Manor Farm Residential 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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 people’s safe care and treatment and safe staffing.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Although staff meetings were held, staff told us concerns raised had not been appropriately investigated or responded to. Additionally, lessons were not always learnt to continually identify and embed good practice. For example, following incidents such as unwitnessed falls and physical abuse between residents.

However, some learning took place following initial feedback provided throughout the inspection. For example, the manager told us they were making improvements to their management of medicines, such as re-training staff and updating records.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People had documents to support the safe transition into other services, such as hospitals. The provider had a policy which outlined procedures and was appropriate for the service. People, their relatives and staff raised no concerns about safe systems, pathways and transitions. One relative told us, “It doesn’t feel like a sterile environment [at the service], it feels like her own home, that’s why it was such a smooth transition.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. For example, safeguarding concerns had not always been shared with the Care Quality Commission (CQC), such as physical and verbal abuse between residents. Not all staff had completed training in safeguarding vulnerable adults.

However, people and their relatives told us people were safe. One relative told us, “[Relative] is perfectly safe living there; there are nice wide corridors where she can walk up and down.” There was a safeguarding policy which outlined the procedure and staff knew how to safeguard people.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People told us they felt risks were managed safely. People’s care plans contained clear information to guide staff how to manage people’s risks, and these were regularly reviewed. We observed staff supporting people to manage their own risks. Staff told us they felt they had enough information to manage these.

The provider did not detect and control potential risks in the care environment. The provider had a fire risk assessment which was completed in January 2023. However, this had outstanding high-risk actions, such as installing smoke detection outside of a lift, and interfacing a new lift with the fire alarm system. The report stated these actions were being looked into, and were due for completion in September 2025, but we found these had not been completed within the recommended time frames and this put people at significant risk from fire. We contacted the fire service, and they told us they would visit the service to ensure compliance.

Further, not all staff had been enrolled on training courses relating to health and safety. For example, 5 out of 16 staff had not been enrolled on ‘Health and Safety Awareness’ training, which is a mandatory training course for all staff working at the service. Additionally, 3 out of 16 staff had not been enrolled on ‘Fire Safety’ training which is also a mandatory training requirement. This meant there was a risk that staff would not know what to do in the event of a fire or know how to support people safely in line with health and safety legislation.

However, health and safety related training completion had improved throughout the inspection. people and their relatives felt the environment was safe. Fire safety checks took place regularly and equipment was serviced regularly.

During our site visit, we observed staff were not always available to meet people’s needs. For example, we observed one person calling out multiple times whilst waiting for their lunch, which was half an hour later than the time the person was told it would be ready. Staff were not available to reassure or redirect this person and appeared occupied with bringing people to the dining area for lunch. We later observed 7 people were sat in a lounge area for a 30-minute time frame with no staff present. Although no person came to harm, we observed some of these people had mobility needs and had previously sustained unwitnessed falls, which meant there was a risk of people coming to harm due to staff not being available to support people if needed.

Staff told us they felt staffing levels could improve. One staff told us, “There have been many recent falls in the past couple of months as staff are rushing around trying to attend to all residents and then others are having falls.” Another staff told us, “The staffing levels can often be low and not always supported by contracted staff. There are limited agency staff that have good knowledge of the home and service user needs.” Unwitnessed incidents occurred at the service, such as incidents between residents and unwitnessed falls. This meant people were at risk of harm. In response to this, the nominated individual told us, "The average falls has been consistent around 4-5 per month in the past 3 months. The agency staff do have an induction process to follow and we request same staff to make sure we get the staff who knows the home well."

We received mixed feedback from people and their relatives about staffing levels. For example, one relative told us, “There always seems to be enough staff on duty. I always see someone senior as well.” However, another relative said, “Although the [staff] are friendly enough, I think they could do with more of them.”

The nominated individual and new manager told us they used a dependency tool to calculate staffing levels. Leaders told us there was a process in place to calculate safe staffing levels and felt the reason for this feedback was related to how staff were deployed. The new manager told us, “When [staff] say there’s not enough staff, I would say that’s to do with planning and the allocation of jobs. When I came in people would have a handover and all disperse into different areas. We now have an allocation form, stating who is doing what, which is more structured.

The provider did not always assess or manage the risk of infection. We received mixed feedback from people, staff and relatives about the cleanliness of the service. One staff told us, “I don’t feel that all areas of the home are clean; for example, the dining room chairs, and workplace areas appear to need cleaning to me.” Another staff member felt there was an infection prevention and control (IPC) concern due to cross contamination from care staff covering shifts in the kitchen when kitchen staff are unavailable. We raised this with leaders who told us they had no knowledge of this happening. They explained there are enough catering staff to cover shifts when other catering staff are unavailable.

One relative told us, “In the main it is [clean]. I do wonder sometimes about her clothes; she spills food down herself. There was an incident where she was wearing the same dirty top more than once.” We reviewed training records for IPC and found 3 out of 18 staff had not completed IPC training. We also found no staff had completed training in legionella. Lack of legionella training for staff meant there was a risk staff did not understand the importance of reporting issues which could put people at risk of harm from legionella, such as a lack of hot water.

However, training completion had improved throughout the inspection, which included training in legionella awareness, due to the new manager starting at the service. There was an IPC policy which was being followed. The service appeared clean and tidy and the time of our inspection. Audits were effective as actions were identified and had then been completed.

Although the service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences, some people’s ‘when required’ (PRN) medicine protocols lacked clarity, and body maps for topical medications were inconsistently used. For example, one person was self-administering a flammable emollient cream, without the risks of this being assessed to ensure this could be done safely. This put the person at higher risk of harm through fire. We also observed people had unsecured prescribed flammable emollient creams in their bedrooms, also without this being risk assessed. This put other people at risk of harm from fire.

However, other medicines were stored safely. Medicines were administered as prescribed and in line with people’s preferences. Staff had completed an appropriate level of training relating to medicines. There was a medicines policy which outlined procedures for staff to follow. The new manager told us they had identified gaps in medicine documentation when they started working for the service and told us about the plans in place to address the shortfalls CQC had identified during the inspection.