CQC report explained · a nursing home
What the CQC found at Manley Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Inspected but not rated; inspectors found staffing appeared sufficient, but care records and quality checks still needed improvement.
This was an unannounced, targeted inspection on 26 July 2023. Inspectors looked mainly at staffing levels and quality assurance, with additional checks on infection prevention and control. They reviewed staffing records, six care plans, risk assessments, audits and policies, and spoke with staff and a health and social care professional.
Inspectors found no evidence that the home was understaffed. Staffing records showed minimum levels were being met, and relatives and most staff said there were enough staff to meet people's needs safely. Infection prevention and control arrangements were also found to be satisfactory.
The provider had made improvements to care records and quality checks, but further improvements were needed. Inspectors found gaps in records about repositioning, creams and thickener, and fluid monitoring. The home was not given a new rating because this inspection did not cover all parts of the key questions. The previous overall rating of requires improvement remained in place.
Staffing levels
Inspectors found no evidence that the home was understaffed. Records showed minimum staffing levels were being met, and relatives were satisfied that there were enough staff.
“We did not find any evidence the home was being understaffed during this inspection.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including safe use of protective equipment and support for visitors.
“We were assured that the provider was using PPE effectively and safely.” from the report
Management support
Staff spoke positively about the support from managers. A registered manager was now in post, which was an improvement since the previous inspection.
“At the time of the last inspection, there was no registered manager in post at the service. This has now been resolved” from the report
Improvements made
The provider had improved some care records and quality assurance processes. Fluid recording charts were put in place for people unable to manage their own fluid intake after inspectors raised this issue.
“The provider had made a range of improvements in relation to care records and quality assurance processes.” from the report
Incomplete care records
needs fixingInspectors found that a repositioning chart was not always followed, with no explanation in the care records. They also found gaps in records for prescribed creams and food supplement thickener.
“One person's turning chart stated they should be repositioned every 4 hours, but the charts showed this was not always happening as planned.” from the report
Fluid monitoring
needs fixingOne person needed staff to make sure they had enough to drink, but there was no fluid chart in place. Inspectors found no evidence that the person was not receiving enough fluids, and the home put charts in place after the concern was raised.
“The lack of process meant the risk of dehydration was not adequately managed.” from the report
Quality checks missed problems
needs fixingAudits were generally good but did not identify the discrepancies inspectors found. Some audits also contained conflicting information, and information initially submitted about staffing levels was inaccurate.
“Although we found these to be of generally good quality they had not identified the discrepancies we found and some audits contained conflicting information.” from the report
- 01How do you now check that repositioning records are accurate and followed for each person who needs this support?
- 02How do you check that prescribed creams and food supplement thickener are given and recorded every time?
- 03Which people need fluid monitoring, and how often do you review their fluid charts?
- 04What changes have you made so that audits identify missing records and conflicting information?
- 05What progress has been made on the previous breaches of Regulations 12 and 17?
This was a targeted inspection of staffing levels, selected Safe issues including infection control, and parts of Well-led; it did not assess the full key questions, so the previous requires improvement ratings remained unchanged. This explanation was written from the published report of 15 September 2023 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 2023
Rated Requires Improvement; inspectors found risks from staffing, medicines and weak care records, with a warning notice issued.
This was an unannounced focused inspection on 26 August and 5 September 2022. Inspectors spoke with people, relatives and staff, and checked care records, medicine records, staff files and management records.
The home had some safeguards in place. It was clean, infection control measures were followed, staff had safeguarding training, and people’s medicines were generally given as planned. However, staffing levels were sometimes below the home’s own planned levels. Risk plans, medicine records and safeguarding records were not always complete or up to date.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected, so their previous ratings were carried forward.
Infection control
Inspectors found the home clean and hygienic. Staff used protective equipment and the infection control policy was up to date.
“We observed the service was clean and hygienic throughout.” from the report
Safeguarding training
Staff understood their responsibilities for reporting abuse and had completed safeguarding training.
“Staff described what they had learnt in their safeguarding training and understood their responsibilities to act on abuse.” from the report
Recruitment checks
The home carried out checks intended to make safer recruitment decisions.
“The checks included the right to work in the UK, job references and a check from the Disclosure and Barring Service.” from the report
Working with professionals
Staff contacted health and social care professionals when people’s needs changed and worked with them for advice and support.
“Records showed that staff frequently contacted health and social care professionals for advice and support when people's needs had changed.” from the report
Staffing levels
seriousThe number of care workers was below the planned level on seven occasions. Inspectors said this increased the risk of delayed or poor care.
“The staff levels fell short of the planned staffing numbers and this increased the risk of poor and delayed care which did not meet people's individual needs.” from the report
Risk plans
seriousSome plans did not give staff enough detail to manage risks safely. This included choking risks and how to support people who were distressed or agitated.
“We found no evidence that people had been harmed however, people did not always have risk management plans to safely manage risks to their health and well-being.” from the report
Medicines management
seriousSome medicine packaging was not dated when opened, a discontinued medicine record was not completed correctly, and there were no recorded checks on blood glucose equipment.
“People were at risk of deteriorating health due to potentially poorly maintained equipment because of the failure to ensure the machine provided accurate readings and was well maintained.” from the report
Management records and checks
needs fixingThe DoLS tracker and some care records were not up to date. Management checks failed to identify the problems inspectors found.
“However, the checks and monitoring of the service failed to identify the concerns we found.” from the report
Mixed experiences
needs fixingSome people said they felt safe and cared for, but others said staff were rushed and that there were not enough staff. One concern about a nurse reportedly sleeping on night duty had not been followed up with inspectors.
“People shared mixed views of whether they were happy living at the service.” from the report
- 01What staffing levels are now planned for each unit, and how do you respond when the planned number of care workers is not available?
- 02How are choking risks, distress and agitation recorded, reviewed and explained to staff?
- 03How do you check that liquid medicines, inhalers and creams are dated when opened, and that medicine records are completed correctly?
- 04How often is blood glucose monitoring equipment checked, calibrated and maintained, and where are those checks recorded?
- 05What action has been taken in response to the warning notice and the continued breaches in staffing and governance?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 25 February 2023 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 Manley Court Care Home
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- September 2023Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- February 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- June 2020Goodup from Requires improvementSafe: Requires improvementEffective: GoodWell-led: Good
- July 2018Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 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.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 2010.
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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