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Archived: The Manor House Inadequate

We are carrying out a review of quality at The Manor House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 28 November 2018

This inspection took place on 12, 22 and 30 October 2018. The first day was unannounced, the second day was announced to ensure the nominated individual who represented the limited company was in the home. The final day was spent telephoning people’s relatives.

At the last comprehensive inspection in February 2018 the service was rated, 'Requires Improvement.' We found the service was not meeting regulations with regard to good governance. The provider had failed to bring about sufficient, sustainable improvements to improve the quality of the service. We issued a warning notice against the provider.

Following the last inspection, we asked the provider to complete an action plan to tell us what they would do, and by when to improve the service. We agreed the providers date for them to make improvements in the management of the service; and the provider told us they would have completed their actions in relation to the other breach of the regulations by the end of May 2018.

The Manor House is a ‘care home’. 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 Manor House accommodates up to 16 people in one adapted building. At the time of our inspection there were 16 people living at the home.

The care service should be developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. At this inspection we did not see the service provided to people met these values.

There was no registered manager in post. Since the last inspection the registered manager had left the role and cancelled their registration with us. 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. The provider had appointed an acting manager in the service.

Health and safety checks were not regularly completed or evidenced to ensure risks to people’s safety were minimised. We identified some health and safety issues to the acting manager on the first day of our inspection visit where we had immediate concerns to people’s safety. These had not been followed up by the acting manager and fully reported onto other interested parties.

We found there was an absence of supervision by the provider to check quality monitoring had been carried out effectively. There was no evidence that quality monitoring had been undertaken since July 2018. The areas not covered included care plans and checks on medicines management.

There were no adequate infection control checks in place, staff were unsure which coloured mops and buckets were used consistently by staff in each area of the home. Staff were also unsure what temperature soiled clothing was washed at. These resulted in a heightened potential for cross infection and cross contamination of infection in the home. Improvements are required for the access to policies and procedures which would give staff the information to operate systems effectively and protect people in the home.

The audit systems in place were not reviewed by the previous registered manager to ensure people received a quality service. The nominated individual did not audit any systems in view of no registered manager being employed. Incidents were recorded but information was not always sent to CQC. Improvements are required in assessing risk to people.

The provider did not have effective systems in place to assess, monitor and improve the quality of ca

Inspection areas



Updated 28 November 2018

The service was not safe.

People were at risk from harm as the provider did not ensure all areas of safety were maintained. Medication administration was not operated safely. Infection control procedures were not detailed or followed, and people were placed at risk from the potential transfer of infection. The environment was poorly maintained. Some areas were not risk assessed to ensure the environment was safe for people. Most staff were recruited safely however staffing numbers did not allow for activities other than basic care.


Requires improvement

Updated 28 November 2018

The service was not always effective.

Staff training was not kept up to date to ensure all staff were in receipt of the latest guidance and best practice. Staff were aware of people�s capacity to make decisions and had some understanding of Deprivation of Liberty Safeguards though little understanding of the Mental Capacity Act 2005. People were not supported to maintain a healthy diet, nor one which fully met their cultural preferences. There was no evidence of people�s health being monitored.


Requires improvement

Updated 28 November 2018

The service was not consistently caring.

Staff were kind and compassionate, respected people�s individuality. However, people�s dignity was compromised by the restricted access to their en-suite showers and the systems in place for the prevention of the spread of infection.


Requires improvement

Updated 28 November 2018

The service was not consistently responsive.

Care was not personalised. People and their families were not involved in planning and reviewing how people were cared for and supported. There was no planned activity programme that met people�s support needs. Staff understood people�s preferences, likes and dislikes. People knew how to raise a complaint; however, the process was not clear for those with communication needs.



Updated 28 November 2018

The service was not well led.

There had not been any recent quality assurance that provided oversight or governance by the provider to ensure people�s safety was not compromised. Records of some tests were completed by staff, however these were not overseen by the nominated individual to ensure that shortfalls were identified, resolved or improved. The provider did not ensure CQC were informed of events that involved people in a timely way.