CQC report explained · a nursing home
What the CQC found at Manorhey Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, with risk assessments, safety checks, safeguarding systems and safe medicines management. Inspectors found vinyl gloves accessible on corridors, but the manager removed this potential hazard during the inspection.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- The home had effective quality checks, feedback systems and leadership from the service manager and deputy manager. There was not a registered manager in post at the time, but a new manager was due to start.
What inspectors found, September 2022
Rated Good; inspectors found safe, kind care, but staffing concerns and a temporary corridor hazard needed attention.
This was an unannounced inspection on 30 August 2022. Inspectors and Experts by Experience spoke with people, relatives, staff and managers. They also reviewed care plans, medicines records, recruitment files and safety checks.
The home was rated Good overall, with Good ratings for Safe and Well-led. People said they felt safe and were treated kindly and respectfully. Inspectors found safe medicines management, suitable infection control, risk assessments and systems for reporting concerns.
There were some issues to keep under review. Some staff said the home could sometimes be short staffed. Inspectors also found vinyl gloves where people living with dementia might reach them, but the manager removed this hazard during the inspection.
Effective, Caring and Responsive were not inspected during this visit. Their previous ratings were carried forward to calculate the overall rating. The home was Good at the previous inspection, published on 24 June 2021.
Kind and respectful care
People and relatives described staff as kind, respectful and caring. Staff knew people well and supported their preferences and wishes.
“People told us they felt safe and were well cared for by staff who treated them kindly and with respect.” from the report
Safe medicines
Medicines were ordered, stored, administered and disposed of safely. Checks and audits were carried out, with action taken when mistakes were found.
“People's prescribed medicines had been administered and managed safely, including the ordering, storage and disposal of medicines.” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including PPE, testing, hygiene and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Open management
The home had systems to check quality, gather feedback and act on problems. Staff and relatives said managers were approachable.
“The provider and service manager had quality assurance systems in place which ensured all aspects of the service were regularly audited.” from the report
Staffing pressure
needs fixingAlthough inspectors found enough staff overall, some staff said there were times when staffing was not sufficient, particularly during sickness. Management said staffing levels would be reviewed further.
“However, we received mixed feedback from staff about staffing levels which we shared with the service manager and regional director who both confirmed they would further review the staff dependency levels.” from the report
Gloves within reach
needs fixingVinyl gloves were stored on corridors where some people living with dementia might access them. The manager removed the potential hazards during the inspection.
“On the corridor's vinyl gloves were stored, to assist staff with infection control measures.” from the report
No registered manager
minorThere was no registered manager in post when inspectors visited. A new manager was due to start and was expected to apply to become registered manager.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How do you check that staffing levels remain sufficient when staff are off sick?
- 02What changes have been made to keep gloves and other potentially unsafe items away from people living with dementia?
- 03Has the new manager started, and have they applied to become the registered manager?
- 04What were the findings and ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
- 05How are medicines audits and any mistakes followed up?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 22 September 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.
What inspectors found, June 2021
Manorhey Care Centre was rated Good; inspectors found major improvements in safety, dignity, activities and leadership since the previous inspection.
Inspectors visited on 19 May 2021. They spoke with people using the home, relatives and staff, observed care, and reviewed care plans, medicines records, recruitment records, safety certificates, staffing information and audits.
They found medicines were managed safely, staffing was suitable for people's needs, safeguarding systems were in place and infection control procedures were being followed. They also found people were treated with kindness and dignity, and received activities based on their interests.
The home had improved from Requires Improvement at the previous inspection, published in April 2020. The earlier breaches had been addressed, and the home was no longer in breach of regulations.
This was a focused inspection. Safe, Caring, Responsive and Well-led were rated Good. Effective was not assessed during this visit, so its previous rating was used when calculating the overall rating.
Safe medicines
Inspectors checked several medicines and controlled drugs and found the records and stock were correct. The electronic medicines system was being monitored closely.
“Medicines administration systems were robust, well organised and regularly reviewed.” from the report
Kind and respectful care
The inspection found better experiences for people living with dementia, with staff showing warmth, enthusiasm and respect.
“Staff were caring and sought to ensure people were treated in a dignified and respectful way.” from the report
Personalised activities
Staff used information about people's interests and preferences to provide meaningful activities. People were seen enjoying music, dancing and other activities.
“The activities coordinator captured this information and then brought it to life through meaningful person-centred activities.” from the report
Improved management
The home had strengthened its audits, quality checks and approach to learning from incidents. Inspectors found leadership and management were effective.
“Systems for audit, quality assurance and questioning of practice were greatly improved and operated effectively.” from the report
Infection control
Inspectors were assured that staff had suitable training, protective equipment and cleaning arrangements. Visiting and COVID-19 testing arrangements followed current guidance.
“We were assured the service was following safe infection prevention and control (IPC) procedures.” from the report
Inspectors raised no specific concerns in this report.
- 01How have you maintained the improvements made after the previous inspection?
- 02What is the current rating and evidence for the Effective key question, which was not assessed during this visit?
- 03How do you make sure staffing levels remain suitable for each person's needs, especially on the different floors?
- 04How are each person's interests, communication needs and preferred activities recorded and reviewed?
- 05How are medicines audits carried out, and how quickly are any problems addressed?
This was a focused inspection of Safe, Caring, Responsive and Well-led; Effective was not assessed and its previous rating was carried forward. This explanation was written from the published report of 25 June 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.
Every inspection of Manorhey Care Centre
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- September 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2019Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Inadequate
- March 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2015
Registered with the Care Quality Commission on 20 May 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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