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Inspection Summary

Overall summary & rating


Updated 18 January 2019

This inspection took place on 27 November 2018 and was unannounced.

The Manor House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation and care for up to 38 people and is part of Park Lane Healthcare. At the time of our inspection there were 26 people living at the home. The accommodation was on two floors with a passenger lift to connect all areas of the home.

At the time of the inspection there was a registered manager in post. The service is required to have a registered manager in post. A registered manager is a person who has registered with CQC 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 last inspection in February 2018 we found that care and treatment was not provided in a safe way. This related to the lack of robust actions to reduce risk and this was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to the overall oversight and governance of the service. Following that inspection, the provider sent us an action plan detailing the improvements they would make.

During this inspection we reviewed actions the provider told us they had taken to become compliant with the breaches identified in February 2018. We found that the necessary improvements had been made and the service was no longer in breach of regulation.

Medicines were managed safely and staff had a good knowledge of the medicine systems and procedures in place to support this. We found staff had been recruited safely and received regular supervision and appraisals. Staff told us they felt supported in their roles and trained to meet people’s needs. Some staff felt additional specialist training in dementia and behaviour would be beneficial and the provider was willing to arrange this.

Staff received training about safeguarding adults from abuse and understood their responsibilities in respect of protecting people from the risk of harm. Accidents and incidents were responded to appropriately and monitored by the management team. The service was clean and infection control measures were in place. People and relatives spoke positively about the clean and well-maintained environment.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. We made a recommendation in the last inspection report in relation to the application of MCA and the provider confirmed they will continue to work to this recommendation.

People’s nutrition and hydration needs were catered for. A choice of meals was offered and drinks and snacks were made readily available throughout the day.

There was a positive caring culture within the service and we observed people were treated with dignity and respect. People’s wider support needs were catered for through the provision of activities provided by activity coordinators, visiting entertainers and activities undertaken in the local community.

There was a complaints policy and procedure made available to people who received a service and their relatives. All complaints were acknowledged and responded to quickly and efficiently. The service sought feedback from people; feedback provided was positive.

There was a range of quality audits in place completed by the director. These were up-to-date and completed on a regular

Inspection areas



Updated 18 January 2019

The service was safe.

People told us they felt safe living at the service.

Medicines practices were safe and robust.

Risks of harm were assessed, managed and reduced through the use of risk assessments.

Staff knew about their responsibilities to safeguard people from harm and how to report suspected abuse.



Updated 18 January 2019

The service was effective.

Staff felt supported in their role despite gaps in supervisions and appraisals.

Some staff felt additional training would be beneficial to meet the needs of people.

People were positive about the food and were supported to eat and drink enough to maintain their health.

People had access to health care professionals when needed.



Updated 18 January 2019

The service was caring.

People and relatives felt that staff were kind and respectful.

People�s independence was promoted as much as possible and staff supported people to make decisions about the care they received.

People�s privacy and dignity was maintained.



Updated 18 January 2019

The service was responsive.

People had care plans in place that described their individual support needs and these were kept up to date.

A variety of activities were provided that met the wider needs of people.

There was a complaints policy and procedure in place, issues raised were rectified.



Updated 18 January 2019

The service was well-led.

The director had implemented governance systems for assessing and monitoring the quality of the service. These systems demonstrated improvements.

There was a registered manager in place. People and their relatives spoke highly about the registered manager.