Manordene

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed, the cleanliness of the service, staffing levels, staff not being appropriately trained and supervised, people not being protected from abuse, the poor maintenance of the service and lack of robust recruitment practices.

This service scored 25 (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 did not have a proactive and positive culture of safety based on openness and honesty. Lessons were not learnt to continually identify and embed good practice.

One relative told us they were not always made aware when an incident occurred with their family member whilst others we spoke with told us they were made aware. We found incidents of distress were not completed in detail. There was a lack of information on what preceded the incident and how staff supported the person. Staff were also not always following the guidance around people’s distressed behaviour. Leaders were not considering this when they were reviewing these incidents. There was also no evidence that debriefs were taking place to understand and learn from incidents. The registered manager told us they did not undertake an analysis of all incidents to look for themes and trends. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

There were 2 people that had recently been admitted to the service. However, leaders failed to ensure they had sufficient information around 1 person’s needs before they moved in. Both assessments had been undertaken over the telephone by the registered manager. One person’s pre-assessment contained minimal information around the person’s health needs. The other person’s pre-assessment was more detailed and determined the person required 2 staff for all their personal care needs. However, there was a lack of consideration by the provider and registered manager whether they had sufficient staff at the service before the person moved in. Both people have since moved out of the service as their needs were not being met in a safe way. One external professional told us, “(Person) had been there for just over a week. The family had been contacting the home regarding their concerns, and no action was being taken.”

Staff told us they were not given sufficient information around people’s needs before they moved in. One told us, “They (assessment plans) say that they're mobile when they come to us, they're not mobile. There's no way they're mobile. You have to work it out for yourself. I don't always believe everything that's on these assessments.” The registered manager who undertook assessments of people told us of 1 person whose needs they were not able to meet, “(Person) was able to mobilise, (person) did not need a hoist and was able to weight bare and transfer.” However, the pre-assessment they completed stated they needed 2 staff to assist them to mobilise. Had they visited the person rather than undertaken the assessment over the telephone, they would have had more accurate information. Not undertaking a detailed pre-assessment meant staff were unable to provide the necessary specialised care, resulting in the person not receiving the right support. The registered manager went on to say, “Most times when we do the assessment, when the residents come it’s the complete opposite."

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

There was a mixed response from people’s representatives around whether they felt their loved ones were safe at the home. Alleged safeguarding incidents were not investigated appropriately or reported to the local authority. We saw from wound care reports there were incidents of unexplained bruising and injuries to people who were unable to verbally communicate due to their cognitive decline how this happened. One member of staff told us, “Everyone has thin skin and bruises easily, so I would not automatically think it was a safeguarding. I would report to the manager, and they could carry out an investigation.” However, leaders had not undertaken a detailed investigation to determined how this occurred. These had also not been reported to the local authority safeguarding team. This was despite the registered manager telling us, “Unexplained bruises should definitely be reported. Any unexplained bruising I will have to raise a safeguarding, and they are aware of that.” However, we found this was not taking place.

We found people were being unlawfully restrained. There was a blanket approach to people having bed rails regardless of whether they had a history of falling out of bed. There were also 4 people that were placed in ‘bucket’ chairs that were slightly tipped back with tables placed in front them. There was no evidence these chairs were required for any of these people. One representative of a person told us, “(Person) was sitting in that (the bucket chair) the whole time we have been there, she is pushed up from the table. She is not moving from there.” Bucket chairs can be considered a restraint if it is used to restrict a person’s freedom of movement or prevent them from rising.

The majority of the remainder of people also had tables placed in front of them preventing any of them from being able to mobilise independently. One member of staff told us they felt this was restricting people. They said, “If the table is put so that it's gone between the leg of the chair, absolutely, it should only be in front of them so they can push it away. I don't agree with sliding it across them as a restraint.”

We found 1 person was routinely being given ‘as and when’ sedative medicine with no evidence this was required when it was being given. This indicated the person was given the medicine solely to control their behaviour instead of managing the person’s distressed behaviour. These actions taken to restrict people were potentially undertaken for staff convenience rather than the person’s safety, potentially constituting abuse.

Where safeguarding concerns had been raised to the registered manager, they were unable to provide any evidence of the investigations that had taken place. They were unable to evidence any actions they had taken to mitigate further risks to people. In addition to this, we saw from the training matrix that out of 23 staff, 15 had not received safeguarding training. This meant staff may be unable to recognise warning signs of abuse, respond appropriately to emergencies, or report concerns, leading to institutional abuse and significant harm.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We identified people’s risk associated with their clinical risks were not being managed in a safe way. For example, there were people with diabetes who required their blood sugar levels monitored 4 times a day by the nurse staff. However, according to their medicine administration records (MAR), more frequently than not, this was only happening once a day. Where 1 person required to have their catheter flushed through by the nurses every other day to reduce the risk of blockage As there had been a history of this, according to their MAR, the nurse was at times was leaving it 2 days before flushing the person’s catheter. This placed the person at risk of their catheter blocking.

Other risks associated with people’s care was not being managed well including (but not limited to) the risk of dehydration, pressure sores and distressed behaviours. Where people required to have their fluid intake monitored, we found frequently people were not reaching the target amounts set by staff. There was a lack of oversight of this by the leadership team and no evidence of actions taken to address this. There were people at risk of developing pressure sores and had pressure mattress machines. However, we found people’s machines were not set to the correct weight of the person. This meant this reduced the effectiveness of the mattresses placing people at risk of pressure sores as staff were not checking they were set correctly. Where care plans stated people were unable to use call bells, there were no risk assessments or guidance in place for staff on how to manage this or how people were able to alert staff if they needed help.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The ‘bucket’ chairs that 4 people were sat on had been donated to the service by families of previous residents. While the design aims to fit the average person's general shape and needs for comfort, the lack of adjustability of the chair meant there was a risk they were not suitable for those people. There had been no action taken by leaders to ensure these were suitable for these people.

We found furnishings and fittings were degraded included heavily chipped and splintered bed frames, wooden tables and wooden arms of chairs. There was a risk this would cause splinters and skin damage to people.

The registered manager told us there was no daily checks of the environment as the maintenance staff only worked 2 days a week at the service. The registered manager told us they nor the maintenance staff regularly recorded any daily checks of the environment. They just relied upon staff writing up issues in the maintenance book. We found there were scissors left on the bathroom windowsill on one person’s room. There was a rusted radiator in another person’s room. In another person’s room, there was a notice on the wall stating the person required an electric radiator in there as the heating was not working in that room. There was no risk assessment undertaken in relation to the use of this radiator. There was a rusted toilet frame in 1 person’s room. The registered manager told us staff were required to complete water temperature checks prior to people having a shower. However, staff had only completed this 9 times since March 2025. In addition, there was no guidance on the sheet to indicate what the safe temperature should be.

People were placed at risk in the event of a fire at the service. There had been a fire safety check by Kent Fire and Rescue (KFaR) in August 2025 where concerns had been identified. However, the registered manager could not locate the notes they had made as result of their visit (whilst waiting for the formal report FKaR). In addition to this, of the 23 staff working at the service, 10 had not completed ‘fire evacuation’ training and 4 staff had not completed this since 2019 and 2021. Six staff had not completed ‘fire safety’ training. Staff need fire safety training because it is a legal requirement, crucial for the safety of vulnerable residents, and essential for effective emergency response. The leaders had failed to ensure this was undertaken.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People and relatives did not feel there was always enough staff. One person told us, “There are not enough staff, when I use the call bell, they don’t come quickly.” We found there were not sufficient numbers of staff deployed to ensure safe care. The registered manager told us that 4 carers and 1 nurse were required during the day for 19 people. However, 17 people had high needs and required 2 staff with all moving and handling (including repositioning) and personal care. We observed during the inspection; there were people being cared for in bed on the 1st floor most of whom could not use a call bell. For the majority of the morning, there were no staff present on this floor. One member of staff told us, “Sometimes there are not enough carers, people are calling out (on the 1st floor) and no one is around.” Other staff told us there were not enough staff during the day. One told us of the morning routine, “We should have 1 staff member in the lounge and 1 upstairs, but what happens is we bring people to the lounge who we know won’t get up and we only bring the people who are mobile into the lounge last when staff are then present. We don’t have staff in the lounge the whole morning.” Another member of staff told us the impact of this can be, “I think (another resident that sits in the lounge) feels responsible when we're not there and she sees one of them shuffling to the edge of their seat. I will hear her shout out to the person to sit back.”

An external professional told us, “Only 1 nurse on shift and a lot of people with high needs, people’s pain not being managed.” We found people were only being offered a shower once each week. Staff told us this because there were insufficient staff to be able to offer this to people every day. This was confirmed by a shower rota that was posted at the nurses’ station. During lunch the majority of people required support with their lunch however due to low staff levels, this meant that some people were waiting a long period of time before their lunch was served.

At night, staff levels were reduced to 2 carers and 1 nurse. multiple people required repositioning every 2 hours. However, we saw from the repositioning records that only 1 staff was recording they had repositioned a person. There were also periods during the night where people were being left more than 2 hours before they were repositioned. As noted in this report, we identified concerns where nurses had not flushed a person’s catheter as often as needed or tested people’s blood sugar levels. A member of staff told us, “Some days we do not have enough (staff). We could do with an extra person (staff). Things get missed. Dressings will need to be done by night staff.” The registered manager told us, “I don’t use a dependency tool to determine staff levels.” In addition, the registered manager told us that staff would not work more than 3 night shifts in a row. However, we noted that 1 member of staff was rostered to work 4 and 5 days consecutively for August 2025. This risked the member of staff being fatigued and placed people at risk.

There were significant gaps showing on the staff training records including clinical training for nurses where the registered manager told us they were unable to confirm the training had been delivered. Examples of this included out of 23 staff, 21 had not received training in ‘Behaviours that Challenge’, Nutrition and Hydration or Diabetes and the remaining 2 staff’s training was out of date. 18 staff not received mental health training, 17 staff had not received dementia care training or ‘Duty of care/dignity, choice and diversity’ training. Of the clinical training for nurses, according to the matrix, no nurses had received Syringe Driver training, there was no ‘venepuncture’ (blood taking) training on the matrix despite care records showing nurses took peoples bloods. Only 1 member of nursing staff had received tissue viability training and only 2 nurses had completed end of life care training although this was not dated.

According to the providers supervision matrix, no ancillary staff had received any 1-1 supervisions with their manager. One member of ancillary staff told us they could not recall receiving a supervision for the last 3 years. According to the providers supervision policy, all staff were required to have 6 supervisions each year. However, according to the matrix, 5 staff had only had 1 supervision this year and the remaining had only had 2 supervisions. In addition to this, the registered manager told us they had not completed any clinical supervisions with the nurses. One member of staff told us of clinical supervisions, “I would find that helpful.” Regular supervision helps ensure staff are competent and confident in their roles, meeting the standards required for their practice. Leaders failed to ensure this, and we identified multiple areas of poor staff competence as noted throughout this report.

The provider did not operate effective and safe recruitment practices when employing new staff. Of the 5 staff files we checked, 3 did not have a full employment history all 5 contained no references for the staff. This meant the provider could not be assured of the staff’s suitability to work at the service. The registered manager told us, “(Administration staff) and I have gone through all the files and know what is missing and we are working on this.” However, when we asked the registered manager for the list of documents they believed were missing, they could not locate this.

The provider did not assess or manage the risk of infection.

We received feedback from people and relatives that the cleanliness of the home was not good. One representative of a person told us, “I already made a complaint, they had a rubber thing that goes over the side (of the bed rail), all down the side was specs of dry faeces. Then I noticed that at the bottom of the bed was a call bell covered in dry blood.” Another told us, “Sometimes it needs a hoover, their room could do with a paint which I have asked for, I have tried to clean it, but it won’t come off.”

The sluice room sink and shelf (where cleaned items were kept) was dirty. There was a urine bottle on the shelf that was stained and smelled strongly of urine. The laundry room was also not set up to ensure good infection control practices. There was no sink in there for staff to wash their hands. There was a large amount of unwashed laundry in the room and there were no counter tops for staff to be able to sort and separate clean and dirty laundry. The registered manager told us they only had 1 housekeeper per day, and they were responsible for washing people’s clothing and also cleaning the home. However, their shift ended at 14.00 each day. One member of staff told us, “There are not enough (housekeeping) staff, they have to do the laundry as well, it’s too much, we need 2 housekeepers.”

We found the environment was not cleaned effectively. People’s bathrooms and bedrooms were not clean including the carpets and flooring. We observed people’s packs of continence aids had been opened and left on dirty bathroom floors. People’s bedrail bumpers were torn, degraded and 2 had faeces stains on them. The arms of lounge chairs were heavily stained and the fabric on the ‘bucket’ chairs was torn. Torn materials cannot be adequately cleaned, and they allow the entry of microorganisms. One member of staff said, “Cleanliness in the home is an issue. In my eyes, I would like to go room by room and just give these rooms a good clean. The cleanliness here has really gone downhill. It's an infection control (issue). Right across the board.” We saw from the training matrix 7 staff had not received infection control training. This placed people at risk of getting infections.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There was no ‘as and when’ (PRN) guidance for staff on when to administer PRN medicines including pain relief, seizure medicine, constipation medicine and medicine for agitation. This is particularly important given most people had advanced dementia and may not be able to articulate when they were in pain. The registered manager told us that PRN was not in place for medicines but had not addressed this. This meant there was a risk people were not always receiving their medicines when needed.

Where people were prescribed topical medicines (prescribed medicated cream) there was no indication on the Medicine Administration Record (MAR) of where the location of the cream needed to be applied. Where people required eye drops there was no information on which or both eyes required the medicine. Staff were also not recording where they had applied a person’s transdermal patch to reduce any risk of skin irritation (if applied to the same area of the body). It is crucial to have clear instructions, body maps, and proper documentation to ensure safe and effective application of medicines and administration of eye drops.

The medicine room was untidy, disorganised and dirty. There was a spillage of liquid over the medicine returns box which had not been cleaned up. We also found the returns box was overflowing. Prescribed topical creams had been left in people’s bathrooms and not securely locked away. One person’s prescribed medicine spray had been left in another person’s bathroom.

We found there were days where the MAR recorded the person’s medicine was out of stock. A member of staff told us the pharmacy was not always reliable with the delivery of the new stock of medicines. However, there was no record of what actions staff had taken when the person had missed their medicine or whether this had impacted them. This placed people at risk of not receiving their medicines where required. In addition, we found that MARs had no information on how each person preferred to take their medicine.

Where a person’s prescription dosage had changed mid cycle, only 1 nurse was signing to confirm the accuracy of this change. We noted from 1 person’s MAR they had been given the incorrect previous dosage of their medicine on 2 occasions. We saw from the training matrix, of the 7 nurses, 4 had completed both parts of the training related to the electronic MAR system and 2 had not completed any of this training. The registered manager also confirmed that no nurses had been competency assessed to administer medicine. They said, “I haven’t started them as yet, they haven’t had any since I have been here.”