Manor House

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. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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. Accidents and incidents were analysed and trends and patterns identified to mitigate future risks. The provider had an accident reporting flow chart in place which guided staff on the correct action to take in the event of an accident. Lessons were learnt to improve practice.

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. Hospital passports were in place to support people when they needed to access hospital care and support. People’s care plans included personal emergency evacuation plans (PEEPS) to ensure people were supported safely in an emergency. These plans were detailed and gave clear instructions to minimise disruption.

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 were knowledgeable about recognising and responding to safeguarding concerns and were passionate about keeping people safe. The service engaged well with community to ensure people were protected. The provider liaised with community locations such as the local bingo hall to ensure people’s risk assessments were adhere to. This ensured people were not financially violated. One staff member said, “If suspected abuse occurred, I would report straight away to my manager and I am confident management would take this seriously and if they didn't I would contact safeguarding.”

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. Risks associated with people’s care and support were identified and managed to keep people safe. Freedoms were not limited, and staff supported people in their choices. People told us they felt safe living at the home. One relative said, “[Family member] is in a very safe place and [family member] is very calm and settled. [Family member] goes into the garden, and they ensure [family member] wears a hat to protect them from the sun. The garden has gates to prevent [family member] wandering.” Staff knew how to minimise risks. One staff member said, “I manage risks by identifying potential hazards conduct risk assessments and keep up to date reading care plans.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Although environmental risk assessments had been carried out throughout the home, some areas of concern were noted as part of this assessment. Radiators were not covered to prevent the risk of burns from a hot surface. Due to the warm weather, radiators were not on and therefore did not pose an immediate risk. We found 2 windows without window restrictors in place presenting a hazard of windows opening too wide. We raised these concerns with the provider who took appropriate actions to address them and minimise the hazards. The window restrictors were immediately addressed and a timely action plan for the instillation of radiator covers was in place. The registered manager completed risk assessments to minimise the risk of harm.

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. There were sufficient staff available to support people in the home and out in the community. People had access to dedicated 1 to 1 hours and used these hours to partake in social outings. The provider had a recruitment policy in place and pre-employment checks were in place to ensure suitable staff were recruited. Staff received training and support to carry out their roles effectively. One member of staff told us, "I look forward to coming to work. I enjoy working here."

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 was predominantly clean, however, some areas of the home required attention. For example, some carpet grippers between room entrances were missing and creating a worn and unclean area and 2 fridge seals were broken and dirty. We raised these issues with the registered manager who took action to address them.

The provider made sure that medicines and treatments were predominantly safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. However, medication amounts in stock were not always carried over on to the medication administration records (MAR). This made it difficult to ascertain if some medicines were given as prescribed. The registered manager took action to address this.

Where people were prescribed medicines on an ‘as and when’ required basis, protocols were in place to ensure safe administration.