CQC report explained · a residential care home
What the CQC found at 13 Manor Crescent
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, suitable risk assessments, safe medicines management, safeguarding training and effective infection prevention arrangements.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found effective management oversight, regular audits, good staff communication and a supportive team culture.
What inspectors found, December 2022
13 Manor Crescent is rated Good; inspectors found safe, well-led care, with staffing and community access improved since the last inspection.
This was an unannounced inspection. One inspector visited the home on 23 November 2022 and reviewed information, care records, staff recruitment records, medicines arrangements, audits and meeting notes. They also spoke with managers, staff and relatives, and observed how staff supported people because residents could not tell inspectors directly about their care.
The home supported four people with learning disabilities and/or autism. Inspectors found enough staff on each shift, safer recruitment checks, suitable risk assessments and safe medicines systems. The home was clean, infection prevention arrangements were in place, and staff understood safeguarding responsibilities.
Relatives said they were kept informed and their views were acted on. Inspectors found regular management checks, good communication between staff and effective teamwork. The overall rating remained Good, but this inspection only assessed Safe and Well-led. Ratings for the other areas were carried over from the previous inspection.
Staffing and community access
Staffing levels had increased and the use of agency staff had reduced. Inspectors said this improved consistency and gave people more opportunities to access their community.
“The number of staff on each shift had increased since our last inspection, which had improved the support people received to stay safe and to access their community.” from the report
Medicines
Staff were trained and assessed before giving medicines. Inspectors found no gaps or errors in the records they checked.
“The medicines administration records we checked during our inspection contained no gaps or errors.” from the report
Management and teamwork
The management team carried out regular checks and staff communicated well about people's needs. Inspectors found that staff worked effectively together.
“The management team maintained an effective oversight of the service.” from the report
Family involvement
Relatives said staff kept them informed about people's wellbeing and involved them in the life of the home. Their feedback was listened to and acted on.
“Relatives said staff kept them up to date about their family members' wellbeing and involved them in the life of the home.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current staffing levels on day and night shifts, and how much agency staff is being used now?
- 02How will my relative be supported to access the community and receive one-to-one support when needed?
- 03How are medicines checked, reviewed and recorded, including medicines given only when needed?
- 04How will you involve me in decisions about my relative's care and respond to concerns or feedback?
- 05How do you work with the GP and Positive Behaviour Support team when my relative's health or behaviour needs change?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 14 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2021
Rated Good; inspectors found safe, kind and personalised care, with some agency staffing and fire training points still being addressed.
Inspectors made an unannounced visit on 5 October 2021. They observed care, spoke with staff, family members and professionals, and checked care plans, medicines, recruitment and management records.
They found people were safe, received their medicines, had enough food and drink, and could access healthcare. Staff supported people with choices, communication, independence and activities. The home was clean and staff followed infection control practices.
The home had improved since its previous inspections. Care plans, mental capacity assessments, staffing levels, the environment and quality checks were all better. The overall rating changed from Requires Improvement to Good, and the home was no longer in breach of regulations.
Safe staffing and medicines
Inspectors found enough staff to meet people's care and emotional support needs. Medicines records were complete and staff competency had been checked.
“We reviewed the MARs and found these had been completed correctly, with no gaps in the recording.” from the report
Personalised support
Care plans included people's needs, preferences, communication methods and behaviour support. Staff helped people make choices and be as independent as possible.
“People received personalised support and were enabled and supported by staff to be as independent as possible.” from the report
Kind and respectful care
Inspectors saw positive relationships between people and staff. Staff protected privacy and dignity and responded to people's communication and wishes.
“We observed throughout our inspection that people enjoyed spending time with staff and were confident to be in their company.” from the report
Improvements since earlier inspections
The home had improved its care records, environment, staffing arrangements, mental capacity work and management checks. It was no longer in breach of regulations.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Use of agency staff
minorThe provider was still recruiting permanent staff. A relative said agency staff needed to learn the person's ways and understand them quickly.
“It would be good to have more permanent staff; agency staff have to learn [relative's] ways and get to understand them quickly.” from the report
Fire refresher training was delayed
needs fixingRefresher fire training for all staff had not yet taken place because of COVID-19 restrictions, although it was booked for the weeks after the inspection.
“Refresher fire training for all staff was booked to take place in the weeks following this inspection.” from the report
End of life plans unfinished
minorThe manager said people's end of life care plans still needed to be developed. No one living at the home needed end of life support during the inspection.
“People's end of life care plans need to be developed; this is an on-going action for me.” from the report
- 01How many permanent and agency staff usually work at the home, and how are agency staff introduced to each person's needs?
- 02Has the delayed refresher fire training now taken place, and how are staff kept ready for an emergency?
- 03How will you complete and review each person's end of life care plan?
- 04How are people's communication methods, food preferences, activities and behaviour support kept up to date?
- 05How will relatives be involved when a major decision is needed for someone who cannot communicate their wishes clearly?
This was an unannounced follow-up inspection of all five key questions, including infection prevention and control, after earlier inspections found breaches that the report says had been addressed. This explanation was written from the published report of 10 November 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 13 Manor Crescent
5 rated inspections over 6 years: the service has held its Good rating throughout.
- December 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2020Requires improvementup from InadequateSafe: GoodWell-led: Requires improvement
- April 2020Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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