The Manor House

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager used systems to monitor, record and learn from incidents.

Incidents and accidents were reported, recorded and reviewed for themes and trends to determine any learning or actions for staff. Identified areas of learning were discussed by the nursing and staff team in regular team and huddle meetings. A huddle meeting is a short staff meeting where recent events, for example people’s health and wellbeing or accidents and incidents, are discussed.

Staff told us, “After something has happened, we discuss it and we have a meeting” and “The manager and nurses tell us if there is anything we need to learn more on and what we need to do.”

The provider worked with people and healthcare partners to establish and maintain 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.

The service had systems to support people being admitted to the service safely. The registered manager completed preadmission assessments before people moved into the service. When people moved in, they were provided with a guide which contained information on the home and its services. A checklist ensured all necessary tasks, including making any referrals to external health professionals were completed. We saw evidence staff made any referrals people required in a timely way, and when people were discharged from the home staff updated healthcare partners. A health professional told us, “They can recognise changes in their resident’s health needs and escalate appropriately.”

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. Any outcomes were shared with the person and their family as appropriate.

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of Liberty Safeguard (DoLS) was applied for through the relevant local authority. Any conditions related to DoLS authorisations were being met.

Staff had received safeguarding training and were clear on how to report any concerns they had. One staff member told us, “If I saw anything that was a worry I would talk to the manager or nurse and tell them what's happened, I have had training.”

Health and social care professionals told us people were safe and there had not been any safeguarding concerns they had needed to raise.

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.

Care plans and risk assessments were detailed and included information for staff to support people to manage risks where required. This included for risks of falls and risks associated with specific health conditions.

The registered manager promoted positive risk taking and spoke passionately about this. They gave an example of supporting 1 person to discuss and plan for the risks associated with going on holiday, this ensured risks were reduced as much as possible, but the person could enjoy the benefits a holiday brings. A health and social care professional told us how the management team of the home had supported a person to adjust their visiting arrangements to manage a specific risk.

Staff understood risks to people and told us they had access to this information, and it was regularly reviewed.

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.

We found 1 hoist had not been checked in a recent safety inspection of moving and handling equipment completed the previous week. After the inspection the registered manager told us this would be arranged, and the hoist would be taken out of use until the safety checks were completed.

We also found on the first day of our inspection some people’s air flow mattresses were not set correctly for their weight, to ensure they were effective in reducing the risk of pressure damage. After the inspection, the registered manager provided evidence of new measures to ensure all settings were correct and checked daily.

The provider was working through a refurbishment plan which included the redecoration of bedrooms and communal areas. They employed a maintenance person who completed most of the refurbishment work. People and relatives were complimentary of the maintenance of the service. One relative told us, “If you mention anything it gets fixed.”

Checks and reviews of essential services including gas, electricity and water were completed regularly. The service had an up-to-date fire risk assessment and each person had a personal evacuation plan, in case of emergency.

Senior staff conducted environmental audits to monitor the safety of the premises and equipment.

People were able to move safely around the environment. There was specialist equipment available to support people who needed it. People were provided with specialist beds, hoists, and other equipment. Equipment was regularly serviced to maintain safety.

The provider made sure there were enough qualified, skilled and experienced staff, who

received effective support, supervision and development. They worked together well to provide

safe care that met people's individual needs.

Safe recruitment practices were followed before new staff were employed to work with people.

The provider used a dependency tool to calculate the numbers of staff they needed. People and relatives told us there were enough staff, and if they pressed their call bell to request support it was answered quickly. One person told us, "They respond to the call bell most times within 2-3 minutes." A relative told us, "There is enough staff, when the call bell rings, they go to check straight away, it's not very long."

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.

The care environment was clean and hygienic. Staff told us personal protective equipment (PPE) and all cleaning materials needed were available. We saw staff wearing PPE appropriately when providing care and support to people.

Staff had received training to support with minimising the risk of infection and information about safe infection prevention and control practices was displayed throughout the home.

We found an area of flooring in a bathroom cupboard required maintenance work to ensure it was not an infection control hazard. We fed this back to the provider to address, they told us their maintenance team would replace the flooring as soon as possible.

Staff knew people’s needs, capacities and preferences with regards to their medicine and treatments. When we reviewed how medicines were administered, we found it was generally safe, and people received their medicines as prescribed. However, we identified some areas of medicine administration for improvement.

Where people had specific instructions for taking medicines, such as to take 2 hours before food, staff were not recording the times of medicines administration. This meant it was not possible to know if this instruction had been followed. Some people in the home were using oxygen however, this had not been prescribed by a health professional, in line with the service’s medicines policy and best practice.

Nurses’ competency to administer medicines was assessed annually however, nurses were not assessed for all medicine forms listed in the competency form, if people living in the home were not prescribed the medicine forms at the time of the assessment. We fed this back to the registered manager to address.

The frequency of nurse training in 1 area was not sufficient and their competency was not routinely checked. We fed this back to the registered manager who advised this specific task had not been completed by nurses in the home and would not be moving forward, they provided their medicines policy which had been updated to reflect this.

The deputy manager and provider had immediately addressed the other medicines issues we found on the first day of our inspection and had fed back to them. We also saw evidence of improvements made. The provider’s medicines audits had not identified medicines issues we found. We did not find any evidence anyone had come to harm.

Medicines were stored safely. With the exception of recording times of medicines administration, medicine administration records were all signed to indicate people had received their medicines as prescribed. For medicines to be administered ‘when required’ (PRN), the service had protocols to explain how and when these medicines should be given. The protocols contained person-centred information. Medicines errors were investigated, and medical advice was sought for the person where needed.

People and their relatives told us medicines administration worked well for them. One person said, “I get given my medication on time.”

One relative told us their loved one, “Receives their medication promptly, and this is very important because of their health condition.” Another relative said, “I think they must be getting it right, I know my loved one so well that I know if they are in pain and I haven't seen them in any pain since they have been there.”