The Manse Residential Care Home

Updated 12 January 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.

Inspection team

This inspection was carried out by 1 inspector, 1 regulatory co-ordinator and 1 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 Residential Care Home 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. The Manse Residential Care Home is a care home without 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

The inspection was unannounced.

Inspection activity started on 31 October 2023 and ended on 1 December 2023. We visited the service on 31 October 2023 and 1 November 2023 and 29 November 2023.

What we did before the inspection

We reviewed information we had received about the service 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 all this information to plan our inspection.

During the inspection

We spoke with 6 people who used the service, 5 relatives of people who used the service and 1 friend of a person who used the service. We also spoke with 9 staff, including the registered manager, the deputy manager, regional managers, a regional director, and care staff. We reviewed a range of records. This included 17 people's care records and 3 staff records. A variety of records relating to the management of the service were also reviewed.

Following our visit to the service, we reviewed more records relating to the management of the service.

Updated 12 January 2024

About the service

The Manse Residential Care Home is a care home providing accommodation and personal care to up to 33 people. The service provides support to older people, people with disabilities and people living with dementia. At the time of our inspection there were 32 people using the service.

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

Risks to people were not always sufficiently assessed and plans to mitigate and manage risks were not always sufficiently detailed, instructive and up to date. Medicines management was not always safe and did not always follow guidelines. There was not always a sufficient number of suitably qualified staff deployed to meet all people’s needs in a timely and safe manner at all times. People’s privacy and dignity were not always respected. People’s care and support was not always designed and planned in a person-centred way. Maintenance checks and repairs were not always carried out appropriately and in a timely manner. The quality assurance systems and processes were not always effective and the provider had not identified the issues we found during our inspection. We found no evidence anyone had been harmed. However, these issues had put some people at risk of potential harm.

There were systems and processes in place to safeguard people from abuse and improper treatment and people and their relatives felt the service was safe. The recruitment of new staff followed safer recruitment procedures. Infection prevention and control was effective.

People were supported to eat and drink enough and participate in activities and exercise. People and their relatives were included in making decisions about their care and involved in the development of the service. Staff were friendly, caring, kind and supportive and managers were approachable.

The provider, managers and staff worked in partnership with other agencies and organisations to provide people with their care and support.

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 CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 15 December 2017).

Why we inspected

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

We undertook a focused inspection to look at the key questions of safe and well-led.

We inspected and found there were potential concerns with the other key questions, so we widened the scope of the inspection to become a fully comprehensive inspection which included the key questions of safe, effective, caring, responsive and well-led.

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, effective, caring, responsive and well-led sections of this full report.

Enforcement and Recommendations

We have identified breaches in relation to person-centred care, dignity and respect, safe care and treatment, premises and equipment, good governance, and staffing. Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.