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Inspection Summary

Overall summary & rating


Updated 25 May 2018

Manor House is a care home for older people, some live with dementia. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is registered to accommodate up to 23 people. There were 20 people living at the home when we visited.

We inspected Manor House on 3 and 14 December 2015, we found two breaches of regulations relating to the management of risks to people’s health and safety and support and supervision for staff.

We then undertook a focused inspection on 17 May 2016 in relation to the breaches of regulation we identified at our previous inspection of December 2015. We found that the service had followed their action plan and had met our requirements. At this inspection on 4 April 2018 the service continued to meet standards and we have therefore rated the service as Good overall.

The service had a registered manager who had worked at the service for several years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found that people’s medicines were administered in a safe way. Records for the management of medicines were maintained and these were correctly completed. Medicines were stored in a locked trolley but the trolley was not secured to ensure it was not easily moved. We spoke to provider about this and they agreed to take immediate action to improve this.

People were protected from avoidable harm. Management plans provided guidance to staff to help them mitigate risks to people. The provider maintained health and safety systems, and carried out regular checks to ensure the environment continued to be safe. The service was clean. Staff were trained in infection control and knew how implement the procedures to reduce risks of infection and contamination. Staff reported incidents and concerns as they should. Records of incidents and accidents were maintained, and the registered manager reviewed them. Actions were put in place to reduce the likelihood of incidents repeating again.

Staff were trained on safeguarding adults from abuse. They understood signs of abuse and how to report it in order to protect people. There were sufficient staff available and well deployed to meet people’s needs. Recruitment checks were conducted before new staff were employed. Staff received training, support and supervision to carry out their duties effectively.

People’s needs were assessed and individualised care plans in place that sets out how people’s needs and requirements would be met. People and their relatives told us they were involved in planning and reviewing their care. Care plans were kept updated.

People’s nutritional needs and dietary requirements were met. Staff supported people to eat and drink enough. People had to access to healthcare services they needed to maintain good health. The provider had arrangements and systems in place to enable people receive consistent care when they moved between services and departments.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff obtained consent from people before they delivered care and support to them. The service complied with the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Relatives and healthcare professionals were involved in making decisions for people in their best interests where this was appropriate.

People told us that staff were kind and compassionate to them.

Inspection areas



Updated 25 May 2018

The service was safe. People received their medicines in line with their prescriptions. Medicines were stored in a locked trolley but the trolley was not secured to ensure it was not easily moved.

Staff were trained to safeguard people from abuse. They understood the various forms of abuse that could occur, the signs to look for and how to report any concerns.

Risks to people were assessed and management plans devised to reduce identified risks.

Staff deployed to work at the service underwent checks to ensure they were suitable to work with people. There were sufficient numbers of staff available to meet people�s needs.

The environment was safe and well maintained. Health and safety checks took place. Incidents were managed well. Staff followed infection control practices.



Updated 25 May 2018

The service was effective. Staff were trained, supported and supervised to deliver care to people effectively. People�s needs were assessed thoroughly.

People consented to their care, and where required, relatives and professionals were involved in the decisions. People�s rights were protected in line with the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Staff and the manager understood their responsibilities under MCA and DoLS.

People�s nutritional and hydration needs were met. People told us they enjoyed the food provided at the service.

The service ensured people received well coordinated care and support. People had access to a range of healthcare services to maintain their well-being and health.



Updated 25 May 2018

The service was caring. People told us staff were kind and considerate. People were treated with respect and dignity.

Staff knew people well and understood their needs. People were involved in planning their care.

Staff encouraged people to be independent as they possibly could.



Updated 25 May 2018

The service was responsive. People received care and support that was planned and delivered in a way that met their individual needs.

People participated in activities they enjoyed. People were supported to maintain relationships which mattered to them. Staff supported people to maintain their culture and religion.

Staff were trained to provide end of life care to people. People�s end of life wishes were noted in their care plans.

People knew how to complain if they were unhappy about the service.



Updated 25 May 2018

The registered manager understood their responsibilities in line with their CQC registration. Staff told us they had the leadership support they needed.

The service worked with the local authority and other organisations to improve the service. Various audits took place to assess the quality of the service. Records were up to date and were stored in accordance with the Data Protection Act.