Mostyn Lodge Residential Home

Updated 11 January 2024

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 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

This inspection was carried out by 2 inspectors and 1 member of the medicines team.

Service and service type

Mostyn Lodge Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Mostyn Lodge Residential Home is a care home without nursing care. 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 not a registered manager in post. The manager who started work in September 2022 had begun the registration process earlier this year. Unfortunately, circumstances beyond their control had prevented the registration process being completed.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and other professionals who work with the service. 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 this information to plan our inspection.

During the inspection

We spoke with 9 people and 3 family members on site. A further 3 relatives provided feedback following the first day. We spoke with 9 staff on site. This included the manager, the provider’s consultant and the nominated individual who was the owner. The nominated individual is responsible for supervising the management of the service on behalf of the provider. Following the site visits, we also spoke with 4 more staff on the telephone.

We carried out a range of observations to capture people’s experiences in the home. We looked at various records on site and remotely. This included 6 people’s care records, medicine records, staff files, health and safety records, policies and procedures and a range of governance documents.

Updated 11 January 2024

About the service

Mostyn Lodge Residential Home is a residential care home providing personal care without nursing for up to 16 people. The service provides support to older people who often have dementia. At the time of our inspection there were 16 people using the service.

The home is an adapted building where each person has an individual bedroom and there are shared facilities. There is access for all to lounges, the kitchen and the garden.

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

People were comfortable in the presence of staff and were able to tell us they felt safe. However, systems to keep them safe from potential abuse were either not being followed or were ineffective. Information was not shared with external bodies such as the Care Quality Commission (CQC) or the local authority.

Some risks and ways to mitigate them were assessed in line with best practice, such as pressure care and use of hoists. However, there were areas where care plans lacked guidance for staff around other risks. For example, supporting people who could become distressed or upset and eating and drinking.

People had individual medicine administration records which included their preference of how to support them. However, concerns were found with other areas of medicine management placing other people at risk of potential harm. Some of these were rectified by the management during the inspection.

People and their relatives felt staffing had recently got better at the home and records demonstrated this. Although, there were feelings that care staff were stretched by having to work in the kitchen as well. Recruitment systems were in place although improvements were required in some of the checks being completed.

Systems were not always in place or effective to manage the service. The management had a wealth of audits they completed. However, concerns identified on the inspection had not always been found within these. The provider’s policies and procedures were not always being followed.

People, relatives and staff were incredibly positive about the manager and the support they provided. Although, differing approaches at management level led to inconsistencies.

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 this service was good (published 27 August 2021).

Why we inspected

The inspection was prompted in part due to concerns received about medicine management, infection control, staffing and safety of people living in the home. As a result, we undertook a focused inspection to review the questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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

Enforcement and Recommendations

We have identified breaches in relation to medicine management, risk assessment, keeping people safe from potential safeguarding and systems to manage the service.

Please see the action we have told the provider to take at the end of this report.

We have also made two recommendations in relation to recruitment and the duty of candour.

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 or assess the home.