Archived: Manor Lodge Care Home

Updated 22 October 2021

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 Care Act 2014.

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 completed by one inspector

Service and service type

Manor Lodge Care Home 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.

The service had a manager who was registered with the Care Quality Commission. 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.

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, safeguarding, infection prevention and control and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with six people and one relative about their experience of the care provided and spent time observing interactions with staff. We spoke with seven members of staff including the registered manger, assistant manager, team leaders, support staff and ancillary staff.

We viewed a range of records. This included three people's records relating to their support and multiple medicine records. We looked at one staff file in relation to recruitment and supervision. A variety of records relating to the management of the service were also reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training and supervision data and quality assurance records.

We contacted nine staff by email and received responses from three. We also spoke with one family member. We had email exchanges with the director of operations and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 22 October 2021

Manor Lodge Care Home is a residential care home providing accommodation and personal care for up to 21 adults in one adapted building. At the time of this inspection 12 people were resident. People who live at Manor Lodge have varied health and social care needs, such as mental health needs, physical needs, learning disabilities and dementia.

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

Since the last inspection widespread changes had been made. A new framework of audits had led to improved monitoring which had led to improvements in the quality and safety of the service. Continuous learning was a clear focus and it was acknowledged that the service was embedding new systems and ways of working.

People told us they felt safe and happy. Safeguarding concerns were reported and responded to appropriately and in a timely manner. Improvements had been made to the environment including the maintenance of the heating and hot water system. Measures to minimise the risks of COVID-19 were in place. Some staff told us they were not wearing PPE appropriately. The registered manager and provider took immediate measures to ensure staff were following the current guidance. Risks were assessed and mitigated where possible. A new electronic support planning system was being rolled out. We have made a recommendation about the review and audit of the content of risk assessments and support plans.

Staff said they felt there were enough of them to meet people’s needs at present. Improvements had been made to the staffing structure and allocation of staff in the kitchen. Staff said they felt well supported and opportunities for training and learning had improved. They described their job role and what was expected of them.

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe, effective and well-led the service was able to demonstrate how they were embedding the underpinning principles of Right support, right care, right culture.

Right support:

• People were supported to access the community.

Right care:

• Care was person-centred and promoted people’s dignity, privacy and human rights

Right culture:

• Improvements had been made to the culture of the home to promote inclusion and involvement in decision making.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 14 April 2021) and there were multiple breaches of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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 carried out an unannounced focused inspection of this service during 2 to 9 March 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve god governance, safe care and treatment, staffing and safeguarding.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions of safe, effective and well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Manor Lodge Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.