24 August 2022
During an inspection looking at part of the service
People’s experience of using this service and what we found
Improvements had been made to quality assurance systems at the service. However, quality assurance checks were not all effective and had not identified some issues identified in our inspection, such as gaps in risk management plans and concerns medicine was not always stored safely.
The provider was taking action to make required improvements to fire safety within the service, including improvements to the fire alarm and fire doors to make them safe.
We were mostly assured infection prevention controls were being followed.
People felt safe using the service. Staff understood how to recognise and report abuse. Staff recruitment processes included background checks to review their suitability to work with vulnerable adults.
People were generally positive about the food provided and told us they received a choice. However, some people’s specialist diets were not accurately recorded.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People spoke positively about the staff and the care they provided. Staff felt supported by the registered manager.
The registered manager was open and honest and worked in partnership with outside agencies. They were committed to making improvements to the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 25 May 2019) and there was a breach of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 15 April 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve their governance systems.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe, Effective and Well led, which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains Requires Improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Manor House on our website at www.cqc.org.uk.
We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this full report.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.