CQC report explained · a nursing home
What the CQC found at The Manor Nursing and Residential Care
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks, staffing, recruitment, infection control and emergency arrangements were generally managed safely, but medicine records and checks needed improvement.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Outstanding
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- The home had a positive culture, clear responsibilities and governance systems. Inspectors found that medicine oversight needed to be more consistent, and the management team acted promptly when this was raised.
What inspectors found, August 2023
The Manor Nursing and Residential Care is rated Good; inspectors found safe, kind care, but medicine records and checks needed tighter oversight.
This was an unannounced, focused inspection on 7 July 2023. Inspectors reviewed care records, recruitment files, training, medicines, accidents, safeguarding records and quality checks. They spoke with people living there, relatives, staff and health and social care professionals.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse, risks were assessed, staffing levels met people's needs, recruitment checks were completed and infection control arrangements were in place. People and relatives said they felt safe and well cared for.
The inspection found some weaknesses in medicine recording and checking. People received their medicines as prescribed, but some medicine administration records were not completed accurately, guidance for some 'when required' medicines was missing, and fridge temperature records were not always completed robustly. The provider was asked to consult current best practice.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report abuse.
“People and their relatives told us they felt the service was safe.” from the report
Risks were managed
Care records included guidance about risks such as falls, skin care and dietary needs. Staff were able to explain how they managed individual risks.
“Risks to people's safety were assessed, monitored, and managed.” from the report
Staffing and recruitment
Inspectors found staffing levels met people's needs and staff responded promptly. Required recruitment checks were completed before staff started work.
“The provider followed safe recruitment practices.” from the report
Positive culture
People, relatives and staff were positive about the care and how the home was run. Staff said they felt valued and listened to.
“There was a positive culture at the service.” from the report
Family contact
People were supported to keep in touch with family and friends, in line with current guidance.
“People were supported to have visits from their family and friends in line with current governance guidance.” from the report
Medicine records and checks
needs fixingSome medicine administration records were not completed accurately. Guidance for deciding when some medicines should be given was missing, and medicine fridge temperature records were not always completed robustly.
“Although, people received their medicines as prescribed we have made a recommendation around governance processes.” from the report
- 01What changes have you made to ensure medicine administration records are accurate at the start of each recording month?
- 02What written guidance do staff now use to decide when a 'when required' medicine should be given?
- 03How do you check and record the medicine fridge temperature every day?
- 04How are care plans and risk assessments reviewed when a person's needs change?
- 05Which ratings were carried forward from the 2017 inspection, and when will these areas next be fully assessed?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection in 2017. This explanation was written from the published report of 9 August 2023 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, December 2017
The Manor Nursing and Residential Care was rated Good overall, with Outstanding caring but some training and activity improvements still underway.
The CQC carried out an unannounced comprehensive inspection over 30 October and 01 November 2017. Inspectors spoke with people living there, relatives, staff and managers. They observed care and reviewed care plans, medicines records, training records, incident records and quality checks.
The home was rated Good for Safe, Effective, Responsive and Well-led. It was rated Outstanding for Caring. Inspectors found kind and respectful care, personalised support, safe medicines practices, enough staff and strong leadership.
There were some areas still being improved. Not all staff had completed mandatory training, and some people wanted more activities and outings. The home had already made plans or taken action in response.
Exceptional compassion
Staff were described as exceptionally kind and compassionate. They spent time listening to people, supporting their feelings and helping them keep their independence.
“People were treated with kindness and endearing compassion by staff who truly respected and valued them.” from the report
End of life care
The home specialised in end of life care. Staff had accredited palliative care training and worked with outside professionals to provide individualised care and prompt pain relief.
“People were supported at the end of their life to have a comfortable, pain free and dignified death by staff who had received accredited palliative care training.” from the report
Strong leadership
Inspectors found that the provider’s caring values were reflected in the culture and staff practice. Feedback, audits and action plans were used to monitor the service.
“People lived in an exceptionally well-led service, whereby the provider's caring values were embedded into the leadership, culture and staff practice.” from the report
Mandatory training gaps
needs fixingNot every staff member had completed the provider’s mandatory training courses. The manager had identified this and created a staff development plan, due to be completed by 2018.
“However, not everyone had completed the providers 'mandatory training' courses.” from the report
More activities and outings wanted
minorSome people and staff said they wanted more activities and opportunities to go out. The home had employed a new activities person and was seeking transport.
“However, some people told us, "I would like it if we went out more" and "I'd like to do more".” from the report
Safety checks missed two cupboards
needs fixingA health and safety audit had not identified two cupboards that should have been locked. The manager locked them immediately and reminded staff to remain vigilant.
“However, the audit had not identified two cupboards that should have been locked because of safety.” from the report
Complaints information was not clear enough
minorPeople and families said they did not know how or who to complain to, despite receiving the complaints policy with their contracts. The policy was then moved to a more visible place.
“Despite people receiving a copy of the complaints policy with their contracts, people and families had told the provider they did not know how, or who to complain to.” from the report
- 01Have all staff now completed the mandatory training that was outstanding at the inspection?
- 02What activities and outings are currently available, and was suitable transport secured?
- 03How are safety checks carried out now to make sure cupboards and other areas are secure?
- 04How will a resident or family member make a complaint, and how will they be kept informed?
- 05How has the home maintained its approach to end of life care and support since this inspection?
This was an unannounced comprehensive inspection covering all five key questions and the overall rating. This explanation was written from the published report of 19 December 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 Nursing and Residential Care
3 rated inspections over 8 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
Read what inspectors found at The Manor Nursing and Residential Care →
- December 2017Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at The Manor Nursing and Residential Care →
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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