Little Manor Care Centre

Updated 2 February 2024

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 prevention and control 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 team consisted of 1 inspector, 1 assistant inspector and a pharmacy inspector.

Service and service type

Little Manor is a ‘care home’. 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. Little Manor is a care home with nursing care. 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 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 provider since the last inspection. 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 this information to plan our inspection.

During the inspection

We spoke to 4 people and 6 relatives about the care they received. We also spoke to 5 members of staff, the Registered Manager, the Maintenance Manager, the Operations Manager, the Business Director, the Acting Head of Care and 2 professionals. We received feedback via email from 5 further professionals. We reviewed medicine records, care plans, health and safety records including emergency lighting, fire risk assessments and legionella management records, 3 recruitment files, 3 staff files, auditing records and the provider’s policies and procedures.

Updated 2 February 2024

About the service

Little Manor is a residential care home providing personal and nursing care for up to 30 people. The service provides short term support to people being discharged from hospital who require support with rehabilitation before returning home or moving to a long-term care home. The provider works in partnership with a local organisation developing therapeutic plans to support people on their discharge from hospital. The aim is to continue supporting people’s recovery, independence, and skills, enabling people to return home or move on to other services. At the time of our inspection there were 25 people using the service.

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

People were not always supported safely. Health and Safety audits were not completed in line with the provider’s policies which meant that there was not adequate oversight of health and safety requirements.

Medicine care plans did not always have enough detail to ensure people were receiving effective and safe support. Medicine audits failed to identify these concerns.

Systems to check for legionella were not detailed and audits were not completed to identify this.

Staff were recruited safely. However, they were not always receiving regular supervisions to support their development.

People and their relatives told us they felt well supported. They valued the involvement they had from the on-site physiotherapist and felt this helped them with their recovery.

There was enough staff to support people and we saw people being supported in a person centred way.

Professionals told us that the home was professional and warm and friendly.

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.

For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 19 May 2016). The service was closed for redevelopment from November 2018 until November 2020. An Infection Prevention Control (IPC) inspection was completed on 19 January 2021 to check how they were managing during COVID-19. We found that the service was supporting people safely. This was not a rated inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe and well-led only.

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.

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 has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Little Manor on our website at www.cqc.org.uk.

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.