CQC report explained · a residential care home
What the CQC found at Himley Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2021
Himley Manor Care Home is rated Requires Improvement; inspectors found gaps in risk records, activities and quality checks, although medicines and infection controls were managed safely.
This was an unannounced inspection prompted by concerns about infection prevention and control and whistleblowing. Inspectors visited the home on 26 November 2020, then spoke by telephone with relatives, staff and healthcare professionals.
The home was not always safe or responsive. Care plans did not fully reflect people's current risks, activities were limited, and communication with relatives could be better. Quality checks did not reliably find problems or make sure they were fixed promptly.
The home was rated Requires Improvement overall, with the same rating for Responsive and Well-led. Safe fell from Good to Requires Improvement. Effective and Caring were not inspected during this visit, so earlier ratings for those areas were used in the overall result.
Medicines
Inspectors found medicines were stored safely, given as required and supported by suitable guidance for medicines taken only when needed.
“Medicines were managed safely. We saw medicines had been stored safely and records indicated people had received their medicine as required.” from the report
Safeguarding
Staff understood how to recognise and report possible abuse. Relatives told inspectors they felt the home was safe.
“All four relatives we spoke with told us they felt the home was a safe place to be.” from the report
Infection control
Staff used personal protective equipment and understood their infection control responsibilities. The provider had worked with the local authority after earlier concerns.
“We were assured that the provider was using PPE effectively and safely.” from the report
Positive new leadership
Although there had been several management changes, staff, relatives and healthcare professionals spoke positively about the new manager's early changes.
“staff, healthcare professionals and relatives all spoke positively about the new manager and the changes she had made in her four weeks in post.” from the report
Risk information
seriousCare plans did not consistently show people's current risks. Examples included unclear evacuation guidance, inadequate planning for someone isolating with COVID-19, and a falls assessment that was not updated after two falls.
“people's care plans did not consistently reflect their current risks and provide consistent guidance to staff to keep people safe:” from the report
Quality checks
seriousAudits did not reliably identify missing care records, an incorrectly completed falls assessment, a broken bed rail or gaps in training records. This was a breach of Regulation 17.
“Processes in place to monitor, audit and assess the quality of the service being delivered are ineffective in identifying all areas requiring improvement and ensuring actions are taken in a timely way” from the report
Management continuity
needs fixingRelatives and healthcare professionals were concerned that repeated management changes affected consistency. The new manager had only been in post for about four weeks at the inspection.
“Relatives and healthcare professionals, we spoke with raised concern about the number of management changes as they felt this impacted on the consistency of the service provided.” from the report
- 01How are you making sure every person's care plan and risk assessment is updated after a fall or change in health?
- 02What equipment and clear evacuation plan are now in place for people who may need help to leave the building in an emergency?
- 03What activities are now available that match each person's interests, culture and abilities?
- 04How will you keep relatives informed and help residents maintain contact with family and friends?
- 05What checks are now used to find missing records, broken equipment and overdue staff training, and how are actions followed up?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 12 January 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, October 2019
Himley Manor Care Home was rated Requires Improvement; inspectors found safer, kinder care but activities and management checks still needed work.
This was an unannounced inspection on 16 and 17 September 2019. Inspectors spoke with people living at the home, relatives, staff and health professionals. They observed care and reviewed care, medicine, recruitment and management records.
The home had improved substantially since its previous Inadequate rating. Safe, effective and caring were rated Good. Inspectors found better risk assessments, medication support, staff training, cleanliness, food and access to healthcare. People were treated with dignity and involved in choices about their care.
Responsive and well-led were rated Requires Improvement. Activities were limited in some areas, and people had not always been consulted about the activity programme. Management checks had improved but did not always identify gaps or incomplete detail in records.
The overall rating Requires Improvement means the home was no longer Inadequate or in Special Measures, but inspectors still expected further improvements before it could be rated Good overall.
Safer care
Risk assessments and staff knowledge had improved. Inspectors found that people were protected from avoidable harm and that staff knew how to respond to risks.
“Staff had a good understanding about potential risks to people and how to support people safely.” from the report
Medicines
People received medicines at the right time, with accurate administration records. Staff were trained and their competency was checked.
“People received the right medication at the right time and people's medicines administration records (MAR) were completed accurately.” from the report
Kind and respectful staff
Inspectors saw staff treating people with patience and respect. People were supported to make choices and maintain dignity and independence.
“We observed staff treating people with patience, and respect.” from the report
Improved staff skills
Training and induction had improved since the previous inspection. Staff told inspectors that the training helped them develop their skills.
“Improvements had been made and a range of face to face and on-line learning and development had taken place to ensure staff had the knowledge and the skills they needed to carry out their role.” from the report
Food and healthcare
Meals were organised, people had choices and staff encouraged drinking. People could access healthcare professionals when needed.
“People at risk of weight loss were closely monitored and provided with a fortified diet (extra calories) to help them gain and maintain a healthy weight.” from the report
Limited activities
needs fixingThere was little activity on the ground-floor lounge for long periods. The home had changed how activities were provided, but inspectors could not see that people had been consulted about what they wanted.
“The days seem so long with nothing to do.” from the report
Incomplete management records
needs fixingManagement checks did not always find gaps or missing detail. Examples included recording only the month for weight monitoring, gaps for refused creams and incomplete fire-drill records.
“There were some gaps on MAR records for refused prescribed creams.” from the report
Training not fully embedded
minorSome staff had limited knowledge of how Mental Capacity Act and Deprivation of Liberty Safeguards training should affect day-to-day care. Further discussions and training were planned.
“Although staff had received training of the MCA and DoLS and there was a system in place to inform staff who had a DoLS in place some staff had limited knowledge about what this meant for people in day to day practice.” from the report
- 01What activities are now available on the ground floor, and how do you find out what each person wants to do?
- 02How do you check that weight and fluid monitoring records contain the right dates and information?
- 03How do you record and follow up when someone refuses a prescribed cream or other medicine?
- 04What further training have staff received about the Mental Capacity Act and Deprivation of Liberty Safeguards?
- 05How do your fire-drill records show who attended and what follow-up action was needed?
This was an unannounced planned inspection covering all five key questions, including the premises and the care provided, following the previous Inadequate rating. This explanation was written from the published report of 5 October 2019 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 Himley Manor Care Home
10 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- January 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2019Requires improvementup from InadequateSafe: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- January 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- September 2017Requires improvementstayed Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- May 2013
Registered with the Care Quality Commission on 3 May 2013.
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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