What the CQC found at The Manor House

Inspectors saw a good staff presence and found rotas showed there were enough staff to support people.

“Staffing rotas supported that there were enough staff available to manage and support people's needs.” from the report

People were treated with dignity and respect. Staff knew people's histories, preferences and the best ways to support them.

“During the inspection we saw that staff, the registered manager, deputy and provider's representative treated people with dignity and respect and provided compassionate support.” from the report

The home offered varied activities, including exercise, outings, games and entertainers. Staff also spent time talking and reading with people.

“Activities included days out, parties for 'celebration days', exercise sessions, ball games, board games, hand massages and manicures, coffee mornings and visiting entertainers such as singers.” from the report

The home had plans for people's end of life wishes and involved relatives where appropriate. Healthcare professionals were particularly positive about this support.

“The service has a particular expertise in dealing with people's end of life care.” from the report

Senior staff carried out regular audits covering areas such as medicines, care plans, incidents, infection control and cleaning. The report says remedial action was taken when needed.

“We reviewed audits and outcomes and saw audits were up to date and that remedial actions were taken with staff when necessary to ensure that care was provided in the right way.” from the report

Three of the five staff files checked did not show all relevant recruitment checks before staff started. The manager said some checks had been completed but not documented, and inspectors recommended revising the process.

“Recruitment systems and processes were in place but in three of the five files we considered, insufficient recruitment checks had been made prior to the members of staff starting work.” from the report

Inspectors found an oxygen cylinder stored incorrectly, a medicinal gel that other people could access and an ineffective bedrail. These issues were addressed during the inspection, but existing checks had not found them.

“A variety of environmental risk assessments and checks had taken place but these had not picked up on the issues seen at the inspection.” from the report

Not all staff had received up-to-date formal training on the Mental Capacity Act and Deprivation of Liberty Safeguards. A new training programme and revised induction were being arranged.

“We noted that not all staff had received up to date formal training on Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).” from the report

The home carried out unannounced checks during night shifts and weekends, but not all were recorded. The provider's representative said records would be kept and actions reviewed.

“Not all of these checks were being documented and the provider's representative said that they would ensure that a record was kept of this and that any remedial action that was noted would be reviewed and acted upon.” from the report