CQC report explained · a residential care home
What the CQC found at Manor House
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- Inspectors were assured about infection prevention and control. This included PPE, testing, social distancing, safe admissions, hygiene, outbreak management and an up-to-date policy.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Outstanding
- Are people treated with kindness and dignity?
- Responsive?
- Outstanding
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Outstanding
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2021
Inspected but not rated; inspectors were assured about the home's COVID-19 infection prevention and control measures.
This was an announced, targeted inspection on 09 February 2021. It checked how the home was preventing and controlling infections during the COVID-19 pandemic.
Inspectors were assured that the home used personal protective equipment safely, supported testing, followed shielding and social distancing rules, and had suitable infection prevention policies. They also found regular health observations, COVID-19 risk assessments and records to help trace close contacts.
The home supported safer visits through a visiting pod, booking system and microphone. The service was inspected but not rated, so this report does not give an overall Good, Requires Improvement or Inadequate rating.
Safer visiting
Loved ones could use a visiting pod without entering the home. A booking system and microphone helped visits take place safely and comfortably.
“A visiting pod could be accessed by loved ones without entering the home.” from the report
Contact tracing
Staff kept a daily record of the people they had worked closely with. This could help the home identify contacts if there were COVID-19 cases.
“Staff completed a daily tracker record of the people they had worked closely with.” from the report
Use of PPE
Inspectors found that staff used PPE in line with government guidance. PPE stations and clinical waste bins were available on each floor.
“Staff wore Personal Protective Equipment (PPE) in line with government guidance.” from the report
Monitoring for symptoms
People's observations were taken regularly, and their COVID-19 risk assessments were updated monthly after test results.
“People's observations were taken regularly to monitor for symptoms of COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your infection prevention and control arrangements changed since the inspection on 09 February 2021?
- 02How do you now arrange visits, and is the visiting pod or another safe visiting option still available?
- 03How do you identify and manage close contacts if someone tests positive for COVID-19 or another infection?
- 04How often are residents' symptoms and infection risks checked and recorded?
- 05How do you make sure PPE, testing and clinical waste arrangements remain suitable?
This was a targeted inspection of infection prevention and control under the Safe question only; the service was inspected but not rated and the other questions were not assessed in this report. This explanation was written from the published report of 3 March 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, December 2017
Rated Outstanding; inspectors found exceptionally caring, responsive and well-led support, with some medicines information needing improvement.
This was an unannounced inspection on 27 September 2017. The inspector and an Expert by Experience spoke with people living at the home, relatives, staff and visiting professionals. They observed care and checked care records, medicines records, staff files and quality checks.
The overall rating was Outstanding. Caring, Responsive and Well-led were rated Outstanding. Safe and Effective were rated Good. People told inspectors they felt safe, respected and listened to. Staff provided personalised support and helped people keep their independence, interests and important relationships.
Inspectors found enough safely recruited staff, suitable training and good support from health professionals. Meals were fresh, well presented and adapted to people's needs. They found some gaps in information for medicines prescribed when needed, and one recording issue, but there was no impact on the person involved and the prescription was later corrected.
Kind and respectful care
People and relatives consistently described staff as kind, attentive and respectful. Inspectors observed warm, compassionate interactions and personalised support.
“People received an outstanding service from staff that were extremely kind, caring and compassionate; people were supported to have meaningful and enjoyable lifestyles.” from the report
Personal choice and independence
People were involved in choices about their daily lives, care, food, clothing and activities. Staff provided help discreetly and supported people to stay independent.
“People were supported to make choices in all aspects of their lives, including the home environment in which they lived.” from the report
Meaningful activities
The home adapted activities and roles to people's interests and abilities. Staff supported people to keep valued routines and relationships.
“We found that people were encouraged to live enriched lives and were supported to engage in activities that were of interest and/or promoted value, purpose and meaning to their lives.” from the report
Responsive management
People, relatives, visitors and staff could give feedback in several ways. Inspectors found that the management team listened and acted on requests.
“Everyone including people, relatives, visitors and staff, were involved in the running of the home by way of providing feedback to the management team” from the report
Strong leadership
The management team was organised, approachable and focused on improving the service. Staff said they felt supported and appreciated.
“The management team had effective systems in place to continuously assess, monitor and proactively promote the quality and safety of the service.” from the report
Information for as-needed medicines
needs fixingFor some medicines prescribed to be given when needed, staff did not always have enough information about when or how to give them. This could make safe decisions harder, especially for people unable to explain what they need.
“supporting information was not always available to support staff to make a decision as to when and sometimes how to give the prescribed medicines.” from the report
Medicine recording issue
needs fixingOne person's as-needed medicines had been given regularly without the prescription and medicine record being checked promptly. The issue was later discussed with the GP, the prescription was rewritten and no impact was found.
“We did not see any evidence that this had been identified by the provider's medicine auditing systems or that it had been followed up with a GP or Pharmacist” from the report
Care plans could be more personal
minorThe manager recognised that changes to care-plan forms had made some plans less personalised than before. The manager said this would be fed back to the provider.
“some of the care plans were not as personalised as they used to be.” from the report
- 01How do you now make sure staff have clear instructions for every medicine prescribed to be given when needed?
- 02How are medicine records audited, and how quickly are prescription or recording discrepancies checked with a GP or pharmacist?
- 03Have all care plans been reviewed to make sure they are personalised and reflect each person's current needs and preferences?
- 04How will you involve my relative and our family in reviewing care, activities and important decisions?
- 05How do you make sure staffing levels remain suitable when people's needs change?
This was an unannounced comprehensive inspection covering all five key questions; the report says the home had previously been rated Good at its June 2015 comprehensive inspection. This explanation was written from the published report of 22 December 2017 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Manor House
Each visit the CQC has published, newest first, back to the day the home was registered.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- December 2017OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- May 2017
Registered with the Care Quality Commission on 11 May 2017.
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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