CQC report explained · a nursing home
What the CQC found at Manor Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2022
Manor Court Care Home was rated Requires Improvement; inspectors found staffing, cleanliness, activities and management systems were not consistently good enough.
This was an unannounced focused inspection on 8 September 2022. Inspectors looked at Safe, Responsive and Well-led because concerns had been raised about staffing. They spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
The home did not always have enough staff to meet people's needs safely. Inspectors also found incomplete cleaning records, areas that were not clean, limited activities and care that could become task-focused when staff were busy. Management checks had not found or fixed some of these problems quickly enough.
There were also positive findings. Staff were safely recruited, medicines were generally managed safely, care plans recorded people's preferences, and staff understood safeguarding and mental capacity requirements. The overall rating fell from Good at the previous inspection to Requires Improvement. Effective and Caring were not inspected, so their previous ratings were carried forward when calculating the overall rating.
Medicines
Medicines were generally managed safely. Records were accurate, stock balances matched, and staff had training and competency checks.
“Overall, medicines were managed consistently and safely in line with national guidance by staff who had received relevant training and who underwent annual assessments of their competency.” from the report
Safe recruitment
The home carried out the main employment checks needed to help ensure suitable staff were employed.
“The provider followed safe recruitment practices to help ensure only suitable staff were employed to care for people using the service.” from the report
Personalised care plans
Care plans included people's preferences, histories and specific care needs. They were reviewed and updated.
“Care plans were person centred and recorded people's preferences about how they wished to receive care.” from the report
Safeguarding
People and relatives said they felt safe. Staff knew how to respond to possible abuse and the home had safeguarding procedures.
“The provider had arrangements to help protect people from the risk of abuse and avoidable harm.” from the report
Staffing and supervision
seriousThere were not enough nurses, care staff and domestic staff at times. Inspectors saw people without enough supervision, delayed responses to call bells and staff interactions that were mainly task-based.
“The provider did not ensure that adequate staffing levels were provided to attend to people's needs.” from the report
Cleaning and infection control
seriousCleaning schedules were often incomplete. Inspectors found dust, unpleasant smells, bird droppings and an unclean toilet, and staff used incorrect cleaning equipment on one occasion.
“Incomplete cleaning schedules, the lack of domestic staff and the use of incorrect equipment meant we were not assured effective arrangements were in place for preventing and controlling infection.” from the report
Activities and social contact
seriousActivities were not consistently available, especially for people staying in their rooms. Inspectors found little evidence that activities reflected people's interests and choices.
“We saw no evidence of people engaged in meaningful activities in their rooms or supported to follow individual interests.” from the report
- 01How many nurses, care staff and domestic staff are currently on each unit, and how does this compare with the needs of residents?
- 02What action has been taken to make sure people receive meaningful activities in communal areas and in their rooms?
- 03How are cleaning tasks checked now, and how do you make sure there are enough domestic staff on every unit?
- 04Who is currently responsible for managing the home, and how is leadership stability being improved?
- 05How have you acted on the risks identified around eating positions, medicines storage and emergency evacuation equipment?
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 15 November 2022 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 2021
Manor Court Care Home was rated Good; inspectors found systems to keep people safe and a well-led home, but noted staffing pressures and some incomplete records.
This was an unannounced focused inspection on 13 and 14 October 2021. Two inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They reviewed care records, medicines records, recruitment files and management records.
The home was rated Good for Safe and Well-led. Inspectors found safeguarding procedures, risk assessments, safe recruitment and systems for managing incidents and complaints. Medicines were generally managed safely, infection controls were in place and managers used audits and meetings to identify improvements.
There were some shortfalls. One person's care plan did not include their most recent fall. In one unit, medicines had not been recorded as carried over to new medicines charts. Some people reported not having enough staff, and not everyone felt able to approach the registered manager.
This was a focused inspection of Safe and Well-led only. The other three areas were not inspected during this visit, so their previous ratings were carried forward into the overall Good rating. The previous overall rating was also Good, published on 9 January 2021.
People felt safe
People told inspectors they felt safe. The home had safeguarding procedures and staff knew how to report concerns.
“People told us they felt safe at the home.” from the report
Safety checks
The home carried out checks on areas such as fire systems, emergency lighting, electrical installations and equipment used to support people.
“Records indicated the provider undertook appropriate health and safety checks with action plans to monitor the premises and help ensure people lived in a safe environment.” from the report
Learning from incidents
Managers reviewed accidents, falls and other incidents. They used meetings, audits and action plans to reduce the chance of problems happening again.
“Managers analysed audits to identify issues and learn lessons to make improvements to service delivery.” from the report
Partnership working
The staff worked with health and social care professionals, including GPs, community nurses, dieticians and speech and language therapists.
“The staff team worked in partnership with others to help ensure people received safe care and support.” from the report
Medicines records
needs fixingIn one unit, medicines were not always carried over onto the new medicines administration records at the start of a new cycle.
“However, in one unit we found examples where there was no record of medicines being carried over onto the medicines administration records (MAR) for the new cycle that started that week.” from the report
Falls information
needs fixingOne of the 11 care files checked did not include a person's most recent fall. Audits had identified missing information and actions were being tracked.
“Although the care plan for one person, out of the eleven people's files we looked at, did not reflect the most recent fall they had.” from the report
Infection control details
minorPeople did not have individual COVID-19 risk assessments, although they had COVID-19 care plans and visitor plans. Inspectors also saw some masks being worn below the nose, which was corrected immediately.
“However, we did see some staff with masks under their noses, but this was immediately addressed.” from the report
Access to senior managers
needs fixingSome people, relatives and other stakeholders did not feel able to approach the registered manager. Not everyone knew who the registered manager was.
“Not all people using the service knew who the registered manager was and a number of people across the stakeholder groups did not feel able to approach the registered manager.” from the report
- 01How many staff vacancies are there now, and how do you make sure each unit has enough trained staff during the day?
- 02What checks now make sure medicines are correctly carried over onto new medicines administration records?
- 03How do you make sure every recent fall is recorded promptly in the person's care plan and risk assessment?
- 04Have individual COVID-19 risk assessments been completed for everyone, as planned after the inspection?
- 05Who should residents and relatives speak to if they need to raise a concern with senior management?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 26 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.
Every inspection of Manor Court Care Home
12 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: GoodWell-led: Requires improvement
- September 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2019Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 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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