CQC report explained · a nursing home
What the CQC found at The Manor House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
The Manor House Nursing Home was rated Good; inspectors found safe, kind and well-organised care, but recommended more varied activities.
The inspection was unannounced and took place on 22 November 2022. Inspectors spoke with 16 people living in the home, 10 relatives and 13 staff. They reviewed care records, medicines records, staff information, complaints and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines support, detailed risk assessments, kind staff, personalised care and good access to health professionals.
The overall rating improved from Requires Improvement at the previous inspection, published in August 2021. The home had improved its care planning, management checks and access to activities, although inspectors said activities still needed more variety.
Detailed risk planning
People had risk assessments covering known risks, with clear instructions for staff on how to reduce them.
“People had comprehensive risk assessments in place which explored their known risks and gave staff clear guidance to reduce these risks.” from the report
Kind and respectful care
Inspectors found that staff knew people well and treated them with kindness, dignity and respect.
“People were supported by kind and caring staff who knew them well.” from the report
Personalised support
Care plans reflected people's preferences, including how they wanted their care delivered and how they preferred to spend their time.
“People had personalised care plans which reflected their preferences.” from the report
Active management checks
The home had detailed checks across its services and took action when these checks found improvements were needed.
“there was comprehensive audits in place across the home to identify where improvements were required and ensure action was taken to make these improvements.” from the report
Limited variety of activities
needs fixingPeople had access to activities in a shared area, which was an improvement, but inspectors found the choice was limited. The provider said more activities had been purchased, and inspectors recommended reviewing the variety.
“We recommend a review of activities to ensure these are varies and in line with people's preferences.” from the report
- 01What new activities have been added since the inspection, and how do you find out what each person enjoys?
- 02How often are care plans and risk assessments reviewed with the person and their relatives?
- 03How do you make sure medicines are recorded accurately, including any missed doses?
- 04How will you support my relative's communication needs, including access to information in suitable formats?
- 05How can relatives give feedback or raise a concern, and how quickly will it be investigated?
This was an unannounced inspection covering all five CQC questions, including the premises and the care provided. This explanation was written from the published report of 10 December 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, August 2021
Rated Requires Improvement; inspectors found significant progress since the earlier Inadequate rating, but some safety practices and quality checks were not reliable.
This was a planned inspection on 3 and 4 August 2021 after the previous Inadequate rating. The inspector spoke with people, a relative and staff, observed care, checked five care plans and reviewed records including medicines, training and safety checks.
The home had improved its safeguarding, risk assessments, care planning, medicines management, staffing and infection control. People told inspectors they felt safe, and staff were available and kind in their interactions.
However, inspectors found unsafe practices. A fire extinguisher was being used as a door stop, and hazardous substances and combustible materials were stored in unsuitable places. The provider corrected these issues immediately, but the quality monitoring systems were still new and had not been shown to work consistently over time.
The overall rating and both inspected areas, Safe and Well-led, were Requires Improvement. The home had improved from Inadequate and was no longer in Special Measures or in breach of the regulations identified at the previous inspection.
Improved care systems
Inspectors found significant improvements in staff training, risk assessments, care planning and medicines management since the previous inspection.
“However, following our last inspection they had made significant improvements on staff training, risk assessments, care planning and medicine management.” from the report
Medicines
People received their medicines when needed. An electronic system alerted nurses and managers when medicines were missed.
“People's medicines were managed safely. People received their medicines when they needed them.” from the report
Enough staff
Inspectors saw staff respond promptly and still have time to interact with people in an unhurried and respectful way.
“We saw staff were available to support people promptly when needed but also had time to interact with them in an unhurried and valuing way.” from the report
Infection control
The home had suitable procedures for infection prevention, testing, protective equipment and visits during the pandemic.
“We were assured the provider was using PPE effectively and safely.” from the report
Open management
People, relatives and staff said managers were approachable, listened to them and kept them informed.
“People, relatives and staff members said the management team was approachable and they felt supported by them.” from the report
Unsafe storage and fire safety practice
seriousInspectors saw a fire extinguisher being used as a door stop. Hazardous substances were left in communal areas and combustible material was stored in a stairwell. The provider removed the risks immediately, but these practices could have harmed people.
“In other areas of the location we saw substances hazardous to health were left in communal areas and combustible material was stored in a stairwell.” from the report
Quality checks not yet proven
needs fixingThe provider had created its own quality monitoring systems after external support stopped. Inspectors could not yet see evidence that the systems worked consistently over time.
“However, at this inspection, this external support had very recently stopped, and the provider had devised their own systems which they had yet to embed.” from the report
Managers had not identified all unsafe practice
needs fixingAlthough managers were regularly present, they had not noticed or corrected the unsafe use of firefighting equipment and unsuitable storage before the inspection.
“However, this increased managerial presence hadn't identified or corrected the staff behaviour regarding using a piece of firefighting equipment as a door stop or incorrect storage of substances hazardous to health.” from the report
- 01What checks now make sure fire extinguishers are kept in their designated places?
- 02How do you prevent hazardous substances and combustible materials being left in unsafe areas?
- 03How will you show that the new quality monitoring systems are working consistently over time?
- 04What improvements have been made since this inspection, and what evidence can you share?
- 05What are the current ratings and findings for Effective, Caring and Responsive?
This was a planned inspection based on the previous rating and rated Safe and Well-led only; infection prevention and control was also reviewed under Safe. This explanation was written from the published report of 21 August 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 The Manor House Nursing Home
6 rated inspections over 8 years: the service has held its Good rating throughout.
- December 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at The Manor House Nursing Home →
- August 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Manor House Nursing Home →
- April 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- February 2020Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
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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