The Manor House - Frenchay

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 did not always have a culture of safety to ensure lessons were learnt to continually identify and embed good practice. Staff listened to concerns about safety and reported safety events. Accidents and incidents were reported and recorded. Staff we spoke with knew the procedures to follow and were observant in their reporting, including near misses. However, forms did not always fully detail how accidents and incidents had been reviewed or all actions taken to mitigate future reoccurrence. For example, for 1 person who had fallen, the follow up was reminding the person to take care, rather than reviewing the environment and circumstances and for another person where a near miss had occurred in bed, preventative actions were unclear. Some questions on the form did not enable useful information to be gathered and was outdated. The provider promptly updated this section.

Senior staff monitored and reviewed incidents and accidents for individuals to identify any patterns or trends. When incidents occurred, staff told us changes were communicated to the team, these were also in the staff communication book. A staff member said, “We have meetings to explain. Managers go through it with us.”

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. The service had a preassessment document to ensure the service could meet people’s needs. People were encouraged to visit and spend time at the service to find out what it was like. The service supported people with respite care and some of these people had chosen to come and live at the service permanently. The service worked to ensure people received continuity in their care.

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. People said their safety was considered. One person said, “My wheelchair is safe and serviced.” A relative said, “[Name of person] is very safe with them.”

Mental Capacity Assessments (MCA) and associated best interest decisions (BID) were completed in specific areas. Some had been recently undertaken others had been completed many years ago, for example in 2016 and had been reviewed once. MCAs did not always fully include how the information had been presented and people’s responses to the area of care being assessed. Best Interest decisions explained the decision made and who was involved in making this. Other options considered but disregarded had not always been recorded.

People’s legal status around deprivation of liberty safeguards (DoLS) was included in care plan information. A tracker monitored current authorisations and when people’s DoLS expired. Staff we spoke with understood the principles of the Mental Capacity Act and demonstrated how they applied this in their support of people. A staff member said, “Putting people at the core value of choices. For example, deciding what clothes to wear or what activities they want to do.”

Staff spoken with knew how to identify and report safeguarding concerns and we reviewed records where this had occurred. Staff had received training in safeguarding. The registered manager notified the local authority and CQC as required of any safeguarding concerns.

The provider did not always work to fully understand and manage risks. Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. People received regular checks during the night if directed in their care plan. However, the specific time of checks was not recorded. Changes between night and day recording forms meant information was not clear of when people had arisen or if checks had been completed. If people went to bed during the day or before the nighttime checks commenced at 22.00, this information was not documented. This was important due to the potential risks for some people when on bed rest or sleeping. Guidance was clear for staff to follow in photographic and written form for people who required support with their sleeping position. Staff supported people with toenail care as directed in their care plan and risk assessment. There was not an associated policy around this. The provider completed this after the inspection.

Risk assessments were conducted for specific areas of people’s care. For example, travelling in vehicles, participating in activities and the use of particular equipment. People’s independence was promoted by taking positive risks. This enabled people to try new experiences. Guidance directed staff for example, in how to manage risks from health conditions such as epilepsy. This ensured people protocols were followed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental assessments detailed risks in the care environment and how these were managed. However, risks from hot surfaces and the use of portable fans had not been assessed. Some exposed pipes were viewed in bathrooms. The registered manager sent through these assessments after the inspection.

The registered manager completed regular checks of the environment and equipment, this included fire safety. People had individual contingency plans in case of emergencies. A maintenance programme identified areas of the service in need of repair and refurbishment. Staff told us repairs occurred promptly and this was evidenced in the maintenance log. A business continuity plan outlined how unforeseen circumstances would be managed such as the impact of adverse weather or loss of essential supplies. An on-call telephone system supported staff out of office hours in emergencies. However, some communal areas of the service showed signs of wear.

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. Recruitment procedures were followed which included employment and police checks. Steps in the recruitment process were monitored for full completion. Interview records reviewed were limited in detail to demonstrate the candidates experience and suitability. It was highlighted to the provider about the consideration of character references used to ensure these were robust.

There was enough staff to support people. We received positive feedback about the levels and quality of staff. This enabled people to participate in activities of their choice. We observed some people being supported to go on their summer holiday, others going out to enjoy community activities or for day trips. A staff member said, “We have consistent staff.” A health professional said, “Always appears to be appropriately staffed, enough staff to service users, staff are visible and accessible onsite during visits.” A relative said, “Always well-staffed and low turnover.” It was highlighted to the provider staffing levels were not evidenced as being reviewed to ensure they met people’s current needs and when people stayed at the service on respite. The registered manager addressed this.

Staff received regular 1 to 1 supervision, which the registered manager monitored. Staff told us they were well supported by managers who were always available. A staff member said, “You can always discuss any concerns or struggles. There is always someone in the office to speak with.”

New staff followed an induction programme which introduced them to the organisation, values, procedures and key learning. Documentation showed inductions topics completed. Staff spoke positively about the induction process and the support in getting to know people living at the service. Managers regular met with new staff to ensure they were fully supported. A staff member said, “Other staff have been really helpful through the induction.”

Staff received regular training relevant to their role, which included online and face to face sessions. A staff member said, “Yes, we get adequate training.” A staff member told us about training in epilepsy they had completed and how they used this training in their support for 1 person. Relatives said, “Staff are well trained” and “Staff know [Name of person] well and understand [Name of person’s] needs.” A training matrix detailed training completed and required. Some staff were due training or planned refreshers, which was highlighted on the matrix.

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 received training in infection prevention and control (IPC). Staff had access to personal protective equipment (PPE) and were observed using this as appropriate and in accordance with guidance. Cleaning materials were stored securely and handwashing guidance was displayed. Cleaning records documented areas cleaned and managed allocation of staff.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines as prescribed. One person said, “Staff give me medicines, they say what they are giving you.” Staff were trained in medicines administration and their competency was reviewed. People’s preferences for taking their medicines were outlined. Medicines that required additional storage were kept in line with legal requirements. Protocols for as required medicines (PRN) were completed. This detailed when a medicine may be a required and how it should be administered. People’s medicines were regularly reviewed in line with the principles of Stopping Over Medication of People with learning disabilities, autism or both (STOMP). The service worked with health professionals and communicated changes within the staff team about people’s medicines. A health professional said, “They seem to have a good working system regarding their medicines management.” Flammable risks from topical creams were assessed to ensure risks were reduced. Topical medicine administration records were completed. We highlighted where body maps had not always been filled out. However, some gaps were identified in the recording of medicine fridge temperatures. This had been raised in a staff meeting and since improved.