CQC report explained · a nursing home
What the CQC found at Manor Park Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2023
Manor Park Care Home is rated Good; inspectors found safe, kind and personalised care, with staffing at busy times and quality checks still needing attention.
The inspection was unannounced and took place on 24 January 2023. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They reviewed care records, medicines, recruitment, training, complaints, incidents and quality checks.
The home was rated Good overall. Safe, Effective, Responsive and Well-led were all rated Good. Inspectors found that medicines were managed safely, care plans gave detailed information about people's needs, the home was clean, and staff supported people with food, healthcare, activities and communication.
There were enough staff to meet people's needs, but some staff and relatives said staff could be rushed, especially in the mornings. Inspectors recommended reviewing how staff were deployed at key times. They also recommended that recently improved quality checks should become firmly established in everyday practice.
The previous inspection rated the home Requires Improvement and found breaches of regulation. This inspection found enough improvement for the breaches to be removed and the overall rating to rise to Good. However, this was a focused inspection, not a full review of every area.
Safe medicines
Inspectors found that medicines were given at the prescribed times and that staff responsible for medicines had suitable training.
“People's medicines were managed safely.” from the report
Personalised care
Care plans described people's individual needs and preferences. People and relatives were involved in planning care.
“We found they were personalised, detailing each person's individual needs and how they liked to be cared for.” from the report
Food and healthcare
People had choices of food and drinks, with support for dietary needs. Healthcare professionals gave positive feedback about improved leadership and care.
“People were provided with a choice of food and drinks which met their needs and preferences.” from the report
Activities and involvement
People had access to individual and group activities and were supported to keep in contact with people important to them.
“People told us there were activities taking place if they wanted to join in.” from the report
Improved management
The provider had improved its checks and addressed earlier problems with care records. People, relatives and staff said they felt involved and consulted.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 17.” from the report
Staffing at busy times
needs fixingAlthough inspectors found enough staff overall, some relatives and staff said staff could be busy or rushed. The report recommends reviewing staff deployment, particularly at key times of day.
“We recommend the provider consider reviewing the deployment of staff at key times of the day.” from the report
Quality checks still bedding in
needs fixingQuality audits had improved and were finding and addressing problems, but some improvements were new and ongoing. Inspectors recommended making the quality assurance systems part of established practice.
“Some of the improvements were relatively new and ongoing.” from the report
- 01How many staff are normally available in the mornings, and what happens if staff are absent or the home is especially busy?
- 02What changes have been made to staff deployment since the inspection?
- 03How do you check that the improved care records and quality audits remain accurate and effective?
- 04Who is currently managing the home, and what is the progress of the application to register the acting manager?
- 05What further work is planned to make the environment more dementia friendly?
This was a focused inspection covering Safe and Well-led, widened to include Effective and Responsive; Caring was not separately rated in this report and the inspection did not provide a full review of every area. This explanation was written from the published report of 30 March 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, May 2022
Rated Requires Improvement; inspectors found some safety improvements but continued problems with care records and management oversight.
This was an unannounced inspection on 27 January 2022. Inspectors spoke with seven people living in the home, 12 relatives and staff. They reviewed care, medicine and management records, and gathered further feedback after the visit.
The home was clean and infection control was satisfactory. Medicines were generally given as prescribed, risks were understood by staff and building safety checks were up to date. However, daily records about repositioning, food, fluids and care needs were still incomplete or inaccurate. There were also concerns about nurse staffing pressures and some safeguarding matters had not been recorded.
The overall rating remained Requires Improvement. Safe and well-led were both rated Requires Improvement. The home was no longer in breach of Regulation 12, but remained in breach of Regulation 17 because its records and quality checks were not reliable enough. This was the home's third consecutive Requires Improvement rating.
Medicines generally given safely
The records inspectors checked showed that people received their medicines as prescribed. Staff had completed medicine training and competency checks.
“Medication administration records we looked at showed people received their medicines as prescribed.” from the report
Clean environment
Inspectors found the home clean. Relatives also gave positive feedback about cleanliness.
“All feedback from relatives around cleanliness in the home was positive.” from the report
Safety checks
Building safety and maintenance checks were current. A recent fire drill had also taken place.
“All building safety and maintenance checks were up-to-date.” from the report
People felt safe
People and relatives consistently said the home was a safe environment and protected people from abuse.
“All of the people and relatives we spoke with consistently told us the home provided a safe environment where people were protected from the risk of abuse.” from the report
Improvement work had started
New daily meetings and staff meetings were being used to discuss care needs and service improvements. The home had also recruited four nurses.
“Flash meetings with department heads had commenced three weeks after the registered manager started in their post.” from the report
Incomplete care records
seriousDaily records about repositioning, food and fluids were still not complete. Some records did not accurately describe people's care needs, creating a risk that required care was not provided or could not be shown.
“Complete care records needed to demonstrate people's assessed needs had been met had not been maintained.” from the report
Weak management checks
seriousThe home's audits and action plans did not clearly explain what needed to be done to correct problems. This issue had continued since the previous inspection.
“These actions only listed the standard not met and did not describe the completion of different tasks to meet the standard.” from the report
Nurse staffing pressure
seriousRecords showed nurses had sometimes worked 24-hour shifts. The provider had recruited four nurses, but inspectors still said safe staff deployment needed reviewing.
“This meant there was a risk to people and the staff themselves.” from the report
Pressure care monitoring
needs fixingNurse walkarounds were not happening consistently, and inspectors recommended that daily meetings include existing pressure care needs, not only new concerns.
“We recommend that flash meetings include existing pressure care needs, rather than solely addressing new concerns.” from the report
Safeguarding records
seriousPeople and relatives said they felt safe, but some safeguarding concerns known before the inspection had not been entered in the safeguarding log.
“We looked at the safeguarding log and found incidents we had been made aware of prior to our inspection were not recorded.” from the report
- 01How do you now check that repositioning, food and fluid charts are complete and accurate?
- 02What action has been taken about the nurses who were working 24-hour shifts, and how are staffing levels now checked?
- 03Are nurse walkarounds now taking place consistently, and what do they check?
- 04How do you record and review safeguarding concerns?
- 05Has the bathroom hoist been repaired, and can residents now access bathing facilities as planned?
This inspection looked at Safe and Well-led; the other key question ratings were not inspected on this visit and were carried over from the previous inspection. This explanation was written from the published report of 11 May 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 Park Care Home
7 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2021Inspected but not ratedSafe: Inspected but not rated
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2016Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- June 2016InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- October 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 14 October 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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