Manor House Residential Home

Updated 7 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Manor House Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Manor House Residential Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

We used information gathered as part of monitoring activity that took place on 8 November 2022 to help plan the inspection and inform our judgements.

During the inspection

We spoke in with 4 people using the service and 2 relatives. We spoke with the registered manager, a senior care assistant and 2 care assistants. We spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 3 people’s care records and multiple medicines records. We looked at 2 staff files in relation to recruitment and a variety of records relating to the management of the service, which included quality monitoring and auditing, minutes of meetings, policies and procedures.

Updated 7 March 2023

About the service

Manor House Residential Home is a residential care home providing accommodation for up to 22 people who require personal care , some of whom are living with dementia. The service is a converted period property. At the time of our inspection there were 17 people using the service.

People’s experience of using this service and what we found

The provider’s systems and processes to assess and monitor the safety and quality of people’s care continued to require further improvement and development.

We found the provider had not fully implemented the actions they told us they would take following their previous inspection.

We found improvements were needed in areas not identified by the provider.

The provider’s policies and procedures were not consistently implemented by staff or understood.

Audits and practices to monitor the service had failed to monitor and keep under review staff knowledge, training and competence in key areas, which included medicine management and safeguarding people from abuse. Some staff had not undertaken training in topics related to the promotion of people’s health and well-being.

People’s safety was not assured as staff were not confident in identifying all types of potential abuse. Staff did not always follow the procedure for the administration of medication or the monitoring of safe medicine management. However, we found no evidence that people had not received their medicine as prescribed.

People and their family members told us they felt safe at Manor House Residential Home, as staff were available to help them when required. People were supported by sufficient staff who had undergone a safe recruitment process. People lived in an environment with safe infection and prevention measures.

People’s health and wellbeing needs were assessed, and their health and welfare monitored by staff. Staff liaised with health care professionals about people’s care. People’s dietary needs were met and people were assisted by staff where required to eat and drink. Snacks and drinks were served throughout the day. A plan for ongoing environmental improvements to décor and furnishings was in place.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and family members were complimentary about the service and spoke of good communication with the management team. The provider sought feedback from family members about the quality of the service and undertook an analysis of the findings.

The provider had identified areas for improvement, which included the planned introduction of an electronic system for the recording and monitoring of people’s care, including medication and medicine systems.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 5 February 2020) and there were breaches of regulation. The service remains rated Requires Improvement. This service has been rated Requires Improvement for two consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We carried out an unannounced comprehensive inspection of this service on 7 January 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Safe care and treatment, Safeguarding service users from abuse and improper treatment and Good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Manor House Residential Home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified continued breaches in relation to safeguarding people from abuse and good governance, which included staff training and competency, and the implementation of some policies and procedures. We also found concerns related to medicine administration and medicine systems.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.