CQC report explained · a residential care home
What the CQC found at Minster Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe and staff understood safeguarding responsibilities. Medicines, recruitment and risk management were generally handled safely, although one missing risk assessment was found and corrected during the inspection.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- The manager had audits, an improvement plan and a contingency plan. People, relatives and staff gave positive feedback about the management and the supportive culture.
What inspectors found, November 2023
Rated Good; inspectors found safe, caring support and good management, with a few minor issues addressed or awaiting repair.
This was an unannounced, focused inspection on 7 November 2023. Two inspectors spoke with five people, two relatives and seven staff. They observed care and checked care records, recruitment files, medicines and management records.
The home was rated Good overall. Safe and Well-led were both rated Good. People and relatives spoke positively about the care, staff knew how to protect people from harm, medicines were given safely and staff were recruited properly.
Inspectors found one missing risk assessment for a flammable topical cream. The manager addressed this during the inspection. Some skirting boards and paintwork were chipped, and these had been reported for repair.
This was a focused inspection because of concerns about care quality and the culture of the service. Inspectors found no evidence that people were at risk of harm from those concerns. The overall Good rating remained from the previous inspection.
People felt safe
People and relatives described the support positively. Staff had safeguarding training and knew how to report concerns.
“People felt safe with staff.” from the report
Safe medicines support
Trained staff gave medicines sensitively and their competence was checked. Medicines were ordered, stored and disposed of safely.
“People received their medicines as prescribed from trained staff whose competencies were regularly checked.” from the report
Good management oversight
The manager used audits and an improvement plan to monitor quality and address the concerns that led to the inspection.
“An improvement plan was in place and had addressed these areas.” from the report
Supportive culture
People, relatives and staff said the manager and staff team were approachable, supportive and easy to talk to.
“Staff gave positive feedback regarding the open, honest and supportive culture of the service.” from the report
Missing risk assessment
needs fixingA risk assessment had not been completed for a topical cream containing flammable ingredients. The manager acted during the inspection.
“We brought this to the attention of the registered manager who took action to address this during the inspection.” from the report
Chipped fixtures and paintwork
minorSome areas had chipped skirting boards and paintwork. The manager said the issue had been reported to the maintenance team.
“As some areas of the home had chipped skirting boards and paint work.” from the report
- 01Has the risk assessment for the flammable topical cream now been completed, and how is it being reviewed?
- 02Have the chipped skirting boards and paintwork been repaired?
- 03What changes were made through the improvement plan after the concerns about care quality and the culture of the service?
- 04How will you keep families informed about feedback from the planned quality questionnaire?
- 05When will the other key questions be fully inspected again?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 23 November 2023 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, February 2022
Minster Lodge Care Home was inspected but not rated; inspectors found good COVID-19 planning but several infection-control shortfalls.
This was an announced, targeted inspection on 14 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19. There were 24 people living in the home.
Inspectors found individual COVID-19 risk assessments and care plans for all residents. People and staff had access to testing, including risk assessments when people refused tests. The home was also meeting requirements about COVID-19 vaccination for non-exempt staff and visiting professionals.
However, inspectors were only somewhat assured about several areas. These included visitor testing and screening, access to protective equipment, cleanliness, staff infection-control checks and recent infection-control audits. The service was inspected but not rated, so this report does not give an overall quality rating.
Personal COVID-19 plans
Each resident had an individual COVID-19 risk assessment and care plan to guide staff in reducing the risk of outbreaks.
“Individualised COVID-19 risk assessments and care plans were in place for all residents which provided guidance for staff to follow so they knew how best to support people to reduce the risk of COVID-19 outbreaks.” from the report
Access to testing
People living in the home and staff accessed testing in line with government guidance. Risk assessments were used when people refused testing.
“Staff and people living in the home accessed testing in line with government guidance.” from the report
Visitor testing and screening
needs fixingVisitors could provide evidence of a lateral flow test taken within 72 hours, rather than having a test on the day of the visit. The screening form was also out of date and did not record the test result.
“This was not in line with the most up to date guidance for completing lateral flow tests on the day of the visit.” from the report
Protective equipment
needs fixingFluid-repellent masks and hand sanitiser were not always available at protective equipment stations for staff, visitors or residents.
“we saw fluid repellent face masks and sanitising hand gel was not always available at PPE stations for staff, visitors or residents to access.” from the report
Cleanliness
needs fixingSeveral communal toilets and bathrooms were unclean, and the larder floor was also unclean. Managers said they planned to increase domestic staffing.
“we observed several communal toilets and bathrooms to be unclean and the larder room floor was unclean.” from the report
Staff infection-control checks
needs fixingInspectors saw a COVID-19 competency check from 2020 but no more recent checks for newer staff.
“We saw staff underwent a COVID-19 competency check in 2020, but did not see any more recent updates or competency checks for newer staff.” from the report
Recent audits
needs fixingAlthough an infection-control audit programme existed, the home could not provide recent audit results or action plans.
“the service was unable to provide us with recent audit outcomes or action plans to improve.” from the report
- 01How do you now make sure visitors complete a lateral flow test on the day of their visit?
- 02How do you make sure the visitor screening form is kept up to date and records test results?
- 03Are fluid-repellent masks and hand sanitiser now available at every protective equipment station?
- 04What action has been taken to keep communal toilets, bathrooms and the larder clean?
- 05When were the most recent staff competency checks and infection-control audits completed, and can we see the action plans?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it was not a full service inspection and the service was inspected but not rated. This explanation was written from the published report of 2 February 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.
Every inspection of Minster Lodge Care Home
4 rated inspections over 9 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- February 2018Goodstayed GoodSafe: GoodWell-led: Good
- June 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- October 2012
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 14 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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