Manor Lodge

Updated 14 October 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Manor Lodge is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Manor Lodge is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Before the inspection, we reviewed information we already held about this service. We sought feedback from the local authority who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with two people who used the service and observed how staff interacted with people. We spoke with three staff; the care coordinator, a support worker and the registered manager. The registered manager was also the provider of the service. We reviewed a range of records. This included two people's care records and three people’s medicines records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 14 October 2022

About the service

Manor Lodge is a residential care home providing the regulated activities of accommodation for persons who require nursing or personal care and treatment of disease, disorder or injury to up to four people. The service provides support to older people. At the time of our inspection there were four people using the service, although one person was in hospital. The premises is an ordinary home in a residential area.

People’s experience of using this service and what we found

Medicines were not always managed in a safe way. Risk assessments did not always include sufficient information about how to mitigate the risks people faced. Quality assurance and monitoring systems were not always effective.

There were enough staff working at the service and robust staff recruitment practices were in place. Systems had been established to help safeguard people from the risk of abuse. Measures had been taken to promote infection prevention and control.

Initial assessments were carried out of people's needs before they started using the service to see if the provider could meet them. Staff received training and supervision to support them in their role. People were able to make choices about what they ate and drank. People were supported to access health care professionals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People told us that staff were kind and caring and treated people well. People were supported to have control and choice over their daily lives. People's privacy was respected, and staff understood how to support people in a way that promoted privacy, dignity and independence.

Care plans were in place, which set out how to meet the individual needs of people. People were involved in developing these plans, which meant they were able to reflect people's needs and preferences. People's communication needs were met. People told us they had confidence that any complaints raised would be addressed. People were able to maintain relationships with family and friends, and to have access to community facilities.

There was an open and positive culture at the service, which meant people and staff could express their views. The provider worked with other agencies to develop best practice and share knowledge.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 9 April 2019 and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to the way medicines were managed, risk assessments and quality assurance practices at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.