CQC report explained · a nursing home
What the CQC found at Manor Park Nursing 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. Medicines, staffing, recruitment, risk management and safety checks were generally effective, although some medicines and infection-control issues needed action.
- Effective?
- Good
- This key question was not assessed in this inspection and no rating was given.
- Caring?
- Good
- This key question was not assessed in this inspection and no rating was given.
- Responsive?
- Good
- This key question was not assessed in this inspection and no rating was given.
- Well-led?
- Good
- Inspectors found effective quality checks, a positive culture and approachable management. Staff said morale had improved and communication systems were in place.
What inspectors found, April 2023
Rated Good; inspectors found safe, well-managed care, with some medicines, risk assessment and infection-control checks still needing attention.
Inspectors visited unannounced on 15 and 16 March 2023. They spoke with people, relatives, staff and visiting professionals. They observed care and reviewed care, medicines, recruitment and management records.
The home was rated Good overall and Good for Safe and Well-led. People were protected from abuse, risks were generally managed, medicines were given safely, and there were enough staff. The home had systems to check quality and learn from incidents.
The inspection found improvements since the previous rating of Requires Improvement, published in July 2022. Some smaller problems remained, including expired medicines competency checks, one unexplained medicine stock difference, one risk assessment that had not been updated, and an infection-control lapse.
Staffing
Inspectors found enough staff to meet people's needs and keep them safe. Recruitment checks were also in place.
“Now we have enough staff. It's very good now.” from the report
Respecting decisions
The home had carried out mental capacity and best-interest work where needed. Staff were seen asking for consent and offering choices.
“We observed staff seeking consent and offering choices during the inspection.” from the report
Improved management
Inspectors found a positive culture and systems for monitoring the quality and safety of the home. Staff said morale had improved.
“Staff told us morale had improved and it was currently good and they worked well together as a team.” from the report
Medicines competency checks
needs fixingAnnual checks that nurses were competent to give medicines had expired. Managers had a plan to address this.
“The nurses received regular training in medicines, however annual checks of their competency to administer medication had expired.” from the report
Medicine stock difference
needs fixingInspectors found a difference in the recorded stock of one medicine. The manager said it would be investigated.
“Stock checks on medicines were carried out regularly by the nurses, we found a discrepancy in the stock of one medicine.” from the report
Infection-control cleaning
needs fixingOn one occasion, a mop and bucket used to clean bodily fluid were not changed before being used elsewhere. Managers said this would be addressed.
“We observed 1 of the housekeeping staff cleaning an area of bodily fluid with a mop and bucket, they did not refresh the water before moving to another area of the service.” from the report
Updating risk assessments
minorOne risk assessment had not been reviewed after a recent incident. The manager completed it during the inspection.
“These had been regularly reviewed, however we found 1 example where a risk assessment was not reviewed following a recent incident.” from the report
PRN medicine guidance
minorProtocols for medicines given when needed were in place, but the manager said they needed more detail about when each medicine should be given.
“The registered manager told us additional information was going to be added to protocols to provide more detailed guidance for staff to know when to administer each medicine.” from the report
- 01Have the nurses' expired medicines competency checks now been completed and recorded?
- 02What was the outcome of the investigation into the discrepancy in one medicine's stock?
- 03What changes were made to the protocols for medicines given when needed?
- 04How do you make sure risk assessments are reviewed promptly after an incident?
- 05What action was taken to prevent cleaning equipment spreading infection after the issue found during inspection?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not assessed and were not rated. This explanation was written from the published report of 15 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, July 2022
Requires Improvement; inspectors found kind and effective care, but medicines records and management still needed improvement.
This was an unannounced focused inspection on 3 May 2022. Three inspectors reviewed the safe, effective and well-led questions. They looked at care and medicine records, staff files, management records, and infection control. They also spoke with staff, relatives and other professionals.
The home was rated Requires Improvement overall. Safe and well-led were also Requires Improvement, while effective was Good. Inspectors found medicines were not always stored safely or recorded clearly. Some decisions about medicines given covertly, creams and lotions, and mental capacity needed better records.
There were also important positives. Staff knew people well, understood safeguarding, and there were enough staff at the time of the inspection. Care plans were personalised, food and drink support was well recorded, and infection control arrangements were judged satisfactory.
The previous overall rating was also Requires Improvement. The provider was no longer in breach of regulations 12, 17 or 18 because enough improvement had been made in those areas. However, inspectors said more time was needed for the new management team's changes to become established. CQC asked for an action plan and said it would monitor progress.
Staff understood people
Inspectors found that staff knew people well and understood how to keep them safe. Relatives and professionals also gave positive feedback about staff knowledge and skills.
“Relatives said they felt staff knew their family member.” from the report
Personalised care plans
Care plans recorded people's needs and preferences and were regularly reviewed. They gave staff useful guidance about risks, behaviour and personal care.
“Care plans were regularly reviewed to ensure they continued to meet people's needs.” from the report
Food and drink support
People's dietary preferences, equipment needs and risks were recorded. Staff offered choices and alternatives, monitored weights and involved specialist services when needed.
“Records were consistently clear and showed when staff had offered food or drink and whether people had accepted or refused.” from the report
Safeguarding
Staff knew how to recognise and report abuse. The management team worked with other agencies when concerns were raised.
“All the staff we asked knew what actions they should take to keep people safe, and they were clear they would act if necessary.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including during the recent Covid-19 outbreak.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Medicine storage and records
seriousMedicines were not always stored safely or recorded clearly. Records for covert medicines and creams and lotions needed review and improvement.
“Medicines were not always stored safely, or records did not always evidence safe storage.” from the report
Covert medicines
seriousSome records did not explain fully why medicines were being disguised in food or drink or why this was in a person's best interests.
“One person had no documentation about why receiving medicines covertly was in their best interests and another person's documentation was incomplete.” from the report
Mental capacity records
needs fixingCapacity had been assessed, but decisions were not always recorded for each specific part of a person's care. The report gave bed rails as an example.
“They had not been assessed for all aspects of their care on a decision specific basis.” from the report
Leadership and communication
needs fixingThe management team was still embedding changes. Relatives and professionals gave mixed views about leadership and communication.
“Some improvements had not yet been realised as time was needed to embed and sustain change.” from the report
- 01What changes have you made to medicine storage and fridge-temperature records since the inspection?
- 02How do you now check and record the reasons for giving medicines covertly and the related best-interest decisions?
- 03How do you record and check that creams and lotions are applied as prescribed?
- 04How do you make sure mental capacity assessments and best-interest decisions are specific to each care decision, including the use of bed rails?
- 05What has changed in management and communication since the inspection, and how do you know those changes are working?
This was an unannounced focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 27 July 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 Nursing Home
6 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
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2020Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- May 2019Goodstayed GoodSafe: GoodWell-led: Good
- September 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 December 2010.
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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