Manor House Care Home LTD

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread shortfalls in leadership. Leaders and the culture they created did not assure delivery of high-quality care. The provider was in breach of legal regulations in relation to good governance. Governance systems were not effective in identifying the concerns we identified during this assessment. The provider and manager did not have the skills, knowledge and understanding they needed to deliver a service that provided safe care and treatment to people living at the service. Whilst staff told us they felt better supported under the new provider, we found the culture of the service was not positive. We observed care that people received was task focused and not personalised. The provider did not have processes to demonstrate they listened to and acted upon concerns. Despite working with partner agencies to make improvements, the provider had not made enough improvement. and the service was not safe for people.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Systems the provider used at the service to ensure the culture of the service was positive were not effective. The provider and manager did not demonstrate the knowledge and understanding of the challenges and needs of people living at Manor House. The provider did not have processes to demonstrate they listened to, acted upon and learned from concerns. The provider did not hold relatives’ meetings and although the provider recorded concerns, they did not have a formal process to audit and respond to concerns.

The services’ statement of purpose stated they pride themselves on offering people a personal touch. However, we found care that people received was task focused and not personalised. Staff, including the manager, were overheard calling people ‘walkers’, and referring to people as ‘double ups.’ This indicated that staff did not have a clear understanding of treating people with respect and ensuring they prioritised people’s equality, diversity and human rights.

The provider and manager did not have the skills, knowledge and understanding they needed to deliver a service that provided safe care and treatment to people living at the service. The provider and manager did not demonstrate an understanding of the regulations or the legislation underpinning the regulations. Records showed the provider, and manager had not always submitted statutory notifications without delay to CQC. We were therefore not assured the manager, or the provider, understood their requirement to notify CQC.

The provider told us they did not have checks to ensure the manager and staff at the service were providing safe care and the environment people lived in was safe and well maintained.

Whilst staff spoke positively about the provider and manager, we found there was a lack of robust and effective provider oversight of staff performance to ensure the health, welfare and safety of people living at Manor House.

The provider’s failings to ensure the service was led by capable leaders contributed to the breach of regulation in relation to good governance.

The manager told us that since the new provider had taken over the service, they felt better supported and able to raise concerns.

The services’ whistleblowing policy pre-dated the current provider and was not up to date with details of who staff needed to go to with their concerns. Although staff received yearly appraisals, whistleblowing was not part of that discussion. Minutes we reviewed from staff meetings did not demonstrate whistleblowing was included in the discussion. This meant staff may not have sufficient opportunity or feel able to raise concerns.

The service had an equality and diversity policy and staff received training. Staff told us they felt they were treated fairly and equally. However, we found there was a closed culture at the service with a lack of external scrutiny and oversight. The service also employed a number of family members, including family members of the manager. This culture could potentially lead to staff feeling afraid to speak up about unsafe practice resulting in a lack of transparency and an environment that was not inclusive.

The provider’s systems, processes and oversight to ensure risks were managed safely, were either not in place or not effective at identifying concerns and driving improvement. This led to the serious failings we identified at this assessment.

The provider did not conduct a monthly provider audit and the manager’s audit was inadequate and had not identified the concerns we found. The provider and manager did not have a clear understanding of good governance systems and processes.

Leaders of the service did not conduct any care plan audits and the variability in the quality and consistency of record keeping meant the provider could not be confident people were receiving safe care. People were at increased risk of harm from skin damage, behaviours that challenge, falling, malnutrition and choking.

Daily monitoring of care was either not in place or not robust and had failed to identify people’s assessed plan of care was not being followed by staff and staff were not following safe practices.

Medicines audit was not robust. There was no check of medicines administration record (MAR) charts, staffs’ administration practice, medicines errors, storage or disposal of medicines.

Governance systems failed to identify care, and treatment was not provided in line with the Mental Capacity Act, 2005.

The provider did not conduct any monthly environment audits to regularly check the safety of the environment or infection prevention and control audit to ensure the service was clean and free from infection risks.

The provider did not have a process or conduct checks to ensure staff had been recruited safely and staff received effective training.

The provider’s systems and processes had failed to identify staffing levels were failing to meet people’s needs and keep them safe.

The provider’s failings to ensure the service had robust governance systems and processes contributed to the breach of regulation in relation to good governance.

The service had been working with the local authority quality team before our assessment. However, the provider had taken insufficient action and our assessment identified further serious failings.

The provider and manager had a limited understanding of safe effective care and had not engaged in local or national forums or development groups for best practice guidance, expertise or resources to improve the service and lead to better outcomes for people.

Although the provider had taken some action to address issues raised by us during and immediately after our site visit, we considered the failings were so significant and people were not safe, we immediately involved partner agencies from the local authority.

Partner agencies supporting the service following our assessment shared further concerns about management and staff ability to keep people safe. This led to the local authority removing people from the service for their safety.

The provider lacked effective systems to monitor and mitigate risks and to learn lessons to prevent incidents from happening again. The provider did not conduct any analysis of accidents and incidents to allow lessons to be learnt to help keep people safe from further injuries. The provider had not analysed falls records to ensure robust action was taken to prevent falls.