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Archived: Manor Hall Nursing Home Good

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Inspection Summary

Overall summary & rating


Updated 19 December 2017

This inspection took place on 3 and 6 November 2017 and was unannounced. The inspection was carried out by two inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Manor Hall Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Manor Hall Nursing Home provides nursing and personal care for up to 44 people in one adapted building. There were 36 people living at the home at the time of the inspection. They had a range of complex health care needs which included people who have stroke and diabetes. Manor Hall Nursing Home also provides care and support for people who require end of life care. Some people had a degree of memory loss associated with their age and physical health conditions. Most people required help and support from two members of staff in relation to their mobility and personal care needs. Accommodation was provided over three floors with a passenger lift that provided level access to all parts of the home.

There is a registered manager at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection the registered manager was temporarily not working at the home. In her absence the deputy manager was responsible for the day to day running of the home with support from the operations director.

At our previous inspection in August 2016 we found the provider had not met the regulations in relation to ensuring there were enough staff deployed. People had not always received the care they wished for or required and people’s records were not always accurate or complete. The provider sent us an action plan and told us they would address these issues by November 2016. At this inspection we found improvements had been made and the provider was meeting the regulations. However, further time is required to ensure these improvements are fully embedded into practice.

There was a quality assurance system in place and this had identified the shortfalls we found. This was evident from the audits, meeting minutes and discussions with the director, deputy manager and staff. We had previously identified people’s records were not consistently person-centred and did not all include the information staff may require. Improvements had been made but further work was required to ensure this was fully embedded into practice. Work was also ongoing to ensure people were able to take part in activities they enjoyed and were meaningful.

Staff knew people really well. They had a good understanding of people’s individual needs and choices. They could tell us about people’s personal histories including their spiritual and cultural wishes. Each person was treated as an individual and their choices and rights were respected and upheld.

People were supported by staff who were kind and caring. Staff knew people well and had good relationships with them. Staff maintained people's privacy and understood the importance of confidentiality. Relatives were able to visit at any time, and were made to feel very welcome.

There were enough staff working to meet people's needs. Staff were deployed to ensure there was a good skill mix in each team. Staff were suitably trained and supported to deliver care in a way that responded to people's changing needs.

There was a range of risk assessments in place and staff had a good understanding of the risks associated with caring for people at the home.

The management and storage of medicines was

Inspection areas



Updated 19 December 2017

Manor Hall Nursing Home was safe.

There were enough staff to meet people's needs.

Risk assessments were in place and staff had a good understanding of the risks associated with the people they looked after.

There were systems in place to ensure medicines were ordered, stored administered and disposed of safely.

Staff understood the procedures in place to safeguard people from the risk of abuse.



Updated 19 December 2017

Manor Hall Nursing Home was effective.

Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

Staff received the training and support they needed to enable them to meet people�s needs.

People were supported to eat and drink a variety of food that met their individual needs and preferences.

People�s health and well-being needs were met. People were supported to have access to healthcare services when they needed them.



Updated 19 December 2017

Manor Hall Nursing Home was caring.

Staff knew people well and treated them with kindness, understanding and patience.

People were supported to make their own decisions and choices throughout the day.

People�s privacy and dignity were respected.



Updated 19 December 2017

Manor Hall Nursing Home was responsive.

People received care that was person centred and met their individual needs. Staff had a good understanding of providing person-centred care. They knew and understood people as individuals.

There was a range of activities taking place and people told us they had enough to do throughout the day.

There was a complaints policy in place and people and visitors told us they would raise any concerns with staff.


Requires improvement

Updated 19 December 2017

Manor Hall was not consistently well-led. Improvements had taken place since our last inspection in relation to people�s records and the quality assurance system. However, these needed time to be fully embedded into practice.

Areas for improvement had been identified and work was taking place to address these.

There was a positive culture at the service. People and visitors spoke highly of the staff team and their life at the home.