CQC report explained · a residential care home
What the CQC found at Manor House Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Risk assessments, staffing, recruitment, medicines management and infection control were assessed as safe.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found effective audits, open management, staff support and systems for gathering feedback and making improvements.
What inspectors found, April 2023
Manor House Residential Home rated Good; inspectors found safe care and effective leadership, with improvements since the previous inspection.
This was an unannounced, focused inspection on 14 March 2023. Inspectors spoke with people living in the home, relatives, staff and a visiting professional. They also checked care records, medicines records, staff recruitment files and quality checks.
The home was rated Good for Safe and Well-led. Inspectors found safeguarding systems, suitable risk assessments, safe medicines practice, enough staff and appropriate recruitment checks. People were asked for consent and staff had training to support their needs.
The overall rating stayed Good. The previous overall rating was also Good, but Safe and Well-led had previously needed improvement and were rated Good at this inspection. The other three areas were not inspected during this visit, so their earlier ratings were used for the overall result.
Safe medicines
People received medicines as prescribed. Staff were trained and checked for competence, and medicines records were accurate.
“People received their medicines safely and as prescribed and were supported by sufficient numbers of staff to ensure that risk of harm was minimised.” from the report
Good risk management
The home had detailed risk assessments, including for people with visual impairments, and personal evacuation plans for emergencies.
“There were robust risk assessments in place to guide staff to how they should support people safely.” from the report
Enough trained staff
Inspectors found enough staff on duty and appropriate checks had been completed before staff were employed. Staff had relevant training.
“Our observations during the day, indicated there were enough staff on duty to support people with their care needs.” from the report
Improved management systems
The home had improved its records for skin-patch medicines and recruitment. Management audits were used to monitor quality.
“Improvements had been made since our last inspection to ensure medicines administered by skin patches were regularly rotated and actions taken recorded.” from the report
Open culture
People, relatives and staff said managers were approachable. Staff felt valued and believed concerns would be acted on.
“The provider promoted an ethos of openness and transparency which had been adopted by all staff.” from the report
Inspectors raised no specific concerns in this report.
- 01Are all outstanding Deprivation of Liberty Safeguards applications now authorised, and how do you check that people’s restrictions remain lawful while they are waiting?
- 02How do you make sure medicines given on an 'as and when' basis are recorded correctly?
- 03How many staff are normally on duty for each shift, and how do you cover absences?
- 04What changes were made to medicine patch records and recruitment documents after the previous inspection?
- 05How would relatives arrange a visit if the home had an infection outbreak?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the last comprehensive inspection. This explanation was written from the published report of 6 April 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, December 2019
Rated Requires Improvement; inspectors found kind, personalised care but medicines records and quality checks were not always reliable.
This was an unannounced inspection on 12 and 13 November 2019. Inspectors spoke with people living at the home, relatives and staff. They observed care and reviewed care, medicines and management records.
People were generally treated with kindness and respect. Their care plans reflected their preferences. Staff had the training and knowledge needed, people's dietary and healthcare needs were met, and activities were available.
The home was not always safe because staff did not consistently follow guidance for some medicines, and some medicine records were incomplete. Inspectors also found that quality checks had not identified these problems, or some other record-keeping and risk-assessment gaps.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. Safe and Well-led had both fallen from Good at the previous inspection in May 2017.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed warm, meaningful interactions and found that privacy and dignity were maintained.
“We observed positive interactions between staff and people. Staff smiled at people and had meaningful conversations about things they were interested in.” from the report
Personalised support
Care plans included people's preferences, histories and communication needs. Staff could explain how individuals liked to be supported.
“Staff we spoke to could tell us about people's individual needs their likes and interests.” from the report
Suitable training and healthcare
Staff had training and induction support. People were referred to healthcare professionals when needed, and professionals reported no concerns about their care.
“Healthcare professionals we spoke with during our inspection told us they had no concerns about people's care.” from the report
Activities and relationships
People were supported to take part in activities and maintain relationships with relatives and the wider community.
“People were encouraged to take part in organised group activities and events.” from the report
Medicines were not always handled safely
seriousSome dietary supplements were left unattended. Staff did not always follow guidance for rotating skin patches, and eye-drop records did not always say which eye should receive the medicine.
“Staff were not always following manufacture guidance for medicines administered by skin patch.” from the report
Short periods without staff in a shared area
needs fixingAt breakfast, inspectors saw short periods when no staff were available in the main lounge and dining area. Some people there were at risk of falls or had difficulty moving with walking aids.
“We observed around breakfast time no staff were available for short periods of time in the main lounge, which was also the dining area.” from the report
Quality checks missed problems
needs fixingAudits and other monitoring systems did not identify the medicines concerns found by inspectors. The systems also missed gaps in recruitment records and risk assessments after falls.
“There were systems in place to monitor the service. However, these had not always been effective at identifying where improvements were needed as identified during our inspection.” from the report
Some risk assessments were not updated
needs fixingRisk assessments were not always updated after a fall to show that the measures to reduce risk were still suitable.
“Risks to people were not always updated following a fall to show the measures in place to mitigate risk remained appropriate.” from the report
- 01What changes have been made to make sure skin patches are rotated and their removal and replacement are recorded every time?
- 02How do you now make sure eye-drop records clearly state which eye should receive the medicine?
- 03How do you make sure prescribed dietary supplements are stored securely and are not left unattended?
- 04What has changed so a staff member is always available in the main lounge and dining area at busy times?
- 05How are falls, recruitment interviews and other records now checked by the management team?
This was an unannounced inspection covering all five CQC questions, including the care provided and the home premises; Safe and Well-led fell from Good at the previous inspection, while the other three ratings remained Good. This explanation was written from the published report of 19 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 Residential Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Manor House Residential Home →
- December 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Manor House Residential Home →
- May 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015
Registered with the Care Quality Commission on 22 July 2015.
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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