CQC report explained · a nursing home
What the CQC found at Manor Farm Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found kind, personalised care, but medicines and quality checks were not consistently safe or effective.
This was an unannounced inspection after the local authority raised concerns about general safety and care. Inspectors visited on four dates, spoke with people, relatives and staff, and checked care records, medicines, recruitment records, audits and building safety documents.
The main problems were with medicines. Inspectors found errors in stock counts and controlled-drug records, missing guidance, medicines used past their discard dates, and other gaps. Quality audits had not identified these problems. The home took some immediate action, including improving guidance and introducing new medicines audits.
People were protected from abuse, there were enough staff recorded to meet people's needs, and infection-control arrangements were satisfactory. Inspectors also found good care, effective support, detailed care planning, activities and positive relationships with people and relatives.
The overall rating was Requires Improvement. Safe and well-led were also Requires Improvement. Effective, caring and responsive were Good. The previous overall rating was Good in 2017.
Staffing and safeguarding
Inspectors found enough staff recorded to meet people's needs, with call bells answered promptly. People were protected from abuse and staff knew how to raise safeguarding concerns.
“There were enough staff on duty to meet peoples needs. We observed during our visits that nobody had to wait long for assistance and call bells were answered promptly.” from the report
Kind and respectful care
Staff were observed treating people calmly and with kindness. People’s privacy, dignity, independence and equality were respected.
“People were well treated and supported by staff who knew them well.” from the report
Personalised care plans
Care plans recorded people's histories, preferences, communication needs and the help they required. They were reviewed monthly and families' views were recorded.
“Care plans were detailed, personalised and included people's history.” from the report
Activities and relationships
People had a range of activities, including options for those staying in their rooms. The home also supported contact with families and people's cultural or spiritual beliefs.
“Records showed a variety of activities were offered to people and included activities for people who stayed in their room.” from the report
Complaints handling
The home had a complaints process and records showed complaints were followed up with outcomes recorded.
“Records showed complaints were dealt with appropriately with the outcome recorded and whether the complainant was satisfied.” from the report
Medicines management
seriousInspectors found ten areas needing improvement. These included missing guidance, medicine stock discrepancies, errors in controlled-drug records, out-of-date opened medicines and missing risk assessments for emollient creams.
“Medicines were not always managed safely. We found ten areas in medicines management which needed improvement.” from the report
Quality checks did not identify problems
seriousThe home's medicine audits had not found the problems inspectors identified. This meant the provider's systems were not reliably checking or improving medicines safety.
“Systems and processes for assessing the quality of the service and mitigating risks had not always been effective in identifying areas for improvement.” from the report
Environmental safety
needs fixingContractors left some rooms unlocked despite hazards including uneven flooring and sharp tools. Managers secured the rooms, but they were found unlocked again later.
“During the inspection there were building contractors in the building and we found they had left rooms unlocked where there were risks of harm to people.” from the report
- 01What has changed in medicines management since the inspection, and can you show us the results of the new daily stock checks and audits?
- 02How do you check that controlled drugs, opened medicines and as-needed medicines are recorded and managed correctly?
- 03Who is currently responsible for the home while there is no permanent registered manager, and when is recruitment expected to be completed?
- 04How do you keep contractor areas locked and safe for people living in the home?
- 05What action has been taken in response to the two CQC breaches, and what evidence can you share that the problems have been fixed?
This was an unannounced inspection covering all five key questions, including infection prevention and control, after concerns were raised about general safety and care; the last overall rating was Good in 2017. This explanation was written from the published report of 2 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, March 2022
Manor Farm Care Home had a targeted infection-control inspection and was inspected but not rated; inspectors found good COVID-19 safety arrangements.
The inspection took place on 18 February 2022 and was announced 24 hours beforehand. It focused on infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19.
Inspectors were assured that the home was managing infection risks. They found screening for visitors, effective use of protective equipment, testing arrangements, good hygiene and an up-to-date infection-control policy.
The home had experienced COVID-19 outbreaks in September and January. During those outbreaks, visitors and new admissions were stopped on the advice of the local health protection team. The home was clean, and staff absences were covered by permanent or regular bank staff.
The service was inspected but not rated. This means the report does not give an overall quality rating, and it does not assess all five areas of care.
Infection control
Inspectors were assured that the home had measures to prevent and manage infections, including an up-to-date policy.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Visitor safety
Visitors were screened before entry, given masks and hand gel, and could use a separate visitors room with a screen during an outbreak.
“Visitors underwent a thorough pre-screening process before entering the care home.” from the report
Clean environment
The home was clean and had hand gel and handwashing facilities available throughout the service.
“The home was clean and free from malodour.” from the report
Staff continuity
The home did not use agency staff. Absences were covered by permanent staff or regular bank staff.
“The service did not use agency and staff absences were covered by permanent staff or regular bank staff.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current visiting arrangements if there is an infection outbreak?
- 02How would you contact families and protect residents if the home had another COVID-19 outbreak?
- 03How are staffing absences covered now, and are permanent or regular bank staff still used?
- 04Is the refurbishment of the top floor complete, and is that floor now occupied?
- 05What are the home's current ratings for care areas that were not covered by this inspection?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 1 March 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.
Every inspection of Manor Farm Care Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- November 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 14 March 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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