Manley Court Care 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

During our assessment of this key question, we were not assured the provider had a robust system of assessing staffing levels according to the needs of the people receiving care. We also found issues with staffing levels during the hours of 8pm to 8am. You can find more details of our concerns in the evidence category findings below.

This service scored 50 (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.

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

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.

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

People had mixed views about staffing levels. One person told us, “I can get help, but they are busy so you have to be patient. I sometimes wait a long time, but it has never caused me a problem.” People and their relatives acknowledged that staff were busy and had limited time to chat with people. One relative told us, “There are enough staff on occasions, but there are occasions when there are not, it’s random. Some days there are lots of people calling out.” Despite this, people told us they were treated with dignity so were not too rushed when receiving care. Relatives did not visit at night so their view was of the daytime care provided, and the people we communicated with were able to tell us their views. Lots of the people who used the service were not able to tell us their views due to memory issues. Call bells were used by people who understood their use and were able to operate them. Call bell audits showed that the majority of delays occurred due to staff being busy providing care to other people. The provider asked people for feedback about staffing and staff availability during feedback surveys but they did not receive any negative feedback.

Prior to this assessment we received a number of concerns from staff about staffing levels in the home. As part of this assessment we reviewed the systems and processes the provider used to plan and evaluate safe staffing levels, including the dependency tool, staff rotas, night-time audits and call bell audits. We discussed the systems and processes used by the provider to evaluate safe staffing levels. The provider initially told us staffing levels were determined by the dependency tool, however, we found the staffing levels set by the dependency tool did not correspond with the staffing level on the rota or with the levels the provider told us the service needed so we were not assured the provider had a consistent method of ensuring there were sufficient staff. We raised this with the provider and they showed us additional staffing projections which were not linked to people’s dependency needs. The provider could not explain how the staffing levels had been determined. We raised our concerns about the processes around determining staffing levels and the provider told us they are working towards introducing new and improved tools to assess staffing needs within the home.

In addition to our concerns with the provider’s process around planning and evaluating staffing requirements we found staffing levels at night varied due to staff sickness, or staff absence. We found over a 2-week period in February 2024 staffing levels were less than the minimum levels set by the provider due to staff sickness and absence. On these occasions the staffing levels were also less than the figure stated in the provider’s fire risk assessment. Daytime staffing levels were much more consistent and less affected by staff absences. The rota for a 2-week period in May showed improvements had been made and staffing levels were in line with the levels the provider told us were needed. Whilst the senior management team were aware of the concerns regarding nighttime staffing levels raised by staff anonymously there was not a process to scrutinise projected staffing levels versus actual staffing levels. We discussed these issues with the provider and they told us there were times when they were unable to find nighttime cover at short notice when staff were absent due to sickness. There were night-time audits being carried out by senior staff but they did not identify the issues with the night-time staffing levels and there were no plans in place to mitigate the issues with staffing shortages at night. This showed the quality assurance processes in place were not effective in identifying and/or resolving the staffing issues we found.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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