CQC report explained · a nursing home
What the CQC found at The Manor House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2019
Rated Good; inspectors found safe, well-managed care, and an earlier concern about fluid intake was not substantiated.
This was a focused inspection after information raised concerns about whether people were receiving enough fluids. The visit took place on 23 and 24 April 2019. One day was unannounced and the second was announced.
Inspectors reviewed fluid records for 13 people, care plans, staff training and recruitment records, audits and compliments. They spoke with 12 people, three relatives and five staff. They found that fluid intake was monitored and that action was taken when people were not meeting their targets.
The home was rated Good overall. Safe and Well-led were both rated Good. The other three areas were not inspected during this visit, so this report does not give new ratings for Effective, Caring or Responsive.
Fluid monitoring
Fluid intake was recorded and checked daily. Staff took further action, including contacting the GP, when someone was not meeting their target.
“Records we reviewed showed that people were reaching or exceeding their fluid target.” from the report
Safe care
Staff understood how to recognise and report abuse. Risks were assessed and medicines were checked and administered safely.
“Staff spoke confidently about different types of abuse, how they would identify abuse and what actions they would take if abuse was suspected.” from the report
Visible management
The manager was regularly present, knew people well and checked the home and staff each day.
“The registered manager was clear about their role, knew people well and was visible to staff and people throughout the home.” from the report
Listening to people
People, relatives and staff had several ways to share their views, including questionnaires, meetings and a suggestions box.
“People, staff and relatives were offered the opportunity to complete questionnaires and these were reviewed by the registered manager so that actions could be taken.” from the report
Staffing at some times
minorFeedback about staffing was mixed. Some people and relatives reported fewer staff or occasional difficulties at weekends and in the evenings.
“During the week days there is always plenty of staff, less so in the evenings and at week-ends” from the report
Activities and decoration
minorThe home had identified that it needed to widen its activities and update some parts of the environment. Work was under way at the time of the inspection.
“The registered manager had identified areas for improvement, including the range of activities available for people and areas in the home that required some cosmetic updating” from the report
- 01How many staff are usually on duty in the evenings and at weekends?
- 02How do you check that each person reaches their fluid target, and what do you do if they do not?
- 03What activities are currently available, and what improvements have been made since the inspection?
- 04Which parts of the home have been cosmetically updated since this inspection?
- 05How can relatives raise concerns and how will the home show what action was taken?
This was a focused inspection of Safe and Well-led only, brought forward because of concerns about fluid management; the other three areas were not inspected. This explanation was written from the published report of 4 May 2019 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, April 2018
The Manor House is rated Good; inspectors found kind, safe care, but noted staffing concerns and limited activities.
Inspectors made an unannounced comprehensive inspection over two days. They spoke with people living in the home, relatives, staff and visiting health professionals. They observed care and checked care records, medicines, staff recruitment and training, accidents, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were described as safe and happy. Staff knew people well, provided effective care and supported access to health professionals. Medicines were managed safely.
Inspectors found some areas to improve. People, relatives and staff raised concerns about staffing levels. Staff did not always knock before entering bedrooms. Activities were limited, and very few staff had end of life training. The provider acted on some problems during the inspection, including fire safety hazards and evacuation plans.
The home was also rated Good at the previous inspection in November 2015, so the overall rating remained unchanged.
Safe care
Inspectors found systems to protect people from abuse and avoidable harm. Staff understood safeguarding procedures and recruitment checks were in place.
“People were safe living at the home and with the staff supporting them.” from the report
Skilled support
Staff knew people well and had the skills and knowledge to meet their needs. People received help from health professionals when needed.
“People received effective care from staff who knew them well and had the skills and knowledge to meet their needs.” from the report
Kind and respectful care
Inspectors saw positive interactions and staff treating people with dignity. People and relatives spoke positively about the care.
“Throughout the inspection we heard and saw staff speaking and treating people in a dignified and respectful manner.” from the report
Safe medicines practice
Medicines were stored securely, given by trained staff and recorded accurately. Administration records contained enough information for safe administration.
“People's medicines administration records were complete and contained sufficient information to ensure the safe administration of medicines.” from the report
Quality monitoring
The management team used audits, meetings and feedback to identify problems and make improvements. Issues found during the inspection were acted on promptly.
“The registered manager had improved auditing systems to assess quality assurance and continue to improve the service for people who lived at the home.” from the report
Staffing levels
needs fixingSome people, relatives and staff felt there were not always enough staff to provide care promptly. The provider said it would review staffing levels and how staff time was used.
“A few people and their relatives, also some staff, thought there were not always enough staff around to provide care in a timely way.” from the report
Privacy at bedroom doors
minorStaff generally protected privacy during personal care, but inspectors saw staff enter some bedrooms without knocking or waiting for permission.
“However staff did not always knock before entering people's bedrooms.” from the report
Limited activities
needs fixingThe activity timetable offered only a small range of activities. It did not clearly show how people staying in their bedrooms were occupied, and the activities organiser also worked as a carer.
“A formal activity programme was on display in the hallway. The timetable we viewed had the minimum of activities” from the report
End of life training
needs fixingPeople's end of life wishes were recorded, but very few staff had completed end of life training.
“However the training schedules showed that very few staff had the end of life training.” from the report
DoLS records
needs fixingInspectors recommended clearer records after finding that an approved DoLS application had expired and had not been renewed.
“We recommend that the service keeps clearer records after we found an approved DoLS application had recently expired but not renewed.” from the report
- 01What did the staffing review find, and how many staff are now planned for each shift?
- 02What has changed to make sure staff knock and wait before entering bedrooms?
- 03What activities are now available, including for people who spend much of their time in their bedrooms?
- 04How many staff have completed end of life training, and when will the remaining staff complete it?
- 05How are DoLS applications and renewals now recorded and checked?
This was an unannounced comprehensive inspection covering all five key questions, and the previous Good rating from November 2015 remained unchanged. This explanation was written from the published report of 19 April 2018 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 3 years: the service has held its Good rating throughout.
- May 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018Goodstayed GoodSafe: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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