The Manor

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 requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 59 (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 always have a proactive and positive culture of safety based on honesty and openness. They did not always manage safety events effectively and lessons were not always learnt to continually identify and embed good practice.

Leaders did not consistently learn from incidents or take appropriate action to reduce future risks. Records showed that where accidents, such as falls took place, improvements had been made, and learning had been shared with staff. For example, when a person had slipped while having a shower, staff had been advised to put a towel on the shower chair foot bar to reduce the risk of this happening again.

However, the provider’s approach to learning from incidents was not consistent. When a person had left the service unnoticed, effective measures, such as ensuring external doors were locked and securing the grounds, were not actioned to prevent this from happening again. The person left the service on two further occasions, highlighting the lack of consistent, effective learning processes at the service.

No complaints had been received by the service. Relatives told us any minor concerns they had were addressed when raised.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

Staff provided people with care which reflected their needs, risks and preferences. When people needed specialist support to manage their health-related risks, referrals were made to community healthcare agencies for additional support. The provider had processes to share important information about people’s needs and risks with ambulance and hospital staff when people attended hospital.

Community professionals who visited regularly were positive about the service. They told us staff were proactive in raising concerns and seeking advice and they followed any advice given.

The provider did not always work well with people and partners to understand what being safe meant to them and how to achieve that.

The provider did not always demonstrate an effective safeguarding culture. Staff had completed safeguarding training and the staff we spoke with understood the action to take if they suspected abuse was taking place. However, while leaders had investigated and reported safeguarding incidents, they had not always taken effective action to protect people from the risk of abuse or neglect. For example, when a person who lacked the capacity to keep them-self safe left the service unsupported, despite the clear safeguarding implications, effective action was not taken to safeguard the person and reduce the risk of this happening again.

Staff supported people in line with the Mental Capacity Act 2005. People’s capacity to make decisions about their care was assessed and when people lacked the capacity to make such decisions, their family members were involved in making decisions in their best interests. When people were being deprived of their liberty to keep them safe, management had made the necessary applications for authorisation to do this in line with the Deprivation of Liberty Safeguards (DoLS). When authorisations to deprive people of their liberty were conditional, records showed those conditions were being met.

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

The provider had not always completed risk assessments where risks to people’s health and safety were present. For example, the front and back garden areas were not secure, which meant people who may not be able to protect themselves from potential hazards, could leave the service grounds unsupported. Risk assessments had not been completed to identify and address these risks. One person had left the grounds on three occasions. The person’s care plan and risk assessments noted they may try to leave the service unsupported, which was unsafe, and stressed the importance of preventative measures, such as ensuring internal doors were locked and accompanying the person in the garden. However, we found a door to the back garden propped open on two occasions, meaning people could access the garden area unsupported.

Similarly, access to the kitchen area, which was on the same corridor as several people’s rooms, was not restricted. This exposed people who lacked the capacity to keep themselves safe, to the risk of injury from hot surfaces or items such as sharp utensils. This risk had not been identified or assessed. We observed the kitchen door open, with no staff member present and a large saucepan of boiling food on the hob.

Records showed and community professionals and relatives told us that when people needed specialist support to manage risks to their health, this was arranged.

The provider did not detect and control potential risks in the care environment. They did not make sure the premises and facilities supported the delivery of safe care.

We found several issues relating to the safety of the home environment. Access to the kitchen was not restricted, which posed a scalding risk. Access to the back garden, which was not secure, was not always restricted and a fire exit was not secure or effectively alarmed. This meant people could leave the grounds unnoticed and unsupported. In addition, furniture had not been made safe, posing a risk of falls or injury.

Water and fire safety had not been managed effectively. A legionella risk assessment had not been completed to ensure people were protected from the risk of legionella, a bacteria found in water which can cause Legionnaires’ disease, a flu-like illness. An audit by Lincolnshire Fire and Rescue Service in September 2024 and an independent fire risk assessment completed in November 2024 had identified several fire safety deficiencies. At the time of our inspection, not all necessary improvements had been completed within the required timescales. This meant people were not always protected from the risk of avoidable harm.

Both the shower room and bathroom were out of use for 4 weeks during June and July 2025, a period of very warm weather. This impacted people’s cleanliness, choice, dignity and potentially their skin integrity. Some people and staff told us they had found this difficult.

We discussed our concerns about the safety of the environment with the registered manager, who made some improvements during the inspection.

The provider made sure there were enough qualified, skilled and experienced staff, to support people well and meet their needs.

The provider followed safe recruitment practices. Appropriate checks were completed before staff started working at the service to ensure they were suitable to support people living there.

People, relatives and most staff were happy with staffing levels and told us people received support when they needed it. A relative told us, “There are always enough staff on duty and that includes evenings and weekends.” During our inspection we observed that people received support when they needed it.

Staff received regular supervision and yearly appraisals and told us they felt well supported. A staff member told us, “We have a good staff team. We are nice to each other and work well together.”

The provider assessed and managed the risk of infection well. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We found the environment generally clean, and records showed management completed regular checks of cleanliness and infection prevention and control. We found some minor issues related to cleanliness, including the carpet on the main stairs and landing being stained and damp towels being left in the hairdressing room. The registered manager addressed these issues during our inspection.

An infection prevention and control audit completed by the local authority in June 2025 had found the service fully compliant with required standards. Community professionals did not have any concerns about hygiene standards at the service. One commented, “The home is always clean. People are always clean and appropriately dressed.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff managed the storage, administration and recording of people’s medicines safely. Some minor improvements were needed to ensure processes fully reflected National Institute for Health and Care Excellence (NICE) guidance, including ensuring copies of people’s prescriptions were kept for reference.

We observed staff administering people’s medicines as and when they should. They sought people’s consent before administering their medicines and followed safe procedures.