Manor House Residential Home

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

At the last inspection, the provider was in breach of regulation 12 Safe care and treatment in relation the medicines management and regulation 13 Safeguarding people from abuse. At this assessment, the provider had made enough improvements and was no longer in breach of this regulation. We found further action was needed to rectify the bedroom fire doors which did not protect people in the event of a fire. People felt safe with the staff, the care provided and lived in a clean and tidy environment. There were enough trained and competency staff to meet people’s care needs and support them with their medicines.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People looked safe and comfortable in the environment. Staff supported people appropriately and we observed people interacting with staff and each other comfortably.

Protecting people from abuse was a priority at the service. There were effective systems, processes and practices to make sure people were protected from abuse. Staff received regular training updates and understood their role and responsibilities in line with the policy for safeguarding people from abuse. Information about what to do and who to contact in the event of suspected abuse was displayed in the reception area of the home. Policies and procedures in place supported staff to ensure people were protected from abuse. The registered manager had oversight of any safeguarding incidents which occurred and they worked collaboratively with the local authority. Mental capacity assessments were completed when required. Where people had been deprived of their liberty, it had been done lawfully and with appropriate authorisations.

Staff were trained in safeguarding procedures and felt confident to raise concerns if needed either internally or externally if no action was taken.

People told us they felt safe. People and their relatives had no concerns and were confident knew how to protect them from risk of abuse.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

There were improved arrangements to monitor the safety and upkeep of the premises and equipment. However, the fire safety checks were not effective and had not identified the concern we found.

People were cared for in safe, clean, and comfortable environment that was designed to meet their needs. Relatives told us their family member had access to the equipment they needed.

We found bedroom doors did not close fully to form a smoke seal to protect people in the event of a fire. One bedroom door had a broken door handle and only closed with force. Staff did not routinely check that bedroom doors closed fully. However, environmental improvements mitigated risks to people. For example wardrobes were secured to ensure they did not topple over. Equipment used to support people was safe and had been tested to ensure they work efficiently and safely. For example, moving and handling equipment and sensor mats.

In response to issues we found the registered manager took some action immediately to reduce risk to people until the maintenance team remedied the fire safety risk and updated the fire safety audit to include checks on bedroom fire doors. Staff told us they received regular training updates in topics related to fire, health and safety, and equipment used in the delivery of care. Staff knew how to report faults and repairs, and confirmed maintenance staff were prompt to remedy the issue.

People and their relatives told us there were sufficient staff to meet their needs. A relative told us, “I have no issues at all with [person’s] carers, they are warm, professional and very caring towards [person].”

Staff numbers were based on the needs of people and the promotion of their safety. Staffing levels were maintained and kept under review. Staff received training for their roles, their competency was checked and they received regular updates on current practice.

There was enough skilled staff to safely meet the needs of people. During the on-site assessment, we observed staff had the time to speak with people individually and took the time to listen and responded positively to their requests.

People were supported by staff who had the skills, knowledge and experience to deliver effective care and support. Feedback we received about the staff included ‘Employees are qualified, knowledgeable, and skilled to do their jobs in a way that enhances resident's quality of life’.

People lived in clean and hygienic environment. A relative told us “[Person] room is always well kept and clean too.” People were able to receive visitors without restrictions in line with best practice guidance.

There were cleaning schedules and audits in place and the registered manager had oversight of this hygiene and cleanliness.

Safe infection control procedures were followed. The home was clean and we observed staff used personal protective equipment in line with best practice guidance. People were able to receive visitors without restrictions.

Staff told us they had training in infection prevention and control which was updated regularly. They had access to sufficient supplies of personal protective equipment and knew when this should be used.

Staff training was kept up to date and their practice was checked regularly. We observed a staff member administered medicines correctly and safely. They followed the administration instructions and staff stayed with the person showing care and kindness to ensure all of the medicine had been consumed.

Medicines were stored securely and administration was in line with current best practice and professional guidance. Records were accurate and up to date. People’s medicines were reviewed to ensure they remained effective. The registered manager had oversight and monitored medicines were managed safely.

People received their medicines safely and as prescribed. Relatives had no concerns in relation to medicines management and told us staff followed the instructions given to them by healthcare professionals.