CQC report explained · a nursing home
What the CQC found at Little Manor Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found caring support and enough staff, but weaknesses in medicines, safety checks and management oversight.
This was an unannounced focused inspection on 22 June 2023. Inspectors looked at whether the home was safe and well-led. They spoke with people, relatives, staff and professionals, and checked medicines, care records, safety records, recruitment files and audits.
People were not always supported safely. Medicine care plans did not always contain enough information, medicine storage was left unlocked for a period, and checks for fire safety, emergency lighting and legionella were not detailed or completed properly. Health and safety audits and medicine audits did not reliably find or fix these problems.
There were also positive findings. People and relatives said they felt supported. Staff were caring, there were enough staff on duty, and people valued the on-site physiotherapy and support with recovery. Care records were person-centred, and staff supported people to make choices and regain independence.
The overall rating changed from Good to Requires Improvement. The home was rated Requires Improvement for Safe and Well-led. The other areas were not inspected during this visit, so their previous ratings were carried forward.
Caring support
People and relatives said they felt well supported. Inspectors found staff supported people in a person-centred way.
“People and their families told us that they felt their stay at Little Manor had been very beneficial for their recovery and that "everyone was very caring".” from the report
Enough staff
Inspectors found there were appropriate staffing levels to support people safely.
“There were appropriate levels of staff on duty to support people safely.” from the report
Recovery and independence
People valued the physiotherapist's involvement. The home supported people to take their own medicines when able, as part of preparing to return home.
“People were empowered to take their own medication when they were able to in preparation for them returning home.” from the report
Good communication
People and families said communication was good. Professionals described a close working relationship with the home.
“People and their families told us that communication between staff and them was good” from the report
Medicine safety
seriousSome medicine care plans lacked important instructions, including guidance about side effects and when to call an ambulance. The medicine room and fridge were also left unlocked and unattended.
“Medicines were not always managed safely. Medicine care plans were not always in place and did not always include the required information.” from the report
Legionella checks
seriousThe home did not have a detailed, service-specific assessment of legionella risks. Inspectors said this meant the home could not be assured that infection risks were fully controlled.
“The provider had implemented a generic risk assessment for legionella to cover all Wessex Care services but had no comprehensive service specific risk assessment” from the report
Weak audits and oversight
seriousHealth and safety and medicine audits did not reliably identify problems. The home also lacked records of some checks and did not always act promptly on issues found.
“The provider did not have effective systems to monitor and manage the service provided.” from the report
- 01What has been done to make sure every medicine care plan includes clear instructions about side effects, seizures and when to call emergency services?
- 02How do you now keep the medicine room and medicine fridge locked and supervised?
- 03Has the home completed a service-specific legionella risk assessment, and how often are the required checks now carried out?
- 04Have all fire risk assessment actions and emergency lighting repairs been completed, and how is this checked?
- 05What regular audits are now in place to identify problems, record actions and confirm that they have been fixed?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 2 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, February 2021
Little Manor Care Centre was inspected but not rated; inspectors found strong infection control arrangements for people discharged from hospital with COVID-19.
This was an announced, targeted inspection on 19 January 2021. Inspectors checked infection prevention and control because the home had been chosen as a designated discharge setting for people leaving hospital after testing positive for COVID-19.
Inspectors found that admissions, visiting, testing, personal protective equipment, cleaning and social distancing were managed carefully. The building was divided into separate pods to reduce the risk of infection spreading.
Staff received detailed training and regular COVID-19 tests. Fire safety checks were up to date, and support was available for staff wellbeing.
The home was inspected but not rated. This means the inspection looked at infection control only and did not give an overall quality rating.
Safe admissions
Hospital discharge assessments were reviewed before admission. People entered through a separate admission entrance and staff wore protective equipment.
“Admissions to the designated unit were carried out safely.” from the report
Visitor controls
Visitors had temperature, oxygen level and lateral flow checks. They were given clear instructions and asked to use protective clothing and masks.
“Robust processes were in place for all visitors to the designated unit.” from the report
Separate areas
The unit was divided into self-contained pods, each with its own facilities and equipment. This was intended to reduce cross-contamination.
“The designated unit was split into self-contained 'pods' of four to six beds.” from the report
Trained and tested staff
Staff had detailed infection control training and regular weekly PCR and daily lateral flow testing.
“All staff had thorough and detailed training on infection control procedures, COVID-19 and the care of people with infectious diseases and end of life care.” from the report
Cleaning and safety systems
The home had detailed cleaning schedules, specialist equipment for decontamination and up-to-date fire safety checks.
“Thorough cleaning schedules were in place and all cleaning materials were PHE approved.” from the report
Inspectors raised no specific concerns in this report.
- 01Do you still use the same admission checks for people coming from hospital?
- 02What checks and protective equipment are currently required for visitors?
- 03How often are residents and staff tested for COVID-19 now?
- 04Are the separate pods, ventilation arrangements and cleaning processes still used?
- 05What infection control training and wellbeing support do staff receive?
This was a targeted inspection of infection prevention and control under Safe; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 27 February 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 Little Manor Care Centre
2 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- May 2016GoodSafe: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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