Manor House

Updated 30 September 2022

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 Health and Social Care Act 2008.

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 was carried out by one inspector and an Expert by Experience who visited the service. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience spoke with people and their representatives, to gather feedback on their experiences of the home.

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 dependent on their registration with us. Manor House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we had received about the service since the last inspection and any recurrent themes of concern. We sought feedback from the local authority and commissioners who work with the service.

We used information gathered as part of monitoring activity that took place on 13 June 2022 to help plan the inspection and inform our judgements.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection.

We looked at four people’s care plans, two recruitment records and a variety of information relating to the management of the service. The inspector spoke with nine staff including the registered manager, the area manager, five care staff including senior care staff, a cook and a housekeeping assistant. We spoke with seven people who used the service and three relatives, about their experience of the care provided. We observed care and support in communal areas. We spoke with three health professionals who supported people at the service, about their experience of the care people received.

Updated 30 September 2022

Manor House is a care home providing personal care and accommodation for up to 26 older adults living with dementia, physical disability or sensory impairment. The service is a two-storey building with 24 en-suite bedrooms, two of which are for double occupancy. There are two communal lounges and a dining room. At the time of our inspection visit there were 24 people receiving care.

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.