Background to this inspection
Updated
6 October 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 17 August 2018 and was unannounced. The inspection was completed by two inspectors. This was the home’s first inspection since their registration with us in July 2017.
We checked the information we held about the service and the provider. This included notifications that the provider had sent to us about incidents at the service and information that we had received from the public. We used this information to formulate our inspection plan.
We also used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.
We spoke with three people who used the service and two relatives. Some people were unable to tell us their experience of their life in the home, so we observed how the staff interacted with them in communal areas.
We also spoke with two members of care staff, the cook and the manager. The regional manager was present when feedback about the inspection was provided.
We looked at the care records for three people to see if they were accurate and up to date. In addition, we looked at audits completed by the home in relation to falls, incidents and infection control. We also looked at minutes for meetings, feedback events and the providers action plan.
Updated
6 October 2018
The inspection took place on 17 August 2018 and was unannounced.
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. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is situated near local amenities. It has two floors and both have bedrooms and communal spaces, however at the time of our inspection only the downstairs communal spaces were in use. There was a secure outside area.
The service is registered to provide accommodation for up to 25 people. At the time of our inspection eight people were using the service.
Manor House had not got a registered manager, however, there was a manager in post who had been in post three months. They had commenced the process to become registered. 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 not always sufficient staff to meet people’s needs. Complaints were not always addressed in line with the providers policy. The governance systems in place to support the development of quality and improvement were not always robust. Audits had not always been completed to reflect on trends and support changes. People’s views had not always been considered.
People had not always been given the opportunity to follow any interests or activities. Care plans did not always reflect all the needs people may have to enable the care they required.
The environment did not always support people’s needs or provide clear signage to support people living with dementia to find their way around the home. Safe medicines systems were not in place to support medicine management in line with current guidance. When risk assessments had been completed they did not always reflect how risks could be reduced to maintain people’s safety. Measures were not always in place to reduce the risk of infections.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, however the policies and systems in the service did not support this practice. We have made a recommendation in relation to following the guidance in relation to the Mental Capacity Act.
Staff felt supported by the manager. People enjoyed the meals and referrals had been made to health care professionals to support people’s health needs and wellbeing.
People received care from staff who had established positive relationships and staff knew how to protect people from harm. However, systems in place did not always ensure staff had the time to provide people with the level of care they needed. Individuals independence was encouraged, when possible. People’s dignity had been considered, however staff time restrictions had an impact on people’s choices.
We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.