CQC report explained · a residential care home
What the CQC found at Mermaid Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, staffing levels were suitable, medicines were handled safely and infection controls were in place. People said they felt safe.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found that quality checks, audits and records had improved. Staff understood their roles, and people and staff gave positive feedback about the management.
What inspectors found, November 2022
Rated Good; inspectors found safe support and improved risk management and oversight.
This was a focused inspection after problems were found in 2019. One inspector reviewed records, checked the building and spoke with three people and three staff members.
The inspection looked only at Safe and Well-led. Inspectors found that risks were assessed, staffing and medicines were managed safely, and infection controls were in place. People said they felt safe and were supported to remain independent.
The home had improved its checks and records since the previous inspection. The overall rating changed from Requires Improvement to Good. The report says there were no current breaches of regulations.
Managing risk
Risks were reviewed and support plans gave staff guidance. People were supported to use public transport and local facilities without staff support.
“People told us they had been involved in decisions about their care which included understanding risk and managing personal safety.” from the report
Safe staffing
Inspectors found enough staff to meet people's needs. Recruitment checks and staff induction were also in place.
“There were enough staff to meet people's needs consistently and keep people safe.” from the report
Safe medicines
Trained staff administered medicines, records were completed and checks were carried out. People were supported to manage their medicines as independently as possible.
“Medicines were managed safely. Medicine Administration Records (MARs) were completed in line with best practice” from the report
Improved oversight
The home had introduced better quality checks and followed up actions. Records about people's care were described as complete and detailed.
“Accurate, complete and detailed records were kept in respect of each person's care.” from the report
People felt safe
People told inspectors they felt safe and knew how to raise concerns. They also had locks on their bedroom doors to protect their belongings.
“People told us that they felt safe. Risks to people had been identified and assessed.” from the report
Inspectors raised no specific concerns in this report.
- 01How often are each person's risks reviewed, especially risks linked to seizures, health, substance misuse or behaviour?
- 02How do you check that the improvements made after the 2019 inspection continue to work?
- 03How are people supported to manage their own medicines, and how are medicine reviews followed up?
- 04What quality audits are carried out now, and can families see how actions from those audits are completed?
- 05What infection control arrangements are currently used for visitors and during an outbreak?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected, and their previous ratings were used in the overall rating. This explanation was written from the published report of 12 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, December 2019
Mermaid Lodge was rated Requires Improvement; inspectors found kind, personalised care but continuing safety and management failures.
The inspection was unannounced and took place on 12 November 2019. One inspector spoke with five people, three staff and five health and social care professionals. They reviewed care, medicines, staff and management records.
People generally said they felt safe and were happy with their care. Inspectors found enough staff, safe medicines support, kind relationships and personalised care. The ratings for Effective, Caring and Responsive were Good.
However, risk assessments and safety checks were not reliable. Fire checks were not always recorded, a serious crack was found in the stairwell, and some known risks were not documented. The home also did not have effective systems to monitor quality or make sure records and staff support were up to date.
The overall rating was Requires Improvement. Safe and Well-led were Requires Improvement. Effective improved from Requires Improvement at the previous inspection to Good, but the home had been rated Requires Improvement at the last two inspections.
Kind and respectful staff
People described staff positively, and inspectors observed relaxed, respectful interactions. A consistent staff team knew people well.
“People were treated with kindness by a caring and dedicated care staff.” from the report
Safe medicines support
Staff who gave medicines had training and were assessed as competent. Systems were in place to identify medicine errors or omissions.
“People received their medicines safely.” from the report
Personalised care
People and relatives were involved in assessments and care planning. Plans reflected personal histories, preferences, mental health needs and changing circumstances.
“People received personalised support which met their needs and preferences.” from the report
Risk assessments were incomplete
seriousRisk assessments were not routinely reviewed or updated. A known risk for a new resident had not been assessed or explained clearly for staff.
“People were at risk of avoidable harm as risk assessments were not routinely reviewed or updated.” from the report
Fire and building safety checks
seriousWeekly fire alarm tests had not been recorded since 18 October 2019. There was no system to check fire doors and emergency lighting, and inspectors found a crack through the stairwell where daylight could be seen.
“In places daylight could be seen through the crack.” from the report
Weak quality monitoring
seriousThe provider did not have effective checks to identify problems with care plans, risk assessments, health and safety or records. This was a continued breach of Regulation 17.
“The provider had failed to establish systems and processes to assess and improve the quality and safety of the service provided or to assess and monitor risks.” from the report
Staff supervision and training records
needs fixingStaff did not receive regular formal one-to-one supervision or annual appraisals. The provider also did not have an up-to-date record of mandatory refresher training.
“Staff did not receive 1-1 supervision in line with the provider's policy.” from the report
Informal concerns were not recorded
minorPeople knew how to complain and said they would feel comfortable doing so. However, informal concerns were listened to but not recorded.
“They said they viewed complaints as a way for improving service provision, so it was important to listen to people's feedback.” from the report
- 01Have personal emergency evacuation plans now been completed and reviewed for every resident?
- 02How are fire alarm tests, fire doors and emergency lighting checked and recorded now?
- 03What has been done about the crack in the stairwell, and has a structural engineer confirmed that the building is safe?
- 04How do you now make sure every resident's risks are assessed, documented and reviewed when their needs change?
- 05How often do staff receive formal supervision and appraisals, and how do you track refresher training?
This was an unannounced planned inspection based on the previous rating and assessed all five key questions, with Safe and Well-led remaining Requires Improvement. This explanation was written from the published report of 11 December 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 Mermaid Lodge
4 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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