CQC report explained · a nursing home
What the CQC found at Flixton Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed or given safely. Other safety arrangements were positive, including staffing, recruitment, risk assessments, fire checks and infection control.
- Effective?
- Good
- People's needs were assessed and reviewed, and they could access health professionals. Food and drink support was good, although staff training and supervision records had fallen behind and were being brought up to date.
- Caring?
- Good
- People were treated with kindness, dignity and respect. People and relatives said they were involved in care decisions and kept informed.
- Responsive?
- Good
- Staff responded to people's needs and concerns. There was a programme of group and individual activities, and communication needs were recorded.
- Well-led?
- Requires improvement
- Leadership had improved since the new manager started, but quality checks had not found the medicines shortfalls. Training and supervision had also fallen behind, so improvement needed to continue and be sustained.
What inspectors found, February 2024
Requires Improvement; inspectors found kind, responsive care, but unsafe medicines systems and weak quality checks created risks.
This was an unannounced inspection on 13 and 14 December 2023. Inspectors spoke with people, relatives and staff, and reviewed care plans, medicines records, recruitment files and quality records. They also checked the building and infection control arrangements.
People and relatives were mostly positive about the care. Staff were described as kind, respectful and responsive. Inspectors found enough staff, safe recruitment, good support with food and health needs, and activities for people to join. The home had also improved since a new manager started.
The main problem was medicines management. Records and instructions were not always complete or followed, creating a risk of harm. The home breached Regulation 12. The overall rating is Requires Improvement, with Safe and Well-led also rated Requires Improvement. Effective, Caring and Responsive were rated Good.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed respectful interactions, reassurance and support with dignity and independence.
“Staff responded to people respectfully at all times, answering their questions, providing reassurance and doing so with a smile.” from the report
Enough staff
Inspectors found staffing levels were safe and staff had the checks needed before employment.
“Staffing levels were safe. There were enough staff to meet people's needs.” from the report
Activities and personal support
The home offered group activities, one-to-one activities and trips out. Staff had also gathered more information about people's interests.
“These included group activities, 1-1 activities and trips out into the community.” from the report
Positive improvement
The new manager had acted on concerns raised before the inspection, working with Trafford Council. Staff reported a marked improvement in leadership and the home.
“Trafford Council had acknowledged significant improvement had taken place.” from the report
Medicines were not always safe
seriousInstructions and records were incomplete or not followed. This included medicines given at the wrong time, hidden medicines, thickening powder and creams or patches. The provider acted during and after the inspection, but the issue created an increased risk of harm.
“The provider had failed to ensure safe systems for the management and administration of medicines.” from the report
Quality checks missed problems
needs fixingThe home's quality assurance system did not identify the medicines problems found by inspectors. The manager agreed to add more oversight and new care and medicines systems were being considered.
“The quality assurance system had not identified the shortfalls in the management of medicines identified during the inspection.” from the report
Training and supervision records had fallen behind
needs fixingStaff training, supervisions and appraisals were not up to date after the previous manager left. An action plan was in place to bring them up to date.
“An action plan was in place to ensure all staff were up to date with supervisions, appraisals and their mandatory training.” from the report
- 01What specific changes have been made to ensure medicines are given at the correct times and according to manufacturers' instructions?
- 02How are you now checking records for thickening powder, covert medicines, creams and patches?
- 03What evidence can you show that all staff training, supervisions and appraisals are now up to date?
- 04How does a second senior staff member review incidents and medicines audits?
- 05What progress has been made with the planned refurbishment and new electronic care-planning and medicines systems?
This was an unannounced inspection covering all five CQC questions, including the building and care provided; it was prompted by concerns raised by Trafford Council and a whistle-blower. This explanation was written from the published report of 15 February 2024 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, December 2020
Flixton Manor was inspected but not rated; inspectors found good infection prevention and control arrangements.
Inspectors visited the home on 26 November 2020 as part of a coronavirus-related review. The visit was announced and focused on infection prevention and control in care homes.
They were assured that the home had safe arrangements for visitors, social distancing, shielding, personal protective equipment, testing, cleaning and managing possible outbreaks. They were also assured that the infection control policy was up to date.
This inspection did not give an overall rating or a rating for safe care. It was not a full assessment of the home, so the report does not provide current findings about care such as whether it is caring, effective, responsive or well-led.
Safe admissions
New people had to provide a negative COVID-19 test before moving in. They then isolated for 14 days and needed another negative test before using communal areas.
“All new admissions then also isolated in their rooms for 14 days and had a negative COVID-19 test before accessing communal areas of the home.” from the report
Infection control training
Staff had completed extra COVID-19 and infection control training. Learning from specialist training was shared with the wider staff team.
“Additional staff training for COVID-19 and infection control had been completed.” from the report
Testing and protective equipment
The home had arrangements for testing people who lived there and staff, and inspectors were assured that PPE was being used safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Overall infection controls
Inspectors found that the home was following safe infection prevention and control procedures at the time of the visit.
“We were assured the service was following safe infection prevention and control procedures to keep people safe.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now for visitors and new admissions?
- 02Do new residents still need to isolate or have tests before using communal areas?
- 03How are staff tested after returning from annual leave?
- 04How are laundry and personal protective equipment handled if there is a suspected or confirmed infection?
- 05Can you show us the home's current overall CQC rating and explain what has been assessed outside this inspection?
This was an announced thematic review of infection prevention and control during the coronavirus pandemic; it did not rate the overall service or assess the other four questions. This explanation was written from the published report of 4 December 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 Flixton Manor
4 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- February 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- January 2017InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- November 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 5 September 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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