The Manor House Residential 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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from 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 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 told us they investigated all incidents and accidents at the home. Once reviewed additional measures were put in place as a way of preventing reoccurrence. Learning was embedded in the home. For example, after a person had a fall, the team reviewed their care needs. Additional equipment was provided, and the GP reviewed their medicines. Changes to their needs were recorded in their care plan for all staff to follow.

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. People moving into the home had an assessment carried out of their needs. The team working in the home knew people well. Admissions and transitions were managed well within the home.

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 told us they felt safe, one person said, “I’m newish, I haven’t had a Christmas here yet, very safe, they are always there, there is always somebody around, they are normal people.”

Staff were able to explain how to protect people from abuse. Staff understood the importance of documenting and reporting their concerns. The registered managerany safeguarding concerns and notified the Care Quality Commission and the local authority in a timely manner.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that where people needed to be deprived of their liberty to keep them safe, the provider ensured a DoLS authorisation had been made, this meant people’s rights were fully respected.

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 documents outlined risks of harm and how to mitigate them. Staff were able to explain how to prevent risks of harm to people. For example, when supporting people in the bathroom, staff told us they checked equipment was working and the area was free from hazards. Equipment was available to prevent people from coming to harm for example, sensor mats were in people’s bedrooms. This meant staff were alerted to people moving around and offered support if needed. During our visit we saw people were prompted to use their walking aids and wheelchairs when moving around the home. Staff followed all guidance in care plans when supporting people in the home.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The home was free from hazards. However, some parts of the home needed updating. The registered manager told us they had a service improvement plan which included redecoration of some parts of the home. Risk assessments for the environment were up to date, and measures were in place to mitigate risks. For example, fire equipment was checked and serviced in line with best practice. Health and safety checks and audits were carried out regularly. Any issues or concerns were addressed without delay.

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. During our visit we observed there was enough staff on duty to meet people’s needs. Staff told us they were well trained and supported to carry out their role effectively. Supervisions and appraisals were carried out regularly. Staff could seek advice and guidance at any time. Recruitment checks were completed, including obtaining previous references for staff. Staff completed a through induction into the service and shadowed experienced staff before being left to work unsupervised.

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 registered manager carried out regular audits on infection, prevention and control. People were protected from the spread of infections as staff had training in this area. During our visit we observed staff wearing personal protective equipment such as gloves and aprons when required. People told us the home was clean, one person said, “They have a very good person who looks after the cleanliness, I’ve no criticism to make.” The home was clean and tidy. Cleaning schedules were complete, and all areas of the home were cleaned regularly.

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 told us they were given their medicines on time, one person said, “I know what I’m taking. If I want a laxative I ask.” Audits of medicines were done regularly which meant any errors or concerns would be picked up and addressed quickly. All medicine documentation was accurate and up to date. Medicines were stored correctly and there was a clear disposal process. We observed staff administering medicines during our visit. Medicines were administered safely.