21 August 2021
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 Care Act 2014.
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.
This inspection was completed by one inspector.
Service and service type
The Manor House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
Day one of this inspection was unannounced. However, we gave the service notice of the inspection on our arrival in the carpark. This was because we had to gather information on the home’s current COVID 19 status and the providers procedures for visiting professionals. Day two of the inspection was announced.
What we did before the inspection
We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.
We asked the local authority and Healthwatch for any information they had which would aid our inspection. Local authorities together with other agencies may have responsibility for funding people who used the service and monitoring its quality. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.
During the inspection
We spoke with three people who used the service and one relative. We spoke with 16 staff members including three health care assistants, four senior carers, one nurse, the deputy manager, finance manager, human resources assistant, two activities coordinators, registered manager, nominated individual and the quality manager. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spent time in the communal areas with people to help us better understand their experience of care.
We looked at the care and support plans for five people and looked at several documents relating to the monitoring of the location including training, medicines, health and safety checks. We confirmed the safe recruitment of two staff members.
After the inspection
We continued to seek clarification from the provider to validate evidence found. This included a review of the continuous service improvement plan developed after our last inspection site visit.
21 August 2021
About the service
The Manor House Nursing Home is a residential care home providing personal and nursing care to 38 people aged 65 and over at the time of the inspection. The Manor House Nursing Home can support up to 125 people in three adapted buildings. One building accommodates people with general nursing needs. The second building accommodates people living with dementia and mental health needs across three separate floors, each of which has adapted facilities. The third building accommodates people who have recently been discharged from hospital and require assessment of their longer-term needs over two separate floors.
People’s experience of using this service and what we found
People were not always safe as some staff members working practices increased the potential for harm.
The provider had improved their quality monitoring systems however, they could not evidence consistent good practice over time. We will check this during our next planned comprehensive inspection.
People were protected from the risks of ill-treatment and abuse as the staff team had been trained to recognise potential signs of abuse and understood what to do if they suspected wrongdoing.
The provider had assessed the risks to people with their care and support. Staff members were knowledgeable about these risks and knew what to do to minimise the potential for harm to people.
People received safe support with their medicines by staff members who had been trained and assessed as competent. The provider had systems in place to complete an investigation, should a medicine error occur, to ensure the person was safe and lessons were learnt to minimise the risk of reoccurrence.
Staff members followed effective infection prevention and control procedures when supporting people.
People, relatives and staff found the management team to be approachable, supportive and their opinions valued.
The provider had kept the CQC informed about significant events at The Manor House Nursing Home.
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 inadequate (Published 29 April 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
This service has been in Special Measures since 29 April 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This was a planned inspection based on the previous rating.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Manor House Nursing Home on our website at www.cqc.org.uk.
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.