CQC report explained · a residential care home
What the CQC found at Manor House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, medicines were administered safely, recruitment checks were completed, and there were enough staff. Infection control and arrangements for coronavirus had also improved.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found robust quality checks, clearer responsibilities and better records. They also found positive relationships with people and improved communication with health professionals.
What inspectors found, November 2020
Rated Good; inspectors found safer care and stronger management after significant improvements since the previous inspection.
The inspection took place on 30 October 2020. Inspectors visited the home, spoke with people, relatives, staff and health professionals, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed, medicines were managed safely, infection control had improved, and there were enough staff. People appeared happy, and relatives gave positive feedback about the care and management.
This was a focused inspection. It checked whether the home had fixed problems found in November 2019. The other three question ratings were carried forward from the earlier inspection. The overall rating improved from Requires Improvement to Good, and the previous legal breaches had been resolved.
Safer care
Risks were assessed, reviewed and managed. Inspectors found that equipment and environmental safety checks were in place.
“Identified risks were assessed and action taken to mitigate these risks where possible.” from the report
Medicines
Medicines were administered as prescribed and records had no unexplained gaps. Storage and stock checks were also secure.
“Medicines were administered as prescribed. Medicine Administration Records (MAR) were complete with no unexplained gaps.” from the report
Infection control
The home had improved its infection control arrangements, including laundry processes, cleaning and the use of protective equipment.
“The whole service was odour free and looked clean and tidy.” from the report
Kind atmosphere
People appeared happy and responded positively to staff. Inspectors observed considerate and kind interactions.
“The interactions we observed between staff and people were considerate and kind.” from the report
Management systems
The home had introduced several layers of checking to improve the accuracy and completeness of records and care monitoring.
“Since we last inspected robust quality assurance systems had been introduced with several layers of checking to ensure documents were complete, accurate and contemporaneous.” from the report
Manager registration
needs fixingThere was no manager registered with the CQC at the time of the inspection. The manager had started the application process, but this remained an outstanding matter.
“The service did not have a manager registered with the Care Quality Commission.” from the report
Consistency of staff culture
minorSome staff had found the changes difficult and some had left since the previous inspection. Management was still working to create a more consistent positive staff culture.
“Some staff had struggled to accept change and some staff had left the service since the last inspection.” from the report
- 01What is the current position of the manager's CQC registration application?
- 02How are you checking that the improvements to risk assessments and care records are being maintained?
- 03How are you making sure staff follow clear guidance before giving PRN sedative medicines?
- 04What are you doing to build a consistent positive staff culture after some staff struggled with the changes?
- 05What further environmental improvements are planned, and when will they be completed?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 25 November 2020 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 2019
Overall rating Requires Improvement, with an Inadequate rating for Safe; inspectors found people were at risk from unsafe care, poor records, infection risks and too few staff.
This was an unannounced focused inspection on 4 November 2019. Inspectors looked at Safe and Well-led because concerns had been raised about management and people's safety. They spoke with 13 people and six staff, and checked care records, medicines, staff files and safety records.
The home was rated Inadequate for Safe and Requires Improvement for Well-led. Inspectors found that risks were not always managed properly. Care plans were inaccurate, some equipment was incorrectly set, cleaning standards created an infection risk, and there were not enough staff to meet people's needs promptly.
There were some positive signs. Medicines were generally managed safely, some falls and nutrition risks were well managed, and action had started to improve staffing, cleaning, training and care records. However, the inspectors said these actions had not yet resulted in a safe service.
The overall rating fell from Good at the previous inspection, published in August 2018, to Requires Improvement. The other three key questions were not inspected at this visit, so their earlier ratings were used in calculating the overall rating.
Medicines usually managed safely
Inspectors saw medicines being given safely, found no gaps in the medicine administration records they checked, and found medicine balances correct.
“We observed the team leader administering people's medicines and their practice was safe.” from the report
Some individual risks managed well
The home used low beds and an extra mattress where bedrails were unsafe. It also sought health advice and recorded preferred food and drinks for a person at risk of poor nutrition.
“Other risks were being managed well.” from the report
Action had begun after concerns
The management team had taken steps to safeguard people and had started a plan to address the decline in care quality.
“They had reflected upon how the service's safety and quality of care had deteriorated since the previous inspection and developed a management plan to address this.” from the report
Staff confidence in new leadership
Staff said they felt listened to and had confidence that the new manager and senior team would address poor practice.
“Staff told us they had confidence in the new manager and the senior management team to address issues of poor practice and to make changes to improve the quality of care people received.” from the report
Care plans and equipment did not always control risks
seriousSome care plans gave outdated or conflicting instructions. Two pressure-relieving mattresses were set incorrectly, and staff did not always have accurate information about transfers and mobility.
“Care plans did not provide staff with accurate information about people's needs.” from the report
Infection control problems
seriousUnclean laundry was left on the floor, and the sluice-room sink used after handling soiled items was dirty and damaged. Inspectors said people were not protected from cross infection.
“People were not being protected from the risk of cross infection.” from the report
Too few staff at the time of inspection
seriousPeople waited for personal care, drinks, breakfast and medicines. Inspectors also saw people moving around without the support needed to keep them safe. Staffing was increased after the inspection.
“There were insufficient numbers of staff on duty to meet people's needs in a timely way.” from the report
Medicine recording needed improvement
needs fixingThe time of some pain-relief doses was not recorded, so it was not possible to confirm that a safe gap had passed before another dose. Some medicines also needed more secure storage.
“It was not possible to ascertain from the records that a safe time period had elapsed before people received another dose.” from the report
Management checks had not prevented serious shortfalls
seriousThe provider had not properly assessed, monitored and reduced risks to people's health, safety and welfare. Accurate and up-to-date care records were also not maintained.
“The service had not properly assessed, monitored and mitigated risks to people's health, safety and welfare.” from the report
- 01What staffing levels are now in place on each shift, and how do you check they are enough for people's care needs?
- 02How have you corrected the care plans that gave conflicting or outdated information about mobility, transfers and pressure care?
- 03How do you now check the laundry and sluice room are clean and safe, and has the damaged sink been repaired or replaced?
- 04How are the times of pain-relief medicines recorded, and are all medicines stored in the required locked cupboards?
- 05What progress has been made on the CQC action plan, and when will you provide an update on the next inspection or monitoring visit?
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 5 December 2019 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 House
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- November 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- August 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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