Manley Court Care 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

People using the service were protected from abuse and avoidable harm.

This service scored 75 (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 positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated when required ensuring safety events were appropriately reported and managed. Lessons were learnt to continually identify and embed good practice.

There were policies and procedures in place for responding to incidents, accidents and complaints. Staff we spoke with were knowledgeable about these and how to respond and report appropriately. Staff meetings were held providing effective communication between staff, highlighting any areas of concern or improvement. Records showed that following events and investigations, managers actioned changes where required which were reviewed and monitored to ensure they were embedded.

Staff worked with people and health and social care partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

Assessments of people’s needs were completed upon admission to the service and regularly reviewed to ensure they were reflective of their needs. Care plans included information from visiting health and social care professionals to ensure staff had up to date information on how best to meet people’s needs.

There were safeguarding policies and procedures in place and staff were trained to recognise and respond to concerns, potential abuse and harm. Training records confirmed staff had received training on safeguarding. Staff told us they felt confident any concerns would be managed appropriately. One member of staff commented, “I know how to report any concerns, management are very good and make sure people are kept safe.” A person using the service told us, “I can leave my door open, so I feel safe.” A relative told us, “When I go home from visiting, I am comfortable about my loved one’s care.”

The service 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 service shared concerns promptly and appropriately.

There were systems in place to ensure oversight of safeguarding concerns, accidents and incidents. The home manager showed us tools used to manage these. Records showed that appropriate actions were taken by staff where required and there were good working partnerships in place to minimise the risk of reoccurrence.

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of liberty Safeguard (DoLS) authorisation was applied for through the relevant local authority. All legal applications had been made in accordance with DoLS, this meant people’s rights were fully respected. The home manager had oversight of DoLS applications, authorisations, and conditions and used records to ensure all documentation was in date.

During our inspection (Published 27 February 2023), we found a breach of our regulations because the provider had failed to ensure service users' risk assessments and risk management plans were effective to mitigate risks. At this inspection we found that improvements had been made, and the provider was no longer in breach of this regulation.

Staff worked well with people to fully understand and manage identified risks by thinking holistically. Staff provided care that met people’s needs and was safe, supportive and enabled them to do the things that mattered to them. Staff followed care plans and risk assessments where people were assessed at risk of harm. A staff member told us they followed people’s care plans where they were at high risk of falls, they stressed the importance of these people being always supervised.

People were involved in assessing the risks to their wellbeing and measures were put in place to reduce risks. Care plans were developed following assessment to mitigate identified risks. For example, risk of falls, wound care and nutrition and hydration. Regular reviews of risk assessments and care plans were completed to ensure they remained reflective of people’s needs. Care plans and risk assessments were clear and accessible which supported staff to help keep people safe.

The design of the premises met people's needs. People had their own bedrooms which they personalised with furniture and belongings. We saw appropriate signage to aid people’s orientation such as lounge, bathrooms and toilets. We saw memory boxes outside of people’s bedrooms and soft seating areas for people to relax. People had equipment they needed to help keep them safe, such as hoists, wheelchairs, walking aids, and bath and shower equipment. There were gardens at the service with suitable furniture that people could enjoy in warm weather. We noted that some areas of the service needed redecorating. The manager showed us a plan and told us that refurbishment had already begun in the lounge and corridors of one of the units. Next steps included redecorating communal wet rooms, dining rooms and people’s bedrooms.

Regular audits and checks were in place that covered health and safety, infection control and moving and hoisting equipment. Checks were carried out on portable appliances, gas safety, the call bell system, water temperatures, window restrictors and pressure mattresses. The fire alarm system and fire equipment was checked, and regular fire drills were carried out to make sure people could evacuate the service in an emergency.

There were no restrictions placed on visitors, and we observed relatives, friends and people visiting the service freely throughout our assessment.

We carried out a focussed inspection of the service (published 23 January 2025.) That inspection was carried out because we received concerns about staffing levels at the service. The inspection looked at safe and effective staffing only.

At this inspection we observed there were enough staff deployed throughout the service to meet people’s needs when required. The manager showed us a staffing rota and a tool they used to determine staff levels and told us staffing levels were arranged according to the needs of the people using the service. A staff member told us, “We have enough staff. Some units have more people with higher needs, and it would be good to have more on those units. But the staff ratio is okay.” Another staff member said, “We have enough now, but we didn’t before.”

Robust recruitment procedures were in place. Recruitment records included proof of identification, application forms with employment histories, employment references, occupational health and right to work in the UK checks. Nursing staff’s National Midwifery Pin numbers were also sought and recorded. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out.DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

We saw a training matrix which indicated that staff had completed training in areas such as fire safety, infection control, food hygiene, moving and handling, falls prevention, safeguarding adults, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Nursing staff had also completed training on for example catheterisation, diabetes awareness, skin care, venepuncture and medicines management. Records showed that staff received regular formal supervision sessions with their line managers.

There were systems in place to help prevent and control infections. We observed that the service looked clean throughout. We observed a member of the housekeeping team cleaning on each floor of the service. We noted some malodours around the service in the morning however later in the day and the malodour had gone. The home manager explained the reason for the malodours and told us they were looking at options to reduce this occurrence. The regional support manager told us the service had been working with the local authority’s continence team to make sure people’s needs were met. Nurses and the managers carried out routine spot checks throughout the day to ensure people were clean, comfortable, and wearing appropriate continence products.

We spoke with the infection prevention and control (IPC) lead. They showed us a cleaning schedule used by housekeeping staff throughout the home. They also showed us the last IPC audit, this was comprehensive and covered areas such as for example, adherence to the cleaning schedule, the use of correct disposal of bags, observation of staff using PPE, handwashing, soap and paper towel availability, sharps disposal and many other areas. Where shortfalls were identified, an action plan was developed with a date for compliance. Staff were provided with personal protective equipment (PPE) when needed. We saw they wore this appropriately. Training records confirmed that all staff had received training on infection control.

During our inspection (Published 27 February 2023), we found a breach of our regulations because the provider had failed to ensure medicine management systems were robust. At this inspection we found that improvements had been made, and the provider was no longer in breach of this regulation.

People’s medicines were managed safely. People received their medicines safely and as prescribed. Medicines were stored securely in locked cabinets and medication trolleys within the home. Medication Administration Records (MARs) were completed accurately, with clear signatures and codes for non-administration where appropriate. Regular audits of medication practices were carried out by the management team. Where issues were identified, action plans were put in place and followed up to completion. All staff responsible for administering medicines had received appropriate training, with competency checks completed annually.