CQC report explained · a residential care home
What the CQC found at 15 Manor Crescent
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had individual risk assessments and guidance for staff. Inspectors found enough staff, safe recruitment, medicines management and infection control arrangements.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found quality checks were being used, staff understood their roles and people, families and staff were involved. This rating improved from Requires Improvement at the last inspection.
What inspectors found, November 2021
15 Manor Crescent rated Good; inspectors found people were safe and the home was well-led, with leadership improved since the last inspection.
Two inspectors made an unannounced visit on 5 October 2021. They spoke with one person and four staff, observed support, and checked care, medicine, accident, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable risk assessments, safe medicines management and appropriate infection control. People were supported to make choices and staff treated them as individuals.
This was a focused inspection of Safe and Well-led only. The other areas were not inspected because no concerns were identified, so their previous ratings were used. The overall rating stayed Good. Well-led improved from Requires Improvement at the last inspection.
People were kept safe
Staff understood safeguarding procedures and people's individual risks. The home reviewed incidents and made changes to reduce the chance of them happening again.
“Risk assessments were in place which identified people's individual health care needs and support.” from the report
Enough staff
Inspectors found staffing levels met people's needs, including when one-to-one support was required. Recruitment checks were also in place.
“There were sufficient staff to ensure that people's needs were being met.” from the report
Medicines managed safely
Medicine records were up to date, medicines were stored securely and staff had training and competency checks.
“People's medicine administration records (MAR) were signed as appropriate and were up to date.” from the report
Improved leadership
A new registered manager had introduced improvements. Audits, staff meetings and regular contact with relatives helped the home monitor and improve care.
“There was a system of quality assurances processes in place that were being used to improve the quality of care.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you make sure people receive consistent support when agency staff are used?
- 02How are each person's choking, behaviour and other risks explained to new or temporary staff?
- 03How are medicines given through a PEG checked, and which staff are trained and assessed to do this?
- 04How will you keep relatives informed and involved in care and activities?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used. This explanation was written from the published report of 9 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.
What inspectors found, November 2020
15 Manor Crescent was rated Good overall, but inspectors found the home was not always well-led because its manager was not registered with CQC.
Inspectors visited on 20 October 2020. This was an announced, focused inspection of Safe and Well-led. They spoke with people, staff and a relative, and checked care, medicines, staff and management records.
The home was rated Good for Safe. Inspectors found improvements in infection control, night staffing, medicines records and risk management. They also found staff understood people's needs and how to protect them from abuse.
The home was rated Requires Improvement for Well-led. Quality checks had improved and the previous breach had been resolved, but the manager had not applied to register with CQC. The overall rating improved from Requires Improvement to Good, partly because other question ratings were carried over from the previous comprehensive inspection.
Improved infection control
The home had replaced or repaired flooring, introduced extra cleaning measures and had clear cleaning schedules. Inspectors were assured that infection risks, including COVID-19 risks, were being managed.
“All areas of the home were clean and there were clear cleaning schedules in place.” from the report
Safe staffing
An extra member of staff had been added to the night rota since the previous inspection. People, relatives and staff said there were enough staff to provide care and activities.
“Since our last inspection, the provider had introduced an additional member of staff to the night duty rota, which staff felt had a positive impact on the service.” from the report
Medicines managed safely
Medicines records were complete, medicines were securely stored and staff had been trained and assessed in safe administration.
“Medicine administration records were fully completed and gave details of the medicines people had been supported to take.” from the report
Person-centred support
Care records reflected people's needs and preferences. Staff supported people to make day-to-day choices and access local shops and amenities.
“Staff were observed to enable people to make day to day choices, including around food and activities.” from the report
Better quality monitoring
The provider had improved its checks of care, medicines, staff records and surveys. The previous breach about governance had been resolved.
“The provider had effective quality assurance systems in place.” from the report
Manager not registered
needs fixingThe manager in post had not applied to register with CQC. This was a legal registration requirement and limited the Well-led rating.
“The manager in post at the time of this inspection was not registered with CQC, which has an effect on the rating of the service.” from the report
Some risks not recorded
needs fixingInspectors found that some known triggers for one person's challenging behaviour were missing from the risk assessment. Staff understood the triggers, and updated assessments were provided after the inspection.
“There were other instances where, through speaking with staff about the people they cared for, we identified that not all potential risks were recorded in the person's risk assessments.” from the report
- 01Has the manager now submitted an application to register with CQC, and what is the current position?
- 02How do you check that every person's risk assessment includes all known triggers and risks?
- 03What changes have been made since the inspection to keep risk records up to date?
- 04How will the extra night staffing arrangement be maintained?
- 05How will you show that the improved quality checks continue to identify and fix problems?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection. This explanation was written from the published report of 28 November 2020 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 15 Manor Crescent
4 rated inspections over 5 years: the service has held its Good rating throughout.
- November 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- August 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 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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