CQC report explained · a residential care home
What the CQC found at The Manor House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, recruitment, infection control and risk assessments were generally well managed, but staff were not always present in communal areas and staffing levels were questioned.
- Effective?
- Good
- Staff had relevant training and people were supported with nutrition, healthcare and decisions about their care. One dining room was not well organised at lunchtime and inspectors noted that more staff would help there.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. They knew people's needs and preferences and supported people to make choices and remain independent.
- Responsive?
- Good
- Care plans were personalised and activities were available every day. Some daily care records had gaps, and there was a lack of planning for people's end of life care.
- Well-led?
- Good
- Inspectors found a positive culture, clear leadership and regular quality checks. People, relatives and staff were involved in suggesting improvements.
What inspectors found, April 2020
The Manor House was rated Good overall; inspectors found kind, safe care, but staffing at busy times and some care records needed improvement.
Inspectors made an unannounced visit on 27 February 2020. Two inspectors spoke with people living in the home, relatives, staff and a healthcare professional. They reviewed care and medicines records, recruitment and training information, and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe, were treated kindly, received their medicines on time and could raise concerns.
Inspectors found some shortfalls. Staff were not always adequately deployed during busy times, some daily care records had gaps, and end of life wishes were not well planned. The registered manager was aware of these issues and was taking action.
Kind and respectful care
Staff offered reassurance, respected privacy and understood people's personal histories, needs and preferences.
“Our observations showed staff treated people kindly and offered reassurance to people.” from the report
Medicines managed safely
People received medicines as prescribed. Records had no gaps, stocks matched expectations and staff had been trained.
“Our review of people's Medicine Administration Record charts showed people were given their medicines as per the prescribed instructions.” from the report
Good activities and relationships
Activities were provided every day, including one-to-one activities for people cared for in their rooms. Visitors had minimal restrictions.
“Two activity staff worked at the service and provided activity provision for every day of the week.” from the report
Visible management
The manager was regularly present, staff understood their roles and audits identified actions for improvement.
“There were good systems in place to monitor and assess the quality and safety of the service.” from the report
Staffing at busy times
needs fixingInspectors saw periods when staff were not always present in communal areas. One lunchtime was not organised, and staff said more staff would help in that area.
“Our observations showed there were periods of time when staff were not always present in communal areas when there were people in there.” from the report
Gaps in daily records
needs fixingSome daily care records, including repositioning charts, were incomplete. The manager said this was a recording issue being addressed, and inspectors found no evidence of pressure ulcers resulting from missed repositioning.
“We noted some gaps in people's daily care records such as repositioning charts.” from the report
End of life planning
needs fixingCare records did not contain enough planning for end of life care. The manager said new ways of having these conversations were being developed.
“We noted there was a lack of end of life planning in people's care records.” from the report
- 01How many staff are normally deployed during meals, and what has been done to make the less organised dining room run better?
- 02How do you check that repositioning and other daily care records are completed accurately?
- 03How will you discuss and record my relative's end of life wishes if they are willing to do so?
- 04How are staffing levels reviewed when people's care needs change?
- 05How can my relative choose activities and receive one-to-one support if they spend time in their room?
This was an unannounced planned inspection that covered the home and all five CQC questions, including accommodation and care. This explanation was written from the published report of 1 April 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.
What inspectors found, August 2017
The Manor House was rated Good; inspectors found safe, kind and personalised care, with some records and medicines storage still needing attention.
This was a comprehensive inspection on 21 and 24 July 2017. The inspector spoke with people living in the home, relatives, staff and the manager. They also observed care and checked medicines, care records, recruitment, training, maintenance and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable training, kind care, personalised support and good oversight by the manager.
At the previous inspection in March 2016, the home had breached a safety regulation because cleaning chemicals were not stored securely. This had been fixed by this inspection, so the home was no longer in breach. Inspectors also noted that one medicines trolley's storage temperature needed monitoring and that some care records were more detailed than others.
Safe staffing and risk management
Inspectors found enough staff to meet people's needs and saw that individual risks were recorded, managed and reviewed.
“Risks to people's wellbeing continued to be managed well and we saw actions that staff took to help reduce any risks to people.” from the report
Kind and respectful care
Staff supported people sensitively, protected their privacy and encouraged them to remain as independent as possible.
“Staff were respectful of people's privacy and dignity.” from the report
Personalised support
Staff knew people well and supported their individual routines, preferences, interests and care needs.
“People told us that staff knew them well and provided the support they needed.” from the report
Open management
The manager was approachable, sought feedback and used audits and action plans to improve the home.
“The manager had continued to foster an open, inclusive and positive culture in the home.” from the report
Medicines storage temperature
minorThe temperature in one area where a medicines trolley was stored needed to be monitored. The manager said this would be remedied.
“the temperature in one area of the home where one medicines trolley was stored needed to be monitored to ensure that medicines were kept within an optimum temperature range.” from the report
Different levels of care-record detail
needs fixingSome care records were less person-centred and detailed than others, although inspectors said all records clearly explained the support people needed. Work to improve them was underway.
“Some people's care records contained more person-centred detailed than others.” from the report
- 01How do you now monitor and record the temperature where medicines trolleys are stored?
- 02What work has been completed to make all care records equally person-centred and detailed?
- 03How do you check that there are enough staff when people's needs change?
- 04How are people and relatives involved in reviewing care plans and agreeing changes?
- 05How do you identify and act on concerns raised by people and relatives?
This was a comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 31 August 2017 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 The Manor House
3 rated inspections over 4 years: the service has held its Good rating throughout.
- April 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 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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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.