The Manse

Updated 14 June 2023

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.

Inspection team.

The inspection was carried out by one inspector.

Service and service type.

The Manse is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both 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 information we had received about the service since the last inspection. We also reviewed information that we held about the service such as notifications. We used information sent to us by the provider in their Provider Information Return. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We used all of this information to plan our inspection.

During the inspection

We reviewed 2 people's care plans and risk assessments. We reviewed all staff training and supervision. We also reviewed other records relating to the management of the service. We spoke with 4 people who lived at The Manse, 4 staff, the registered manager and the deputy manager. We spoke with 4 relatives of people living at The Manse.

Updated 14 June 2023

About the service.

The Manse is a residential care home providing personal care to up to 21 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 21 people using the service.

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

People received their medicines as prescribed. However, some of the systems and processes used at the service, regarding the management of medicines, were not always effective in ensuring medicines were accurately recorded. The medicines audit was not effective. We were given assurances by the registered manager that this would be addressed.

The recruitment processes used at the service did not always ensure past employment dates were accurately recorded. We were given assurances by the registered manager that this would be addressed.

We toured the premises and found the service to be clean and decorated to a good standard. There were no malodours.

The provider had effective safeguarding systems in place and staff knew what actions to take to help ensure people were protected from harm or abuse.

The Manse was fully staffed. There were enough staff to meet people's needs and ensure their safety. Staff were happy and many had worked at The Manse for many years.

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.

Staff worked within the principles of the MCA and sought people's consent before providing personal care and assistance. Guidance in care plans guided staff to help build independence wherever possible.

Identified risks were assessed and monitored. Care plans contained guidance and direction for staff on how to meet people’s needs. However, where some people’s needs had changed this information was not always reflected in the care plans in a timely manner.

Food looked appetising and there were staff available to support people where needed.

The registered manager, deputy manager and the provider had oversight of the service. There was an audit programme to help identify any areas of the service that may require improvement. However, the medicines audit had not identified the concerns found at this inspection.

People, staff and relatives were asked for their views and experiences by the manager and the provider. Staff meetings were held to share information and seek their views. Relatives told us, “We are so pleased with The Manse. We are very happy”, “We have no complaints, and we visit regularly” and “The manager and staff are warm, they always let us know when things change. It is a lovely home like environment.”

The registered manager understood their responsibilities under the duty of candour. Relatives were kept informed of any changes in people’s needs or incidents that occurred.

The registered manager and staff worked closely with local health and social care professionals to meet people’s needs.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was good (published 10 December 2018.)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 COVID-19 and other infection outbreaks effectively.

Enforcement

We have found a breach of regulations in relation to records at this inspection. Please see the action we have told the provider to take at the end of the full version of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.