Manor Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. There were systems in place to monitor and identify aspects of care which could be improved and lessons from this were learnt to continually drive good practice. The registered manager discussed the lessons they learned with staff and discussed these in their staff meetings giving staff the opportunity to discuss practice and ways in which it could be improved.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider safely assessed people’s needs before offering support. They were able to work flexibly with people and partner agencies, providing respite to a person when this was required. The provider was able to take referrals from a wide range of sources and told us they were able to respond to the demands local authorities placed upon them when accepting referrals at relatively short notice.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns with other professionals quickly and appropriately. Staff told us they received safeguarding training and spoke confidently about what they would need to report if they were concerned. The provider had policies to safeguard people from abuse and keep them safe.

Professionals we spoke with told us how safeguarding practices were clearly embedded in day-to-day care. One added, “People know the staff well and have formed safe, trusting relationships. All incidents are quickly communicated, and the provider follows escalation procedures to local health services consistently.”

The provider did not always work well to understand and manage risks. Actions from a fire risk assessment carried out in April 2025 had not been fully addressed. This meant that people were placed at risk unnecessarily. We followed this up with the provider and asked them to action our findings. Following our site visit the provider arranged a contractor to install door release mechanisms and we agreed with the provider a date for this work to be completed and for the Care Quality Commission to be informed when it has been carried out.

Comprehensive risk assessments were in place for each person which addressed risks associated with older people’s care. The quality of the assessments meant staff were able to provide care safely whilst maintaining aspects of people’s independence where possible.

Staff we spoke with knew about risks people faced which included expected risks to an older service user group.

Professionals we spoke with told us the provider was able to manage risks to people. A health professional told us, “Staff demonstrate strong awareness of individual risks and take appropriate measures to ensure residents are protected both physically and emotionally.”

The provider detected and controlled potential risks in the care environment. They made sure equipment supported the delivery of safe care. The environment was free of hazards and well maintained. The provider carried out robust assessments of the environment to ensure it kept people safe and free from harm.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff told us they had worked for the provider for a number of years and understood the needs of the people they supported.

The provider carried out checks on prospective staff to help ensure they were suitable to work in a care setting. These included employment references, proof of identification and of the right to work in the UK and criminal records checks.

A professional advocate we spoke with told us, “Staff have formed safe, trusting relationships with people. They are knowledgeable about each client and able to answer questions clearly, showing a strong understanding of care plans.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service had cleaning procedures and practices in place which were carried out by staff on duty. The provider had an infection control policy and training for staff which gave guidance on best practice and advice on any necessary steps to take in the event of a breakout of any infectious diseases.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The registered manager ensured medicines were administered safely. Stock levels were monitored on the providers electronic care planning system so accurate checks could be carried out to ensure all medicines were administered correctly. The provider worked with local pharmacies and GP services to maintain the correct medicines were received and necessary changes could be actioned immediately. Staff were trained in administration of medicines, and their competency was periodically assessed ensuring their knowledge was up-to-date and people received their medicines safely.