Updated 15 September 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.
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 an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
The Manse is a ‘care home’ with nursing care. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a manager in post who intended to apply to register.
Notice of inspection
This inspection was unannounced on the first day.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 this information to plan our inspection.
During the inspection
During the inspection, we spoke with 6 people who used the service individually and 6 people in a group over lunch. We also spoke with 2 people’s relatives on site and gained feedback from 2 relatives via email. We spoke with 7 staff, including the manager, nurses, carer staff and kitchen staff. We also gained feedback from two staff via email. Following the inspection visit, we gained feedback from 3 external professionals about their experience of working with service.
We looked around each area of the home to make sure It was safe, homely and suitable. We spent time observing the care and support people received. This helped us to understand the experience of people who could not or chose not to speak with us.
We reviewed 5 people’s care documentation and multiple medicines administration records, along with associated medicines documentation. We observed medicines administration and checked how medicines were stored.
We reviewed a range of records related to the management of the service, including safety certificates, staff training data and quality assurance systems.