CQC report explained · a residential care home
What the CQC found at The Manse Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2024
Rated Requires Improvement; inspectors found kind support but gaps in safety, staffing, dignity and care planning.
This was an unannounced inspection. It started by looking at Safe and Well-led, then widened to cover all five areas after inspectors found potential concerns. They visited on 31 October, 1 November and 29 November 2023, spoke with people, relatives and staff, and reviewed care, staff and management records.
Inspectors found risks were not always properly assessed or managed. Medicines records and instructions were not always safe. Staffing levels were not always enough to provide timely support, including at night. Some people's privacy and dignity were not respected, and care plans were not always up to date or personalised.
There were also problems with radiator safety, fire door repairs, staff training and the home's checks on quality and safety. Inspectors found no evidence that anyone had been harmed, but said the issues had put people at potential risk of harm. The home had previously been rated Good in 2017, but all five current ratings are Requires Improvement.
Kind staff
People and relatives described staff as friendly and supportive. Inspectors also observed kind interactions.
“Staff interactions with service users were friendly, caring, kind and supportive.” from the report
Food and drink
People were supported to eat and drink enough. They had dietary assessments, a varied menu and choices of meals.
“People were supported to eat and drink enough and maintain a balanced diet.” from the report
Activities and relationships
People could take part in activities, go out, see family and friends, and choose how they spent their time.
“People spent time with family and friends, participated in activities, went out into the community, and went on day trips.” from the report
Involvement in care
People and relatives were involved in planning and reviewing care and in decisions about support.
“People and their relatives were included in planning and reviewing their care and making decisions about their care and support, including any changes.” from the report
Risk management
seriousSome risks had no assessment or did not have clear, up-to-date instructions for staff. Inspectors found no evidence of harm, but said people were at potential risk.
“Risks to people were not always sufficiently assessed and plans to mitigate and manage risks were not always sufficiently detailed, instructive and up to date.” from the report
Medicines
seriousSome people did not always receive prescribed medicines. Records, stock totals and instructions for medicines given when needed were not always reliable.
“Medicines management was not always safe.” from the report
Staffing
seriousThere were not always enough suitably qualified staff. During a night shift, one person needed immediate help but was left without staff support until inspectors raised the issue.
“The provider did not always deploy enough staff to meet all people's needs and health and safety requirements at all times.” from the report
Privacy and dignity
seriousInspectors saw two incidents where privacy and dignity were not respected. Two bedrooms also had carpets that continued to smell of urine.
“People's privacy and dignity were not always respected and maintained.” from the report
Quality checks
seriousThe home's audits and checks had not found several problems with care plans, medicines, staffing, training, safety and records.
“The provider's quality assurance systems and processes were not always effective.” from the report
Premises safety
seriousSeveral radiators lacked covers in areas used by people with limited mobility. The covers were still missing when inspectors returned four weeks later.
“During our inspection we identified a number of radiators without radiator covers in people's bedrooms and communal areas.” from the report
- 01What action has been taken to make risk assessments and care plans complete, personalised and up to date?
- 02How are medicines now checked, including topical creams, stock totals and medicines given when needed?
- 03How many staff are deployed on each shift, especially at night, and how is this matched to people's changing needs?
- 04Have all radiator covers been fitted, and have all fire safety and maintenance checks been completed?
- 05How does the home now check that people's privacy, dignity and personal hygiene are protected?
The inspection began as a focused inspection of Safe and Well-led, then widened to a comprehensive inspection covering Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 12 January 2024 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, November 2020
Inspected but not rated; inspectors were assured that infection control measures were being followed safely.
This was an announced, targeted inspection on 23 October 2020. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors were assured that the home used personal protective equipment safely, followed hand hygiene and social distancing guidance, and had suitable cleaning arrangements. They were also assured about testing, admissions, visiting arrangements and managing possible outbreaks.
The home was inspected but not rated. This means the inspection did not give an overall quality rating or full ratings for all five areas of care.
Individual COVID-19 risk checks
The registered manager assessed the individual COVID-19 risks for staff and people living at the home, including how they could be supported.
“The registered manager had undertaken risk assessments to establish the individual risks from COVID 19 to each staff member and person using the service” from the report
PPE and hand hygiene
Staff had infection control training and inspectors saw them using PPE and hand hygiene appropriately.
“Staff followed best practice in relation to good hand hygiene and using PPE.” from the report
Cleaning
The home had a cleaning and disinfecting schedule, including regular cleaning of frequently touched surfaces.
“All staff were involved in ensuring frequently touched surfaces such as door handles were disinfected every two hours.” from the report
Reduced staff movement
The home no longer employed staff who also worked at other care services, to reduce the risk of spreading infection.
“The service no longer employed staff who worked at other care services, to reduce the risk of staff spreading COVID19 infections.” from the report
Contact during restrictions
People receiving end-of-life care could still have visits from relatives with PPE. Other contact included window visits and video calls.
“People on end of life care could still receive visits from their relatives, who were provided with full personal protective equipment (PPE).” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current visiting arrangements, and have they changed since this inspection?
- 02How will you support visits and contact if my relative is receiving end-of-life care?
- 03What infection prevention and control training do staff currently receive?
- 04How often are frequently touched surfaces cleaned and disinfected now?
- 05Can you share the home's ratings or inspection information for care areas that this targeted inspection did not cover?
This was a targeted inspection of infection prevention and control measures only; the service was inspected but not rated in this report. This explanation was written from the published report of 14 November 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.
Every inspection of The Manse Residential Care Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Manse Residential Care Home →
- November 2020Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at The Manse Residential Care Home →
- December 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Croydon
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 £980 to £1,230 a week. 77 can care for a couple. 11 years' experience on average.
“She cared for my mum with Alzheimer's with endless patience and kindness, always arriving with a smile and a positive attitude”
“Terry has been of invaluable help to our family while working as a part-time live-in carer for our mother for approximately 6 months”
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.