Manor Care Home - Middlewich

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 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 people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

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. Staff did not always report safety events. Lessons were not always learnt to continually identify and embed good practice.

We identified one incident had not been dealt with in line with policy. When incidents were investigated, learning was not embedded in practice. For example, care plans were not consistently updated to reflect changes required following incidents, which limited the opportunity to improve care outcomes.

However, relatives told us they were kept informed when concerns arose.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. However, they did make sure there was continuity of care when people moved between different services.

There was no evidence the provider completed their own assessments of people’s needs prior to commencement of the service. Instead, the provider relied on local authority care plans and gathered additional information through discussions with professionals and relatives. As a result, people were not consistently involved in planning their own transitions into the service. In response to this feedback, the provider ensured assessments involving people were now being carried out.

Referrals to external professionals were not always made in a timely manner. For example, people requiring mobility equipment had not been referred promptly due to lack of clarity who these referrals were made to. In response to delays, the provider carried out their own mobility assessments and used their own equipment in the interim. The provider had since established the correct partner to make referrals to ensuring delays are no longer occurring.

Staff told us they became familiar with people’s needs through handover meetings and the provider’s electronic messaging and care planning systems.

Relatives confirmed their confidence in staff’s knowledge, with one saying, “Staff are knowledgeable about [person’s] condition,” and another adding, “Staff all know [person] well, and I feel [person] is safe and well cared for.”

When people transitioned from this service, staff accompanied them to their new setting and stayed to support them to settle in.

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. However, the provider did not always work well with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

People were treated with kindness and appeared well cared for. One person told us, “I am treated well here.” Relatives consistently told us their loved ones were safe. One relative told us, “[Person] seems happy here, and it feels like a safe place for them.”

The provider demonstrated a commitment to safeguarding by sharing concerns promptly and appropriately with external agencies. Safeguarding concerns were recorded in detail, and the provider worked effectively with the local authority to ensure timely follow-up and resolution.

Staff demonstrated a good understanding of safeguarding procedures, and the actions needed to keep people safe. They told us they received regular safeguarding training and were confident in reporting any concerns. One staff member said, “If someone was being abused, I would report this to the management.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive.

Risk assessments and care plans were not consistently completed or sufficiently detailed to mitigate risks effectively. For example, people on modified diets did not have appropriate risk assessments in place, placing them at risk of choking. In other cases, care plans for people who experienced emotional distress lacked personalised strategies to support them safely and effectively.

While accidents and incidents were regularly reviewed and analysed, some emerging trends and patterns were not followed up with appropriate actions, limiting opportunities for learning and prevention.

The provider had policies aligned with best practice guidance and supported people’s independence, including promoting safe and independent access to outdoor spaces. However, not all risks associated with this support were consistently identified or addressed through person-centred planning and involvement.

People were not always involved in the assessment and planning of risk, and their preferences and views were not consistently reflected in their care records.

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.

The provider did not have effective systems in place to regularly monitor and ensure the safety of the environment and equipment. We observed several environmental risks, including fire doors that required adjustment, unsecured access to fuse cupboards in communal areas, trailing wires in people’s rooms posing a potential trip hazard, and hazardous materials not stored safely.

Despite these concerns there was evidence of good fire safety practice. Regular fire drills were undertaken, all people had up-to-date Personal Emergency Evacuation Plans (PEEPs), a fire risk assessment had been completed, and all staff had completed relevant fire training.

We shared our concerns with the provider, who took immediate action to address the issues. A new maintenance reporting and monitoring system was implemented to help ensure timely identification and resolution of environmental risks.

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.

The provider maintained sufficient staffing levels and ensured safe recruitment practices were followed. Staff completed an induction, mandatory training, and ongoing supervision, appraisal, and competency assessments. Additionally, staff were encouraged and supported to pursue further professional qualifications.

However, we found some staff had been working without adequate breaks between shifts or adequate days off. Upon identifying this, the provider took prompt action to review and adjust staff rotas to better support staff wellbeing and maintain safe staffing levels.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We found the sluice room was not being used for the cleaning of continence equipment and lacked the necessary cleaning products for staff to use. Communal equipment, including wheelchairs and hoists, were unclean.

The kitchen environment was unhygienic, greasy food containers, a stained oven exterior, mop heads stored on the floor and debris accumulated between a kitchen unit and the wall were noted. Additionally, kitchen cleaning schedules showed gaps in record-keeping increasing the risk of food contamination.

People’s mealtime protective aprons were cracked compromising their effectiveness. PPE was sometimes disposed of improperly, with some items found in general waste bins unsuitable for clinical waste, and external waste bins were not secured.

However, the provider maintained good supplies of PPE, staff had completed infection prevention and control training, and relevant policies were in place to guide infection risk management.

We raised these concerns with the registered manager, who took immediate action to address the issues and ordered replacement equipment.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Medication incidents remained an ongoing concern, including occurrences of missed doses and administration of incorrect medication. We identified an incident where one person received medication prescribed for the following day, exposing them to potential side effects, dosage errors, and risk of harm. The provider responded promptly by seeking medical advice, closely monitoring the individual’s health, and reporting the incident to the appropriate external partners.

We found no body maps to guide the rotation of transdermal patches, which is essential to help prevent skin irritation and complications from repeated application on the same area. Staff explained the feature for recording patch rotation had been deactivated on their medication system.

Whilst protocols for ‘when required’ medications were in place; there was no mechanism for documenting the effectiveness of these medicines. Staff were uncertain whether the medication administered had achieved the desired outcomes or whether further medical intervention was required.

Some prescribed creams were stored in communal drawers accessible to other people, raising concerns about medication security. We noted gaps in temperature recording for medication storage, which risked compromising the effectiveness. Medication audits had not identified these issues.

However, systems were in place to ensure time-critical medications were administered as prescribed. One person told us, “I receive my medication when I want it.”

The provider had previously implemented various strategies to reduce medication errors. This included retraining staff, conducting competency checks, collaborating with the local authority’s medicine optimisation team and holding regular meetings with the medicine administration team. This remained ongoing.