CQC report explained · a residential care home
What the CQC found at Manton Heights Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Rated Requires Improvement; inspectors found substantial progress, but staffing consistency, medicines records and leadership still needed work.
This was an unannounced follow-up inspection on 14, 20 and 22 April 2021. Inspectors spoke with people, relatives, staff and outside professionals. They observed care and checked care, medicines, recruitment and management records.
The home had improved since its previous inspection. People were generally safe, staff were kind, training had improved, and infection control measures were thorough. Food, healthcare support and consent arrangements were also found to be good.
The overall rating was Requires Improvement. Safe and Well-led were Requires Improvement, while Effective was Good. Some people had too little staff interaction at busy times, some medicines records were incomplete, and staff roles and practice still needed to become more consistent.
Improvement since the last inspection
The home had made substantial progress since the previous inspection. It was no longer in breach of the regulations identified at that time.
“There had been a lot of improvements put in place since our last inspection.” from the report
Kind and respectful care
People and relatives gave positive feedback about the care. Inspectors found a calm atmosphere and said people were treated with kindness and respect.
“People were treated with kindness and staff spoke to people with respect.” from the report
Training and support
Staff received job-related training, supervision and competency checks. New staff also had an induction before working independently.
“Staff told us, and records confirmed that they received training and supervisions relevant to their job role.” from the report
Food and health support
People were offered regular food and drink suited to their needs and preferences. The home worked with health professionals, and some people had improved their nutrition.
“Several people had gained some weight and were no longer at risk of malnutrition due to the support they had received.” from the report
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including COVID-19. Cleaning, testing, protective equipment and visitor controls were in place.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Too little staff interaction at busy times
needs fixingAlthough there were enough staff to meet physical care needs, some people were left without staff interaction for periods of time. Staffing in the acquired brain injury unit was also not yet consistent.
“As a result of this some people were left without staff interaction for periods of time.” from the report
Incomplete PRN medicines guidance
needs fixingSome people did not have care plans or protocols explaining when and how as-needed medicines should be given. The home acted immediately during the inspection to put these in place.
“Some people did not have care plans or protocols in place for PRN (as and when required medicines).” from the report
Safeguarding knowledge was uneven
needs fixingSome staff were still unsure how to recognise non-physical abuse and who they could contact outside the management team if they had concerns.
“Some staff we spoke to were still unclear as to what signs to look for when it came to abuse that was not physical.” from the report
New staff and roles still settling
minorStaff changes meant several people were new to their roles. Inspectors said more time was needed for staff to fully understand safeguarding and person-centred activities.
“Some staff spoke to us about how change at the service was making them feel unsettled.” from the report
- 01How do you now make sure people receive staff interaction at lunchtime and when physical care needs are busiest?
- 02Do all residents who need PRN medicines now have clear care plans and protocols explaining when and how those medicines should be given?
- 03How consistent is the staffing team in the acquired brain injury unit, and which roles are still covered by temporary or senior staff?
- 04How do you check that every staff member can recognise non-physical abuse and knows how to report concerns outside the management team?
- 05What changes have been made to person-centred activities and mealtimes since this inspection?
This was a focused inspection of Safe, Effective and Well-led; the report says the other key questions were not looked at on this occasion and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 11 May 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.
What inspectors found, October 2020
Rated Inadequate and still in special measures; inspectors found serious ongoing risks involving safeguarding, medicines, staff training and management oversight.
This was a targeted inspection in September 2020. Inspectors checked whether the home had carried out actions promised after serious concerns found at the previous inspection in July 2020. They spoke with people, relatives, staff and health and social care professionals, and reviewed care, medicines, training and management records.
The inspectors found that not enough improvement had been made. Some alleged abuse and injuries were not reported or acted on properly. Medicines were not always given and recorded safely. Many staff had not received the promised training, supervision or coaching.
There were some improvements. Care staffing levels had increased, and some people and relatives said the atmosphere and management had improved. However, the home remained in breach of regulations and its overall rating remained Inadequate and in special measures.
Care staffing
Care staffing levels had increased. This meant people were less likely to wait for care or be left alone for long periods.
“The provider had increased the levels of care staff to sufficient levels to enable staff to safely monitor the risks associated with people's needs.” from the report
Some improved reporting
The most recent abuse incident was reported promptly and appropriate safeguarding action was taken. This was not consistent across all incidents.
“The provider had reported the most recent incident of abuse in a timely manner and acted appropriately to safeguard those involved.” from the report
New managers' induction
The new manager and deputy manager had received detailed induction and ongoing support, although the induction was still being completed.
“The new manager and deputy manager had both received in-depth inductions which were still in process” from the report
Safeguarding failures
seriousInspectors found serious allegations that had not been reported to the CQC or other relevant authorities. Some people were not protected while an internal investigation took place.
“We were made aware by sources outside of Manton Heights Care Centre of a serious allegation of sexual assault which had not been reported to the CQC or other relevant authorities.” from the report
Unsafe medicines
seriousMedicines were not always recorded immediately or administered safely. Inspectors found a risk of people receiving too much or too little medicine, and heard about further medicine errors after the inspection.
“People's medicines were still not always administered and recorded safely meaning they were at risk of over dosing or missing medicines.” from the report
Insufficient staff training
needs fixingMost staff inspectors spoke with had not received training beyond e-learning, and many had not received supervision or coaching. This left a continuing risk that incidents and abuse would not be managed properly.
“14 of the staff we spoke with told us they had not yet received 1:1 supervision or any on the job coaching” from the report
Poor management oversight
seriousThe manager was not initially aware that they were responsible for the brain injury unit. The provider had also missed deadlines in its improvement plan and had not fully introduced its new monitoring system.
“Therefore, until inspectors raised this, the manager had no knowledge of the people, staff, care or concerns at the ABI unit side of Manton Heights Care Centre.” from the report
Infection control risks
seriousInspectors saw unsafe handling of soiled waste and found that staff changing areas for protective equipment were not placed near an isolating person's room. Housekeeping staffing was also insufficient.
“This meant staff risked the spread of infection for a person who was potentially Covid-19 positive as staff had to walk to the nearest donning station in order to change their Personal Protective Equipment (PPE) and sanitise.” from the report
- 01What evidence can you show that all staff now understand how to recognise, report and prevent abuse?
- 02How do you check that medicines are given at the right time and that medication records are signed immediately?
- 03How many staff have completed practical training, supervision and competency checks, rather than only e-learning?
- 04How are serious incidents and safeguarding concerns now reported to the CQC and other relevant authorities?
- 05How does the manager monitor the brain injury unit, medicines, incidents and care records across the whole home?
This was a targeted inspection of specific concerns from the previous inspection, so it did not assess all parts of the five key questions and the previous ratings carried over. This explanation was written from the published report of 15 October 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.
Every inspection of Manton Heights Care Centre
7 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2020Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- September 2020Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- June 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- September 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: InadequateResponsive: Requires improvementWell-led: Requires improvement
- November 2016Goodstayed GoodSafe: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- September 2014
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- April 2012
Registered with the Care Quality Commission on 23 April 2012.
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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