CQC report explained · a nursing home
What the CQC found at The Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found mixed feedback about staffing and delays in responding to people's needs, especially on Hestercombe. Risks, medicines and infection control were generally managed safely, but diabetes care plans and two fire door alarms needed improvement.
- Effective?
- Good
- People received suitable food and support with eating and drinking. Staff were trained, healthcare needs were monitored, and the home worked with health professionals.
- Caring?
- Good
- People were generally treated with kindness, dignity and respect. Staff involved people in care decisions and supported independence, although two people reported difficulty communicating with some overseas staff.
- Responsive?
- Good
- Care records were more personalised and staff understood people's needs and preferences. Activities, visits and communication support were available, although one formal complaint had not yet received a response.
- Well-led?
- Good
- Inspectors found positive changes under the new registered manager, including better communication, staffing, morale and oversight. Some expected external and contractual quality audits had not been completed during the management changes.
What inspectors found, December 2022
Rated Good overall, but Safe was Requires Improvement because staffing levels did not always meet people's needs promptly.
Inspectors visited the home unannounced on 25 October and 01 November 2022. They spoke with 30 people, nine relatives, 13 staff and seven professionals. They also checked care records, medicines records, recruitment files and quality checks.
People were mostly positive about the care. Inspectors found kind and respectful staff, personalised care plans, safe medicines support, good healthcare arrangements and a range of activities. The home was accessible, bright and spacious.
The main concern was staffing, especially on the Hestercombe unit. Some people waited too long for help with toileting, bathing and other needs. One extra care worker was added during the inspection, and inspectors recommended continued monitoring of staffing.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, meaning there was limited assurance that care was always safe and a greater risk that people could be harmed. The previous overall rating was Requires Improvement, and the home was no longer in breach of regulations.
Kind and respectful care
People and professionals described staff as caring, respectful and person-centred. Staff supported privacy, dignity and independence.
“People were supported in a respectful and dignified way and their privacy was respected, and their independence was promoted.” from the report
Improved care planning
Care records had become more personalised and gave staff clearer guidance about people's needs, wishes and preferences.
“We found improvements had been made to the care records, which were more personalised and provided guidance to staff about the level of care and support each person needed, and in the way they preferred.” from the report
Good activities and relationships
People could take part in varied activities, individual interests and trips. Visitors were welcomed and people were supported to keep in touch with family and friends.
“People were supported and encouraged to pursue activities and interests.” from the report
Improved leadership
Inspectors found that management, communication, staffing and morale had improved after the new registered manager took up the post.
“Staff and professionals described the positive impact since the registered manager's appointment.” from the report
Staffing and response times
seriousSome people, particularly on Hestercombe, said they waited too long for help and could not always bathe, shower or attend activities when they wanted. One extra care worker was added during the inspection, but staffing still needed monitoring.
“We received mixed feedback about staffing levels, and whether people's needs, and requests were responded to promptly, especially from people living on the Hestercombe unit.” from the report
Diabetes risk plans
needs fixingDiabetes risk assessments and care plans did not contain all the detail required by the provider's guidance. Inspectors said they needed clearer actions and outcomes.
“However, risk assessments and care plans relating to diabetes were not detailed as per the provider's policy guidance.” from the report
Fire door alarms
seriousTwo external fire doors did not trigger an alarm when opened. The home took immediate action by adding them to daily checks and reminding staff not to disarm the alarms.
“We found two external fire doors on the first floor leading out to the fire escape stairs which did not alarm when activated.” from the report
Incomplete medicines records
needs fixingStaff did not always record when people declined creams or other external preparations. The home was considering how to improve this.
“However, it wasn't always recorded when people declined to have these applied, and staff told us they were looking into the best way to improve this.” from the report
Outstanding complaint
needs fixingA relative had made a formal complaint and was waiting for the provider's response when inspectors visited.
“They had submitted a formal compliant and were waiting for a response from the provider.” from the report
- 01How many care staff and nurses are normally allocated to each unit, especially Hestercombe?
- 02How often are staffing shifts short, and what cover is arranged when this happens?
- 03What has been done since the inspection to reduce delays with call bells, toileting, bathing and attending activities?
- 04Have the two fire door alarms been repaired and how are they now checked?
- 05How are cream refusals, diabetes risks and complaints recorded and followed up?
This was an unannounced inspection covering all five key questions and infection prevention and control; the report refers to the previous inspection as the last comprehensive inspection. This explanation was written from the published report of 21 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, January 2021
Rated Requires Improvement; inspectors found safer care and better management, but concerns remained about choice, communication and support for independence.
This was an unannounced inspection on 1 and 14 December 2020. Inspectors spoke with people, relatives, staff and a health professional. They reviewed care records, medicines records, incident records, audits, health and safety records and recruitment checks.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safer medicines systems, suitable safeguarding arrangements and better checks on quality and safety. Infection control arrangements were also found to be in place during the pandemic.
The overall rating remained Requires Improvement. Communication with people and relatives was not always effective. Some routines restricted people's choice and freedom, including people being in bed early and not being able to go outside or see a hairdresser. People with acquired brain injuries did not have detailed plans to help them reach their full potential.
The inspection only reviewed Safe and Well-led. The ratings for Effective, Caring and Responsive came from the previous comprehensive inspection, so this report does not provide new findings in those areas.
Safer medicines
People received their medicines as prescribed. Staff were trained and checked as competent, and audits were used to address problems.
“People received their medicines as prescribed from staff who had received training and had their competency assessed.” from the report
Staffing and safeguarding
Inspectors found enough staff to meet people's needs. Staff understood how to report abuse and felt able to raise concerns.
“There were enough staff on duty to meet people's needs.” from the report
Infection control
The home had measures to reduce infection risks during the pandemic. Visitors used adapted visitor suites to see their relatives safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Improved oversight
The home had strengthened its checks and audits covering medicines, safeguarding, accidents and clinical care. This supported improvements since the previous inspection.
“The registered manager had ensured a robust system of checks and audits were carried out, reviewed and discussed with staff.” from the report
Choice and daily routines
needs fixingSome people were in bed by 5.30pm, and inspectors found that routines had restricted some people's freedom of movement and choice. The home said it was addressing this.
“We saw five people who were in bed by 5.30.” from the report
Limited activities and access
needs fixingPeople said they were bored and could not go outside. Relatives were also concerned that people had not been able to have their hair cut since March 2020.
“I do get bored we used to be able to go outside now we are not allowed” from the report
Support for independence
needs fixingPeople with acquired brain injuries had access to physiotherapy, but did not have detailed plans to help them reach their full potential.
“They did not have detailed plans to ensure each person reached their full potential.” from the report
Management changes
needs fixingStaff and people expressed concern about planned management changes. This was important because staff and people said the current manager had made a significant improvement.
“Staff had confidence in the registered manager, and they expressed their concern about their departure in the New Year.” from the report
- 01How do you make sure people choose when to get up, go to bed and spend time outside?
- 02What activities and social contact are now available for people who previously felt bored?
- 03Has a hairdresser been arranged, and how do you support people's personal choices about their appearance?
- 04What detailed plans are in place for people with acquired brain injuries to support their independence and potential?
- 05What changes have taken place in management since the inspection, and how have they affected care and communication?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 27 January 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
5 rated inspections over 8 years: the service has held its Good rating throughout.
- December 2022Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2021Requires improvementstayed Requires improvementSafe: GoodWell-led: Good
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Inspected but not ratedSafe: GoodCaring: Requires improvement
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
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.
- February 2011
Registered with the Care Quality Commission on 15 February 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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