruitment checks, suitable staffing and safe risk management.
“People told us they felt safe and that staff supported them well.” from the report
Safe medicines management
Medicines were administered, monitored, stored and disposed of appropriately. The provider worked with health professionals to review medicines affecting mood and behaviour.
“Medicines were administered, monitored, stored and disposed of appropriately.” from the report
Choice and independence
People were involved in decisions about their care and were supported in the least restrictive way. Staff helped people build confidence and take part in community activities.
“People were encouraged to make decisions and choices about their care.” from the report
Activities and community access
People chose daily activities and took part in outings such as shopping, cinema visits and meals or coffees outside the home.
“People chose which activities they would like each day and the provider planned outings which people told us they enjoyed.” from the report
Good management
The home had quality checks and gathered views from people, relatives, staff and health professionals. Inspectors said improvements were identified and acted on.
“Quality assurance systems were in place which identified and actioned improvements in the service.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and regularly update my relative's care plan and communication preferences?
- 02What activities and community outings could my relative take part in, and how would you support them to become more independent?
- 03How are medicines affecting mood or behaviour reviewed with health professionals?
- 04How would you support my relative to make decisions if they lacked capacity for a particular decision?
- 05How would you respond if my relative or our family wanted to raise a complaint or concern?
This was an unannounced planned inspection covering all five CQC questions, including the care provided and the home environment. This explanation was written from the published report of 29 November 2019 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 Marina Lodge
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Goodstayed GoodSafe: GoodWell-led: Good
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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28 live-in carers within about an hour of North Yorkshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,010 to £1,290 a week. 27 can care for a couple. 12 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.