Manor Lodge

Updated 26 November 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 and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

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

Registered manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the home since the last inspection. We sought feedback from the local authority and professionals who work with the provider. We reviewed notifications from the provider about the service. A notification is information about important events or incidents in the home, which the provider is required to tell us about by law. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all of this information to plan our inspection.

During the inspection

We spoke with the registered manager, 2 senior staff, 1 member of staff and a senior representative of the provider. We carried out observations of people’s care and support and spoke with 4 people and 1 visiting relative, for their feedback about the home.

We reviewed documents and records that related to people’s care and the management of the service. We reviewed 5 care plans, which included risk assessments. We looked at other documents such as those for medicine management, staff training and infection control. After the inspection we continued to seek clarification from the provider to validate evidence found.

Updated 26 November 2022

About the service

Manor Lodge is a residential care home that supports people aged 65 or over, some of whom have dementia care or mental health needs. It is registered to accommodate and support up to 15 people. At the time of the inspection, 11 people were living at the home. The home has two floors with adapted facilities and ensuite rooms.

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

The provider had made some improvements in the home following our last inspection. However, there were some ongoing issues with quality assurance systems that needed further work to ensure the home was safe. Medicines for people were not always managed safely because we found they were not being recorded accurately against the dates they were administered.

Staffing levels for the home were assessed but the registered manager told us they needed to recruit additional staff for the home. We have made a recommendation about assessing suitable staffing levels.

Lessons were learned following accidents and incidents in the home. Systems to prevent and control infections were in place. Care plans and risks to people’s health were regularly assessed and reviewed.

Staff were trained to carry out their roles and received support with their continuous development. People were supported to maintain a balanced diet and their nutritional needs were monitored. People were supported to attend health appointments with professionals to help maintain their health.

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 received personalised care. Staff treated people with dignity and respect. People pursued their interests and were supported to avoid social isolation. Staff understood people's communication needs and were aware of promoting equality and diversity. Systems were in place to manage complaints about the home. Feedback was sought from people to help make continuous improvements to the home.

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

Rating at last inspection

The last rating for the service was Requires Improvement, (published on 13 October 2021) and there were breaches of regulation.

We issued requirement notices to the provider for breaches of Regulation 12 (premises and equipment), Regulation 9 (person-centred care), Regulation 10 (dignity and respect) and Regulation 11 (need for consent).

We issued a warning notice for breach of Regulation 17 (good governance).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made but the provider was still in breach of regulation 17 but no longer in breach of other regulations.

The service remains rated Requires Improvement. This service has been rated Requires Improvement for the last two consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

Enforcement and recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a continued breach in relation to good governance 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.