The Manor Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.This is the first assessment for this service registered under a different legal entity/provider. This key question has been rated requires improvement. This meant some aspects of the service were not always safe, and there was limited assurance about safety. There was an increased risk that people could be harmed.The service was in breach of legal regulation in relation to the ways people’s medicines were managed safely and staff recruitment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had systems in place to record accidents and incidents; however, these were not consistently effective in supporting learning and prevention. Records did not clearly demonstrate what actions had been taken following incidents or how these actions reduced the risk of recurrence. Staff used different forms to review incidents. However, the records were not always clear if all the learning from the incidents was noted and disseminated, any actions or training identified and completed, and any follow-ups and reviews done. There was risk that meaningful learning would not be applied.This reduced transparency and effectiveness about how learning informed improvements in practice and risk management.

The management team acknowledged these weaknesses and confirmed they had identified similar themes within the reflective practice records. They told us they were monitoring actions identified from incidents and working with staff to ensure changes were implemented. Additional information was provided following the on-site assessment to evidence actions taken. However, at the time of inspection, the systems did not consistently demonstrate there was effective learning or oversight.Incidents and accidents were discussed in quality and clinical governance meetings. Information was fed into the provider’s quality improvement plan and reviewed through quality assurance and governance processes.

People and their relatives were supported to raise concerns, and staff were aware of how to report incidents and act to maintain people’s safety. The manager promoted an open-door approach, and staff understood their responsibilities in responding to risks. However, this positive intent was undermined by gaps in how learning and transparency were consistently applied following safety incidents.

There had been notifiable safety incidents where the duty of candour applied. The provider had a policy outlining the actions required; however, this policy was not followed consistently. As a result, the provider could not demonstrate that they had always acted in an open and transparent way with relevant people following incidents that met the threshold for duty of candour. This limited assurance that people and their families were consistently informed and supported when things went wrong.

The provider worked effectively with people, their relatives and healthcare partners to establish and maintain safe systems of care. Risks were identified, shared and monitored through partnership working, which supported continuity of care and reduced the risk of harm, including when people transferred between services or required hospital admission. The home manager maintained oversight through regular staff meetings, communications and professional liaison, where risks, changes in need and gaps in practice were identified and addressed promptly. Where improvements were needed, actions were agreed, monitored and embedded into practice. There was a process in place when people transferred into the service. Initial assessments and care plans reflected people’s individual needs, circumstances and expected outcomes, supporting safe, coordinated care from the admission. One professional added, “Recent reviews have not alerted us to any concerns and feedback was mostly positive, the team noted that any feedback that needed action the manager had reviewed immediately and responded.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.The manager told us about their responsibilities regarding safeguarding people and reporting concerns to external professionals accordingly. They took timely actions to investigate to ensure concerns were addressed appropriately. The manager worked with staff to ensure people were supported to raise concerns when they did not feel safe and monitored for any changes in the safety of people. The manager and staff followed safeguarding systems, processes and practices to ensure there was learning and people’s human rights were upheld and they were protected from discrimination. People told us they felt safe at the service and could ask staff for support or help.Staff were able to explain the safeguarding process. They knew how to identify and raise incidents and who to report to. Staff were assured the management would respond to concerns. One staff member added, “Safeguarding is well managed by the current leadership. They are much more engaged and involved. [The home manager] is great and is right on top of responsibilities in safeguarding.” The manager and staff demonstrated there was a commitment to taking immediate action to keep people safe from abuse and neglect.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.Staff were able to explain how to support people while using least restrictive option to maintain their safety but also respect people’s wishes.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People had care plans and risk assessments describing support and care needed. However, some information how the risks were managed needed further review to ensure the right care and mitigation was provided consistently. For example, the provider did not ensure risks relating to paraffin-based creams were monitored and managed effectively. Some people were also using oxygen and smoking. 2 people who smoked had emollients and additional flammable ointments in their rooms. Staff did not demonstrate awareness of these products and the associated risks. We also found these additional creams and ointments were not considered in people's risk assessments. We spoke to 1 person using these products, who required use of oxygen and was an active smoker. They told us they were unaware of the associated fire risks to themselves. This meant people were at risk of avoidable harm due to the lack of oversight and management of this risk. We raised these concerns to staff and management at the time of our assessment. Following our assessment, we were informed by the manager that risk assessments were being reviewed for all people at the service.

We identified 1 person at the service who had been taking medicine to treat epilepsy. Their care plan did not include a dedicated epilepsy care plan or any additional information to manage any risks related to this condition. Senior staff told us the person had experienced seizures whilst living in the service and explained what they would do if the seizure lasted over 4 minutes. After the site visit, we were informed there was no official diagnosis of epilepsy. The staff have arranged a GP review for the medicine and its appropriateness. However, our findings demonstrated clinical oversight needed further improvement to ensure such specific medicine and associated risks were regularly reviewed to ensure it was still needed.

Although care plans and risk assessments were in place, they were not sufficiently robust to identify and manage known risks, resulting in people being exposed to avoidable harm. The manager started taking actions following the site visit. But systems were not consistently effective at the time of assessment.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Some people in the service required oxygen therapy and stored oxygen concentrators in their rooms. Some of these people were smokers. Although smoke detectors were serviced every 6 months by an external company, there was no evidence of internal monitoring of smoke detectors. This meant the provider did not always maintain oversight of all environmental risks. After the site visit, the provider informed us internal monitoring of smoke alarms was in place now. The provider also confirmed the fire authority visited the service in January 2026 and did not raise any concerns. Health and safety checks were completed by the provider regularly. However, at the time of the assessment, there had been refurbishment works going on in the service for 1 year. The provider did not evidence there were regular risk assessments and reviews taking place to ensure the associated risks with building works were monitored and managed.

We completed a King’s Fund Assessment of the service with the provider. This is an environmental assessment tool designed to make health and care settings more dementia friendly. The manager was engaged in the review, and we identified areas of good practice and areas to improve to support people living with dementia with design features to enhance their orientation, experience and wayfinding around the service. For example, light switches did not significantly contrast with the wall colour. The lighting did not have a dimming feature to suit people’s care needs. Crockery and tablecloths did not have a clear contrast that would help people identify items during mealtimes. Handrails were in place, however they did not contrast significantly with the wall colour to support people to identify they were available to support mobility and independence. We noted there was no artwork or local photography displayed in the corridor to signify points of interest. The lift was not easy to find, and there was no large control buttons displayed. We reviewed the toilet on the first floor and the taps for the sink needed to be marked more clearly as hot and cold. We discussed and agreed these findings with the provider.

Other checks were completed to ensure equipment, facilities and technology supported the delivery of safe care. We reviewed evidence which demonstrated external agencies attended the service and completed relevant assessments. The maintenance team ensured they monitored additional risks to people including water temperatures, fire drills and emergency lighting. Although checks and external assessments were in place, the provider did not consistently identify, monitor or control environmental risks, resulting in potential safety concerns for people using the service.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The provider did not operate effective and robust recruitment to ensure they employed suitable staff. In 9 staff files we found missing information such as clear and full employment history; evidence from previous employments related to health and social care regarding staff's conduct and verifying the reasons for leaving. We found 2 Disclosure and Barring Service (DBS) checks were not completed prior to staff commencing work at the service. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Not having all required recruitment information before staff started work could put people at risk of being supported by unsuitable staff.

The provider did not always ensure they deployed their staff effectively. The manager told us they used a dependency tool to determine the staffing levels according to people’s needs and staff skills. However, our observations confirmed the provider needed to make improvements to staff deployment. There were insufficient staff to provide timely and responsive care to people. This was particularly visible at lunch time and the mealtime experience was not always managed well. For example, during lunch time, we observed staff were helping people eat but they did not remain with people to ensure consistent support with eating meals. Staff kept getting up and coming back. Staff kept doing other tasks so the meal experience was not very consistent. On the first floor, people needed support with eating and sitting together. During another mealtime, we observed 1 staff was supporting 2 people at once by sitting in the middle of those 2 people. This safety risks relating to swallowing and chewing, compromised the dignity of the people and did not show individualised support with meals. Staff told us there were not enough staff to support all the people in a timely manner thus people often needed to wait longer periods. Some staff told us their feedback about needing more staff was not always taken into consideration. One staff member said, “Staffing levels sometimes make my job very very hard. However, I have to say that people get the good care they need, but probably later than they would want it…this is not what person-centred care should look like.” Another staff member said, “To be honest, I do not think we have enough staff and we have already discussed this in our staff meetings and we are told that it will be sorted out. But now, they are talking about cutting our hours again. There are 3 care staff (instead of 4) now on the ground floor for 15 persons. We cannot always respond to people and yet we are getting told off for not being available to all residents.” A further staff member added, “The mornings are chaotic. There are 3 staff on duty on the first floor, and there are 7-8 people who need 2 to 1 staff to support them to get them out of bed, this leaves just one staff to get breakfast and answer all the call bells. So whoever needs assistance, their care can be interrupted whilst the call bell is answered.”

Staff had not always received regular refresher training to ensure their knowledge in supporting people with specific medical conditions was up to date. For example, people needed support with aspects of care such as diabetes, epilepsy, oxygen and using concentrators, catheter support. Some of the staffing team needed refresher training in these areas as it has expired or was incomplete according to due dates noted. This put people at risk of receiving care that may not reflect their individual needs and treatment. We considered this under the key question of well-led.

There was a schedule for staff supervisions and appraisals the staff team. Sessions were carried out to support staff’s development, wellbeing and practices. However, senior staff such as registered nurses did not have clinical supervisions. They told us they completed clinical supervision with each other. Although they noted this was not an issue, there was no senior clinical oversight to ensure registered nurses’ competencies and practices were maintained accordingly. The provider did not consistently ensure safe recruitment, sufficient staffing or effective staff deployment, which resulted in delays to care and placed people at risk of avoidable harm.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff were aware of infection prevention and control (IPC) and had access to gloves and aprons. People were protected as much as possible from the risk of infection because the premises and equipment were kept clean and hygienic. The service had a dedicated domestic team that maintained the cleanliness of the service. Staff used appropriate personal protective equipment (PPE) to help protect people from the risks relating to cross infection. People and relatives confirmed they did not have any issues with the cleanliness of the service. We saw the provider completed regular audits for IPC. These demonstrated a daily cleaning schedule was in place, with cleaning equipment available for staff. These audits had not identified any concerns with IPC practice. The manager told us they had appointed a staff member as an IPC champion for the service. The manager also held health and safety meetings to oversee the service. The manager added, “We have a fantastic domestics and maintenance team. Any issues with IPC, all staff address it, rather than leaving it to domestic team. I am out myself and oversee it. It is all our responsibility.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not involve people in planning.We found issues with the management of medicine that could put people at risk of not receiving it safely. For example, people were prescribed ‘as required’ (PRN) medicine to manage different ailments or conditions. However, the protocols did not always indicate at what intervals it should be administered to ensure safe spacing of the doses. A sedative was administered to one person 2 hours apart instead of 8 hours. We raised this with the senior staff and managers to address it. We found that PRN protocols were not in place for some of PRN medicines prescribed. Some PRN medicines were also given, but without monitoring in place for effectiveness. When people had more than 1 PRN medicine to treat the same ailment, it was not always clear which one to use first. When people had to have PRN medicine to support their emotional wellbeing, it was not recorded how staff supported people first before administering medicine as a last resort. Protocols for using sedatives needed more details on how to support people with reassurance. We also found some medicines were not administered in line with the protocols. For example, one person was prescribed a laxative, with a maximum dose of 1 in 24 hours. The person’s medicine administration record (MAR) chart showed the dose administered was ‘5’. Another person had 2 tablets administered in a day, when the prescribed guidance stated 1 tablet to be administered in 24 hours.

In the clinical room, we found some expired items, including test strips, alcohol wipes, adhesive remover, and extractor skin staples. We showed these to the nurses on shift, who confirmed they would address this.People had transdermal patches prescribed. However, there were no body maps in place to monitor where this medicine should be applied to the body. There was no evidence to demonstrate these patches were checked between applications to ensure the desired therapeutic effectiveness was maintained. The GP had authorised some homely remedies for people. However, these were not regularly reviewed to ensure they were safe and effective to continue administration. We found 3 boxes of olive oil ear drops, which had not been prescribed or authorised by the GP as a homely remedy. Staff were unable to explain why these products were in the medicine room. We also found medicine which was opened in November 2025 but was not discarded 3 months after opening as per note on the bottle. This was shown to staff who confirmed they would discard this immediately. However, this demonstrated there was a lack of oversight and management of medicines. This meant we could not always be assured people received their medicines safely and as prescribed and this placed people at risk of harm. We discussed our findings with the managers and the nurses to ensure they made amendments as needed.