Manor House

Updated 25 November 2020

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of one inspector who visited the service, one assistant inspector who contacted staff and one Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Manor House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided. The manager who was in post saw to the day to day running of the service and had started the process for applying to register.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because we wanted to ensure the manager would be available.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, Healthwatch and professionals who work with the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We received feedback from four people who used the service and eight relatives about their experience of the care provided. We spoke with five members of staff including the nominated individual, manager, clinical lead manager, quality manager and a team leader. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included various aspects of three people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits, risk assessing relating to COVID-19 and accident and incident processes were reviewed.

After the inspection

We continued to seek clarification from the manager to validate evidence found. We looked at further records we requested to be sent to us. We spoke with three professionals who work with or regularly visit the service. We contacted care staff for feedback, but no care or domestic staff chose to feed back to us.

Updated 25 November 2020

About the service

Manor House is a residential care home providing personal and nursing care to 15 people aged 65 and over at the time of the inspection. The service can support up to 30 people.

Manor House is in a residential area and is an adapted older style two floor detached building with a garden. There is lift access for people who may struggle with stairs.

People’s experience of using this service and what we found

Prior to our last inspection the nominated individual had identified there were concerns in the service and raised a safeguarding alert. When we inspected in November 2019 some action had been taken to make people safer but there were still several concerns. At this inspection we found there were no longer breaches in regulation and recommendations have been met. The service had gradually improved over the twelve months between inspections.

People looked happy, healthy and responded positively when staff approached them or spoke with them. The atmosphere was friendly and peaceful.

Improvements to the environment were clear, renovations had taken place in several rooms, and improvements had been made to the laundry, bedrooms, fire systems and dining area.

Risks were assessed and monitored, and guidance given to staff on how to mitigate them. Risks that people faced and care needs were regularly reviewed. Learning from accidents and incidents was shared and clear systems were in place for safeguarding concerns.

Medicines were managed safely. Improvements to infection control processes had been made. Staff wore personal protective equipment (PPE) and clear guidance was in place regarding keeping people safe from the risks associated with the coronavirus pandemic. Staff were recruited safely and there were enough of them to meet people’s needs.

Quality systems were robust and staffing structure and accountabilities were clear. Relatives gave us positive feedback about the manager and care staff.

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.

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 5 December 2019). At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We had previously carried out an unannounced comprehensive inspection of this service on 4 November 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

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 Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.