Manor House Care Home LTD

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• 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

This key question was previously rated good. At this assessment the rating has changed to inadequate. We identified 6 breaches of regulation. This meant people were not safe and were at risk of avoidable harm. People were at risk of not receiving safe care because risks to people’s health and safety were not adequately assessed and action was not taken to mitigate risk. The service did not have effective systems to ensure incidents and risks were analysed effectively and action was taken to prevent re-occurrence. The provider had failed to respond sufficiently to previous incidents of harm. The provider had not always identified or appropriately reported incidents of abuse, neglect and improper treatment. Staff were not complying with the principles of the Mental Capacity Act, 2005 which was leading to unlawful restrictions on people. People were not protected from being cared for by unsuitable staff and there were not enough staff to keep them safe. Staff lacked the skills and knowledge to keep people safe. People were not safe from infection control risks and the environment they lived in was not safe.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst some people and relatives told us they were happy with the care they received others described incidents and accidents where people were not receiving the care and support needed to keep them safe. Our assessment found care did not meet the expected standards which put people at risk of harm.

The provider did not have systems and processes that promoted a learning culture. Whilst the service had processes to report and record incidents and accidents, the provider did not have effective systems to ensure incidents and risks were analysed effectively and take action to prevent re-occurrence.

The provider had failed to respond sufficiently to previous incidents of harm to learn from and mitigate risk within the service. For example, following an incident where a person was able to access the kitchen and eat frozen chicken, the provider had failed to mitigate the risk by installing a suitable lock to the kitchen door, which we found unlocked during our assessment. Similarly, the provider had not taken appropriate action to mitigate the risk of people falling down the stairs.

There was little or no evidence of a learning culture throughout our interactions with staff. For example, 1 staff member described their unsafe medicines administration practice which they knew was unsafe, but admitted they carried on with this behaviour.

The above concerns contributed to a breach of regulation with regards to safe care and treatment.

The provider had failed to ensure there were robust and safe systems of care to ensure people’s safety. There was a lack of understanding of systems and processes to keep people safe. This led to people not being safe or having the right care and treatment to meet their needs.

When people needed support from healthcare professionals, staff did not always make referrals and people suffered harm as a result. For example, people who were at high risk of serious harm from the risk of choking and falling had not been referred to health professionals and therefore had not received appropriate care and treatment. The provider had not always effectively used systems to monitor signs of deterioration such as weight loss or skin integrity to provide people with adequate and prompt care. Because of this, people had experienced harm and were at risk of ongoing harm.

The above concerns contributed to a breach of regulation with regards to safe care and treatment.

The provider had failed to operate effective safeguarding systems and processes to protect people from abuse, neglect and improper treatment. There was a lack of action to mitigate and reduce risk and people were not being supervised by staff resulting in serious accidents and incidents leading to unavoidable harm. Whilst there was online safeguarding training for staff, the provider had failed to ensure staff had a clear understanding of their roles and responsibilities to recognise and report safeguarding concerns. We found there was a culture amongst the staff team of an acceptance that abusive behaviours seen at the service was normal behaviour rather than incidences of abuse that should be reported. Staff had failed to recognise potential abuse and failed to report these to the local authority and CQC.

As a result of our assessment, we raised 5 individual safeguarding concerns with the local authority safeguarding adults team and the service was placed in whole service safeguarding.

The above concerns contributed to a breach of regulation with regards to safeguarding people from abuse.

Most people who were able to speak with us, told us they felt safe and most staff were kind to them. However, we found people were not safe living at Manor House.

The providers governance systems and processes had failed to identify that people’s rights were not always protected and staff had not acted in accordance with the Mental Capacity Act, 2005. The manager had identified people who they believed were being deprived of their liberty. However, despite restrictions on people, the manager could not show us evidence they had made Deprivation of Liberty Safeguard applications to the supervisory body. In addition, people’s mental capacity had not always been assessed and decisions which had been made in people’s best interests, were not documented.

This contributed to the breach of regulation in respect of need for consent to care and treatment.

People were at risk of harm because the provider had failed to ensure risks to people’s health and safety were adequately assessed and action was taken to mitigate risk. These included risks relating to skin care, choking risks, risks associated with malnutrition, falls and managing people’s behaviours that posed a risk to themselves and other people.

Care plans and risk assessments were either not in place or lacked sufficient guidance for staff on how to manage the risk. For example, 1 person living with dementia was at risk of falling and had 8 falls in February 2025, including a fall when accessing the stairs unaided. Their care records told staff they were at risk of falling down the stairs and had refused to use the stair lift. This person did not have a care plan or risk assessment to manage this person’s refusal to use the stair lift and there was no mitigation recorded to reduce their risk of falling, such as, a sensor alarm mat to alert staff.

Where the provider had guidance, there was a lack of provider and managerial oversight to ensure actions taken to mitigate risk had been followed by staff. For example, people were not always repositioned according to their assessed need and we saw people who had an identified risk of falling and needed supervision, were left unsupervised.

When people had lost weight, staff had failed to recognise this risk and take appropriate action such as escalating concerns to health professionals and minimise the risk of further weight loss by monitoring people’s weight appropriately.

This contributed to the breach of regulation in respect of safe care and treatment.

People were at risk of harm as the environment they lived in was not safe. The providers systems and processes to ensure the safety of the environment were inadequate. Management and provider oversight had failed to identify the significant safety concerns we found at the service.

People were not protected from the risks of fire. Fire safety records showed that routine checks on fire and premises safety were either not carried out at all or within the required period, which the service is legally required to complete. Personal Emergency Evacuation Plans (PEEPs) guiding staff on how to evacuate people safely were not up to date and did not give staff sufficient guidance. The provider did not have an up-to-date fire risk assessment.

People were not protected from the risks associated with legionella. The provider had not ensured regular monitoring and water testing had been undertaken according to the provider’s own policy and health and safety legislation.

We observed people were not protected from the risk of falling from a height. We saw 3 windows were not restricted according to Health and Safety Executive guidance and other windows were not always restricted with tamperproof restrictors.

Radiators throughout the service were not guarded in line with health and safety legislation. We saw radiator covers were not always secured to the wall and could be moved away exposing people to the hot radiator surface.

People were at risk of falling because communal corridors on the first floor were poorly lit with heavily patterned carpets. There were steps leading down to another level which did not have hazard signs or highlighting tape alerting people to the steps.

The lack of robust systems and processes put people living at the service at risk of harm and contributed to a breach of regulations in relation to safety of the environment.

People were at risk as there were not enough knowledgeable and skilled staff to care for people safely. We observed multiple occasions when there were no staff supervising people in communal areas. People did not have the support they needed, which resulted in an escalation of incidents of challenging behaviour and falls. On several occasions, members of the assessment team had to intervene and locate staff to assist people, as no staff were available. We observed staff were task focused and were not able to keep people safe and spend meaningful time with people.

Most people told us there were not enough staff available to meet their needs. Comments included, “There’s not enough staff, they need more. They are always rushing with very little time to chat” and “I don’t think there’s enough staff. They need more. It’s not fair on the one’s they’ve got; they need more help.” Staff also told us there were not enough staff.

The provider had a training programme. However, observation of staff practice did not assure us staff had learnt from their training and had the skills and knowledge to keep people safe. For example, whilst staff received infection control training, we observed poor infection control practice throughout our site visits. In addition, staff had failed to identify when people’s health issues required medical intervention and referral. Staff failed to identify aspects of their practice was not safe.

Failing to ensure people were cared for by enough knowledgeable and skilled staff is a breach of regulations in relation to staffing.

Staff were not always being recruited safely. Recruitment checks such as previous employment reference checks and Disclosure and Barring (police) checks, had not been completed before staff began working at the service.

People were at risk of being cared for by unsuitable staff who may not be competent or safe to care for vulnerable people and is a breach of regulations in relation to fit and proper persons employed.

The provider had failed to ensure people were protected from the risks from infections. The provider was not ensuring staff consistently maintained appropriate standards of cleanliness and hygiene.

We observed rooms on the first floor, including people’s bedrooms, had unpleasant smells and visual signs of damp and mold. Some people’s bed bases, mattresses, commodes and chairs were dirty and heavily stained. One person’s bedroom had a strong smell of urine and a dirty stained carpet.

The provider’s processes to manage service users’ laundry and medicines placed people at risk from infections and cross contamination. Medicines and laundry were being managed in 1 room. There was no separation between the medicines area and laundry area. There was no separation of clean and dirty laundry. There were no areas for sluicing heavily stained linen. The sink was dirty and contained a dirty washing up bowl where staff were cleaning used medicines pots.

We observed staff not following best practice guidelines in relation to infection control. For example, we observed staff assisting people without wearing PPE or washing their hands. Two staff members, including the manager, had long nail extensions. Staff were not always bare below the elbows and long hair was not always tied back.

Most people and their relatives did not express any concerns in relation to the environment. Although people were mainly positive about the environment and infection control, we found the service was not clean and the provider had not implemented safe infection prevention and control practices.

Failing to follow safe infection control practices contributed to a breach of regulations in relation to safety of the environment.

People did not describe safe practice with regards to their medicines. For example, some people told us staff left their tablets with them and did not watch them take their tablets. One person told us, “I’ve seen [name] put hers in her bag when staff are distracted.” Another person said, “They leave me to take my own meds when I am ready.”

People were not protected from risks associated with unsafe management of medicines. We observed and staff described unsafe medicines practice. For example, 1 staff member admitted to administering 2 people’s medicines at the same time. We observed another staff member administer a person’s medicine on the floor of their room. These practices placed people at risk and were not in line with safe medicines practice guidance.

People’s medicines were not stored safely. Medicines were stored in individual lockers. We saw keys had been left in 3 locker doors and the key safe holding the locker door keys had been left open. This room was accessible to all staff having access to the laundry facility. This meant staff not be authorised to do so, had access to people’s medicines.

Staff were not recording medicines storage temperatures and medicines that required storage in a refrigerator, were not stored in an appropriate medicines’ fridge. This meant medicines may not be stored at the correct temperature in line with safe practice guidance.

The provider did not have any guidance to help staff give “when required” medicines (PRN) safely or appropriately.

People were not having their medicines administered to them lawfully according to good practice frameworks.

Staff were not following safe processes when making written changes to people’s medicine records. For example, additions to record charts had not been signed by the staff member making the changes nor had a second staff member signed to witness that changes were correct.

These concerns contributed to the breach of regulations in relation to safe care and treatment.