The Manor House Roundhay

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.

There was a clear culture of learning and reflection within the service. Staff reviewed incidents and accidents promptly to understand what had happened, why it occurred, and how similar incidents could be prevented in the future. Records showed that all incidents were documented and investigated, with outcomes discussed in team meetings and, where appropriate, shared with relevant health professionals. Themes and trends were monitored on an ongoing basis to identify patterns and reduce risks. For example, falls data was reviewed regularly, and if an increase in falls was noted at particular times of day, staffing levels were adjusted to provide additional support during those periods. Staff told us that learning from incidents was routinely shared within the team. This helped to strengthen consistent practice and promote a proactive approach to managing risk.

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.

Comprehensive pre-admission assessments were carried out, including input from relevant healthcare professionals involved in people’s care, such as social workers and the community mental health team. These assessments were detailed and considered whether the service could meet each person’s needs and whether they would be a suitable fit for the service. There were strong working relationships with partner organisations to support continuity of safe care and smooth transitions. Referrals to healthcare professionals were made promptly when required.

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. Staff demonstrated a clear understanding of safeguarding principles and were confident in how to recognise and report concerns about abuse within the service.

People and relatives also told us that people were safe and well cared for. Comments included, “I trust them one hundred per cent.” Safeguarding referrals were made to the local authority when required, and notifications were submitted to The CQC appropriately. People can only be deprived of their liberty to receive care and treatment with the appropriate legal authority. In care homes, this is completed through the Deprivation of Liberty Safeguards (DoLS), which form part of the Mental Capacity Act 2005 (MCA). We reviewed how the service applied the principles of the MCA and managed DoLS authorisations. We found that appropriate processes and procedures were followed to ensure people were not unlawfully deprived of their liberty.

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. People and those important to them, including health and social care professionals, told us they were fully involved in planning how risks were managed to keep people safe. One person explained, “They [name] got the care plan in place yesterday and went over everything with me,” showing they had meaningful input into decisions about their care.

Risk assessments were tailored to each person’s needs, ensuring strategies reflected their preferences, routines and circumstances. These were reviewed regularly and updated promptly when needs changed, supporting safety while promoting independence and dignity. Professionals also confirmed that staff followed agreed procedures and communicated effectively to maintain consistent risk management. People with specific health conditions received well planned support that helped reduce the risk of avoidable harm. Risk assessments supported independence as well as safety, and people who wished to move freely around the home were encouraged to do so.

Staff followed clear guidance and implemented appropriate measures that balanced risk with personal choice. Individual care plans provided detailed instruction for staff, helping ensure people’s needs were met safely, consistently and in ways that respected their preferences. The service also supported people living with dementia, and staff demonstrated an understanding that people may sometimes experience distress. Their approach helped ensure people received thoughtful, sensitive support that maintained dignity and choice.

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 environment was safe, well maintained, and adapted to meet people’s individual needs. Regular environmental risk assessments were completed, and any actions identified were recorded, monitored, and reviewed to ensure the premises remained suitable and free from hazards. The provider had considered accessibility throughout the home, for example by providing outdoor space on upper floors so everyone could use these areas.

Health and safety documentation was up to date and demonstrated that required checks, for example, fire safety, equipment, and general maintenance were carried out as needed. The service used technology to enhance people’s safety and independence, such as thermal heat sensors to help reduce the risk of falls. Although the environment was decorated to a high standard and felt homely, further improvements could be made to ensure it is fully dementia friendly.

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.

Staffing levels were appropriate to meet people’s needs, and this was reflected in the rota information we reviewed. Most people and relatives told us they felt there were enough staff on duty, with one person commenting, “I would say there are enough staff, put it this way, I can always find someone if I need them.”

Staff received appropriate training for their roles, and the provider ensured staff stayed up to date with training. Recruitment processes were safe, and staff had received suitable training to carry out their roles effectively.

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 service maintained a high standard of cleanliness and infection prevention throughout the building. People lived in a clean, comfortable, and well presented environment that was free from odours and clutter.

Records showed the provider had effective systems in place to monitor and manage infection prevention and control. Regular environmental checks and cleaning audits were completed, and any issues identified were promptly addressed. Staff understood their responsibilities for maintaining hygiene and safety, and cleaning schedules were followed consistently.

All staff had completed infection prevention and control training, with refresher sessions provided to maintain ongoing awareness. Staff told us they had the equipment and knowledge needed to prevent infection and reduce risks.

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.

Medicines were managed safely, and people received their medicines as prescribed. Medicines Administration Records (MARs) were completed accurately and showed that staff followed appropriate procedures. Clear protocols were in place to guide the safe administration of medicines given on an ‘as -required’ basis, helping to ensure these were used appropriately.

Although we found that some prescribed creams were not being stored securely, the manager took prompt action to address this during the assessment. This was an isolated issue and did not impact the overall safe management of medicines.

Routine medicine audits were completed and helped maintain safe practice. Staff had received appropriate training in medicines management, and they told us they felt confident in their roles. The registered manager demonstrated good oversight of medicines safety, including ensuring staff received refresher training and competency assessments to maintain their skills and knowledge.