Archived: Manor Park

This inspection took place on 1 and 2 February 2017 and was unannounced. This was the first rated inspection of the service since its registration with the Care Quality Commission (CQC) in March 2015.

The service had a registered manager in post. 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.

People told us that they felt safe living at Manor Park with the support from the staff. Policies and procedures were in place and up to date to ensure staff understood their responsibilities and to assist them to support people with the most appropriate approach.

Records were kept regarding accidents and incidents including those of a safeguarding nature. Incidents were recorded, investigated and reported in a timely manner to other relevant authorities such as the local council or CQC. These were monitored by the registered manager and used to review care needs, risk assessments and implement or improve preventative measures.

The service managed risks associated with the health, safety and well-being of people, including carrying out regular checks of the property, equipment and utilities in line with their legal responsibilities as the landlord. Individual care needs had been assessed for risks related to aspects of daily living and we saw evidence in care records which demonstrated these were reviewed regularly.

Medicines were administered and managed safely and medicine administration records were well organised, detailed and correct. Medicines were stored in a safe and secure place in line with best practice guidance. The staff followed a strict policy and procedure regarding the receipt, storage and disposal of medicines.

Staff told us they felt there were enough staff employed by the service to meet people’s needs; people and their relatives confirmed this. Staff records showed the recruitment process was robust and staff had been safely recruited. Training was up to date, and the staff team had a mix of skills, knowledge and experience. Staff had opportunity to enhance their knowledge further and all were qualified in health and social care.

Staff were supported by the registered manager through supervision and appraisals which were held regularly and documented. The registered manager observed staff performance on a daily basis; however competency checks were not currently undertaken to formally assess the staff’s suitability for their role. Staff and ‘resident’ meetings took place and we were able to review the minutes of previous meetings. Relatives were welcome to contact or visit the service. This meant everyone with an interest in the service had a chance to speak to the management and raise any issues.

The Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. In England, the local authority authorises applications to deprive people of their liberty. We found the provider was complying with their legal requirements and applying the principals of the MCA.

People enjoyed nutritious, well-balanced meals which were prepared by the staff. We observed everyone enjoying their food at mealtimes. People had choice around mealtimes but often ate one of the planned meals from the menu, although other options were available if they preferred. People’s individual nutritional needs were met. The service involved external health professionals as necessary to meet people’s changing needs and to promote their general health and well-being.

Staff were kind, caring and compassionate and people told us the staff and the management were nice to them. Staff knew people well and we observed staff treated people with respect and they ensured people’s dignity and privacy were maintained. People described a “happy atmosphere” within the home.

Person-centred care plans were in place. People’s individual needs had been initially assessed and were periodically reviewed with the involvement of the person, any relatives and external professionals. Care plans which detailed the care and support people needed were up to date and accurate. They included extensive information about life history, family, school life, working life, interests and hobbies. Where appropriate people had consented to the care and support they received and some had been involved in writing the plans which included their own personal goals.

A newly employed activities coordinator encouraged and promoted activities which reflected people’s hobbies and interests. A generic activity programme was devised which the whole staff team encouraged people to participate in to reduce social isolation and boredom. Most people were independent and accessed their local community as they wished, however others were supported by staff to get involved in external activities which they showed a keen interest in. Staff helped people to engage in a social life with family and friends.

There were a low number of complaints received by the service, which the registered manager kept a record of. She explained to us how the complaints procedure was shared with people, relatives and external professionals which detailed how complaints were investigated and managed. People told us they had very little to complain about but would feel confident to tell the staff or the management if something was wrong or upsetting them.

Regular quality monitoring had taken place until recently. The registered manager had not overseen these checks and subsequently had not realised that these checks were overdue. However we did not find any issues with the safety and quality of the service.

The service asked people, relatives and staff for feedback. Surveys had been issued to people annually to gain their opinions about how the service was managed and how it could be improved. We observed a good response to those surveys which allowed the registered manager to collate the responses, evaluate and gather an overall opinion. We reviewed an action plan which had been produced to address the issues raised.

The registered manager and director of care operations had an extensive employment history in the care industry working with people with mental health related conditions and/or a learning disability and they were well established in their roles having known some of the people who used the service for a long time. The staff team were consistent although there had been a few recent changes to the staffing structure and recruitment was on-going to fill the vacancies. Staff told us they enjoyed working at the home and felt valued and appreciated by the management team.