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Mansion House Residential Home Good

Inspection Summary

Overall summary & rating


Updated 17 May 2018

On 3 February 2017 we inspected Mansion House Residential Home and found them to be in breach of three Regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breach of Regulation 12 was in relation to improvements needed to the safe administration of medicines; Regulation 17 not having sufficiently robust quality assurance audits and Regulation 19 staff were being recruited without the necessary employment checks in place.

We rated the service as ‘Requires improvement’ for the key questions of Safe and Well led and ‘Good’ in Effective, Caring and Responsive. We asked the provider to complete an action plan as to how they would improve the service. The provider wrote to us showing the actions they had taken since our last inspection.

We carried out this unannounced inspection on 10 April 2018 to see if the provider had made the necessary improvements to the service. We saw that improvements had been made to ensure people had their medicines in a safe and timely way and robust monitoring audits about the quality of the service and the recruitment of staff had been improved. All of the key questions were rated as ‘Good’ and the service received a rating of 'Good' overall.

Mansion House Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates up to 37 older people. Care is provided over two floors. At the time of our inspection there were 27 people living at the service. Mansion House Residential Home also provides a personal care service within the community called Mansion Care which provided care to five people with three staff supporting them.

A registered manager was in post at the service. 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.

There were systems in place to safeguard people from avoidable harm and staff knew how to report any concerns. The risk assessments undertaken provided staff with the necessary information and guidance on how risks to people could be minimised. The service regularly reviewed their staffing arrangements to ensure there were sufficient staff available to support people safely.

Recruitment procedures had been improved for the safe employment of staff. Improvements had also been made to the way in which medicines were managed and administered. Infection control procedures were followed in order to keep people safe and well. Systems were in place to learn from incidents and accidents and to improve the service as a result.

An organised programme of induction, training, supervision and appraisals for staff were in place. Staff had the knowledge and skills to care for people effectively. They understood their roles and responsibilities to seek people’s consent prior to care being provided.

People were supported to have a choice of food and drink and to have a balanced and varied diet. The registered manager and staff ensured access to healthcare services were readily available to people and worked with a range of health professionals to implement care and support plans.

The service had been adapted from a manor house into a care home. The design and decoration of the premises met people’s needs.

Systems were in place to ensure that people’s rights were respected and protected under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Where people did not have capacity to consent to their care or make decisions about their lives, this was managed in line with the requirements of the MCA.

Staff were respectfu

Inspection areas



Updated 17 May 2018

The service was safe.

Staff knew the correct procedures to follow if they thought someone was being harmed.

Risks were assessed so that staff knew how to keep people safe.

There was enough staff who had been recruited safely to meet people�s needs.

People were getting their medicines safely and as prescribed.

The premises were clean and well maintained and infection control procedures were in place.

Improvements are made from lessons learnt.



Updated 17 May 2018

The service was effective.

People�s needs were assessed in line with current guidance.

Staff were trained and supported and had the skills and knowledge to meet people�s needs.

People enjoyed the choice of food they were given and had their nutritional needs assessed and monitored.

Staff and professionals worked together well and people were supported to access health care professionals.

Systems were in place to ensure people�s rights to consent to their care were in place.



Updated 17 May 2018

The service was caring.

Staff treated people with respect, were attentive to their needs and respected people�s need for privacy.

People were encouraged to express their views and be as independent as possible.



Updated 17 May 2018

The service was responsive.

People received personalised care that met their needs and respected their preferences and wishes.

A complaints process was in place and people and their families knew how to use it.

People and their families were supported at the end of their life.



Updated 17 May 2018

The service was well led.

The registered manager provided visible leadership, effective management and was proactive and inclusive.

Systems were in place to monitor the quality of the service for people who used it and worked in it.

People were engaged and involved in developing the service. Staff were supported, motivated and enthusiastic in carrying out their role and responsibilities.

Resources and support were available to drive improvement.