Archived: Manor House

Updated 25 May 2018

We carried out this comprehensive inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 site visit took place on 4 April 2018 and was unannounced. The inspection was carried out by an inspector and an expert by experience (ExE). An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

During the inspection we spoke with four people, two relatives, the registered manager, the provider, deputy manager, three care workers, two night care workers, the chef and a visiting community nurse. We looked at six people’s care records, and 20 people’s medicines administration records (MAR). We also reviewed five staff records and other records in connection with the management of the service including complaints records, health and safety information, and quality assurance systems. We carried out general observation of how staff provided care to people.

Updated 25 May 2018

Manor House is a care home for older people, some live with dementia. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is registered to accommodate up to 23 people. There were 20 people living at the home when we visited.

We inspected Manor House on 3 and 14 December 2015, we found two breaches of regulations relating to the management of risks to people’s health and safety and support and supervision for staff.

We then undertook a focused inspection on 17 May 2016 in relation to the breaches of regulation we identified at our previous inspection of December 2015. We found that the service had followed their action plan and had met our requirements. At this inspection on 4 April 2018 the service continued to meet standards and we have therefore rated the service as Good overall.

The service had a registered manager who had worked at the service for several years. 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.

At this inspection we found that people’s medicines were administered in a safe way. Records for the management of medicines were maintained and these were correctly completed. Medicines were stored in a locked trolley but the trolley was not secured to ensure it was not easily moved. We spoke to provider about this and they agreed to take immediate action to improve this.

People were protected from avoidable harm. Management plans provided guidance to staff to help them mitigate risks to people. The provider maintained health and safety systems, and carried out regular checks to ensure the environment continued to be safe. The service was clean. Staff were trained in infection control and knew how implement the procedures to reduce risks of infection and contamination. Staff reported incidents and concerns as they should. Records of incidents and accidents were maintained, and the registered manager reviewed them. Actions were put in place to reduce the likelihood of incidents repeating again.

Staff were trained on safeguarding adults from abuse. They understood signs of abuse and how to report it in order to protect people. There were sufficient staff available and well deployed to meet people’s needs. Recruitment checks were conducted before new staff were employed. Staff received training, support and supervision to carry out their duties effectively.

People’s needs were assessed and individualised care plans in place that sets out how people’s needs and requirements would be met. People and their relatives told us they were involved in planning and reviewing their care. Care plans were kept updated.

People’s nutritional needs and dietary requirements were met. Staff supported people to eat and drink enough. People had to access to healthcare services they needed to maintain good health. The provider had arrangements and systems in place to enable people receive consistent care when they moved between services and departments.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff obtained consent from people before they delivered care and support to them. The service complied with the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Relatives and healthcare professionals were involved in making decisions for people in their best interests where this was appropriate.

People told us that staff were kind and compassionate to them. Staff treated people with respect and dignity. Staff encouraged people’s independence and choices. Staff were trained in end-of-life care. People’s end-of-life wishes were noted in their care plans. People were engaged and occupied in activities they enjoyed. The service respected and supported people’s protected characteristics such as heir disabilities, culture and religion.

The service obtained the views of people and their relatives and used them to drive improvement. People told us they were listened to, and their views acted upon. People and relatives knew how to raise their concerns. The provider regularly checked and monitored the quality of service provided to people. The provider worked jointly with other organisations and services to deliver effective care to people.