CQC report explained · a residential care home
What the CQC found at Mostyn Lodge Residential Home
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 problems with safeguarding, risk assessments, medicines and infection control. They also found that some fire risk assessment work had not been completed on time.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Management systems did not reliably identify or address risks. Audits did not always find problems or record who should complete actions and by when.
What inspectors found, January 2024
Mostyn Lodge Residential Home is rated Requires Improvement; inspectors found risks in safeguarding, medicines, infection control and management systems.
This was an unannounced focused inspection on 26 October and 6 November 2023. Two inspectors and a medicines specialist visited. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, staff files and management records.
People generally felt comfortable with staff and said they felt safe. However, safeguarding procedures were not always followed, important risks were not always clearly assessed, and medicines and infection control were not always managed safely. Some fire safety work had also not been completed when expected.
The home had many audits, but these did not always identify problems or track whether actions were completed. The manager was viewed positively and staffing had recently increased, but different management approaches caused inconsistencies.
The overall rating changed from Good at the previous inspection, published in August 2021, to Requires Improvement. The inspection covered Safe and Well-led only. The other question ratings were carried forward from the previous inspection.
People felt reassured
People were comfortable with staff and management. Staff reassured people when they became distressed.
“People were comfortable in the presence of staff and management and were reassured when they became distressed.” from the report
Staffing had recently increased
People, relatives and staff said staffing had improved recently. Rotas confirmed that staffing levels had increased.
“All were positive the manager had recently increased staffing levels and rotas confirmed this change.” from the report
Some risks were managed well
Inspectors found clear guidance for some people who needed hoisting or support to prevent pressure ulcers.
“Other people had risks of pressure ulcers and there was guidance for staff on how to mitigate these risks.” from the report
People could receive visitors
Visitors could come whenever they liked, and people said they were happy to receive them.
“People were able to have visitors and they could come whenever they liked.” from the report
Safeguarding concerns were not reported
seriousIncidents, including injuries after unwitnessed falls and incidents between people, were not always recognised as possible safeguarding matters. The home did not always inform the local authority or CQC.
“The management were not alerting external bodies such as the local authority and CQC when these incidents had occurred” from the report
Medicines were not always safe
seriousInspectors found one person's topical medicine applied to another person, missing records for eye drops, incomplete patch records and weak guidance for medicines given when needed.
“Medicines were not always managed safely placing people at risk of potential harm.” from the report
Care plans did not always explain risks
seriousSome care plans were contradictory or lacked guidance about falls, eating and drinking, and distress. This meant staff, especially new or agency staff, might not know the right way to provide support.
“Risks to people outlined in care plans had not always been assessed fully, contained contradictions and lacked guidance for staff to follow.” from the report
Infection control was not effective
seriousStaff were seen reusing gloves and wearing used aprons through the home. Inspectors also found a used incontinence pad in a bedroom and strong smells of urine.
“People were placed at risk of infections spreading due to ineffective systems around managing infection control.” from the report
Audits did not reliably drive improvement
needs fixingThe home completed audits, but these did not always identify problems or show who was responsible for completing actions and by what date.
“Audits were completed for a range of areas in the home.” from the report
Staff were sometimes stretched
needs fixingPeople and relatives said staff were doing caring and cooking duties and that people sometimes waited for help or were not checked regularly in their rooms.
“There were long periods of time when people went without interactions.” from the report
- 01What has been done to make sure every possible safeguarding incident is reported to the local authority and CQC?
- 02How are medicines now checked, including topical medicines, eye drops, patches and medicines given when needed?
- 03Have all care plans been reviewed so they clearly explain how to manage falls, eating and drinking, and distress?
- 04What has changed in infection control, including the use of gloves and aprons and the checking of bedrooms?
- 05How do you now track audit actions, including who is responsible and the deadline for completion?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection in 2021. This explanation was written from the published report of 11 January 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, August 2021
Rated Good; inspectors found safe, kind care, but medicines records and management arrangements needed attention.
This was an unannounced inspection on 3 August 2021. Inspectors looked into concerns about safeguarding and staffing, and checked infection prevention and control. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. People appeared comfortable and settled. Relatives were positive about the care, cleanliness and safety. Staff were trained, recruited safely and worked with health professionals to support people's needs.
There were some shortfalls. Two medicines administration entries had not been signed, water temperature checks had not been recorded, and there was no registered manager. The provider dealt with the water recording issue immediately and had arrangements for the day-to-day running of the home.
The other three areas were not inspected during this visit. Their previous ratings were used when calculating the overall rating. The previous overall rating was Good.
People felt safe and settled
People appeared relaxed with staff, and relatives said they were confident their family members were safe and receiving the care they needed.
“People were happy and settled at Mostyn Lodge.” from the report
Kind and respectful staff
Inspectors saw warm interactions. People and relatives described staff as friendly, helpful and respectful.
“We observed people were relaxed with the staff team and supported, for example, to go into the garden.” from the report
Clean environment
The home was clean, fresh and maintained so that surfaces and fittings could be cleaned easily. Relatives also praised the hygiene standards.
“The home was clean and smelt fresh throughout.” from the report
Good oversight and teamwork
The provider used audits and an improvement plan, and staff said they were supported and worked well together.
“The provider had a range of service and provider level audits in operation.” from the report
No registered manager
needs fixingThere was no manager registered with the CQC at the time of the inspection. The provider said they were trying to recruit one.
“The service did not have a manager registered with the Care Quality Commission.” from the report
Medicines records
needs fixingMost medicines arrangements were safe, but one person's chart had not been signed on two occasions. Ask how this is now checked.
“However, on two occasions one person's chart had not been signed.” from the report
Staffing had fluctuated
needs fixingInspectors found enough staff to meet people's needs, but staffing levels had changed during the pandemic.
“However, staffing levels had fluctuated since the start of the pandemic.” from the report
Water checks were not recorded
minorWater temperatures were checked to reduce scalding risks, but the checks had not been recorded. The provider addressed this immediately.
“Whilst water temperatures were checked to minimise the risk of scalding these had not been recorded.” from the report
- 01Who is currently responsible for managing the home while there is no registered manager?
- 02How do you make sure every medicine administration is recorded and signed?
- 03What are the current staffing levels on each shift, and how do you cover absences?
- 04How are water temperatures recorded now, and how often are these checks reviewed?
- 05What were the ratings and findings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led, including infection control; the other three key questions were not inspected and their previous ratings carried over. This explanation was written from the published report of 27 August 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 Mostyn Lodge Residential Home
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Mostyn Lodge Residential Home →
- August 2021GoodSafe: GoodWell-led: Good
Read what inspectors found at Mostyn Lodge Residential Home →
- April 2021Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 17 August 2012.
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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