The Manor Nursing Home is a ‘care home with nursing’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. It provides accommodation for older people, people living with a learning disability and those with mental health conditions or dementia. The home can accommodate up to 26 people. At the time of our inspection there were 22 people living in the home. Care is provided in two units which are based on a single site.

At the last inspection in August 2017 the service was rated, ‘Requires Improvement’. We found a breach in Regulation 17. The provider had failed to put in place processes and systems to address issues previously identified by CQC. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question to at least good. We undertook an unannounced focused inspection of The Manor Nursing Home on 15 June 2018. The team inspected the service against two of the five questions we ask about services: is the service safe, is the service well led? This is because these were areas where concerns had been raised. At this inspection we found the overall rating remained requires improvement. Issues identified at the previous inspection had failed to be fully addressed. This is the third time the service has been rated ‘Requires improvement’. We found their remained a continuous breach of Regulation 17.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. In this report when we speak about both the company and the registered manager we refer to them as being, ‘the registered persons’.

Quality checks were being completed but these had not identified some of the issues we found at inspection. Issues identified at previous inspections had not been addressed fully.

Medicines were not managed consistently safely. Where people received their medicines without their knowledge (covertly) the provider had not followed best practice guidelines.

There were arrangements to prevent and control infections.

The provider had ensured that there was enough staff on duty. In addition, people told us that they received person-centred care.

There were systems, processes and practices to safeguard people from situations in which they may experience abuse including financial mistreatment. Risks to people’s safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected. Background checks had been consistently completed before new staff had been appointed.

There was a registered manager who promoted a positive culture in the service that was focused upon achieving good outcomes for people. Staff had been helped to understand their responsibilities to develop good team work and to speak out if they had any concerns. People, their relatives and members of staff had not been consistently involved in the running of the service. The registered manager had put in place arrangements that were designed to enable the service to learn and ensure its sustainability. There were arrangements for working in partnership with other agencies to support the development of joined-up care.

The provider had infor

This inspection took place on 3 August 2017 and was unannounced. The Manor Nursing Home provides care for older people who have mental and physical health needs. It provides accommodation for up to 26 people who require personal and nursing care. The service provides care in two units, the main house and the ‘cottage’. At the time of our inspection there were 19 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations.

We found the provider had failed to address fully some of the issues raised at our previous inspection. There was a breach of Regulation 17. You can see what action we told the provider to take at the back of the full version of the report.

On the day of our inspection staff interacted well with people. People and their relatives told us that they felt safe and well cared for. Staff knew how to keep people safe. The provider had systems and processes in place to keep people safe.

Medicines were administered safely however they were not consistently managed safely.

We saw that staff obtained people’s consent before providing care to them. Where people could not consent, staff worked in ways that protected their rights.

We found that people’s health care needs were assessed and care planned and delivered to meet those needs. People had access to healthcare professionals such as the district nurse and GP and also specialist professionals. People had their nutritional needs assessed and were supported with their meals to keep them healthy. People had access to drinks and snacks during the day and had choices at mealtimes. Where people had special dietary requirements we saw that these were provided for.

There was sufficient staff available to meet people’s needs. Staff responded in a timely and appropriate manner to people. Staff were kind and sensitive to people when they were providing support. People were treated with respect.

Staff were provided with training on a variety of subjects to ensure that they had the skills to meet people’s needs. The provider had a training plan in place. A plan was in place to provide staff with supervision. People were provided with a limited amount of leisure and social activities. They were supported to maintain relationships that were important to them.

Staff felt able to raise concerns and issues with management. Relatives were aware of the process for raising concerns and were confident that they would be listened to. Regular audits were carried out and action plans put in place to address any issues which were identified. Accidents and incidents were recorded and investigated. The provider had informed us of notifications. Notifications are events which have happened in the service that the provider is required to tell us about.

This inspection took place on 18 August 2016 and was unannounced. The Manor provides care for older people who have mental and physical health needs including people living with dementia. It provides accommodation for up to 26 people who require personal and nursing care in two units, the main house and the cottage. At the time of our inspection there were 22 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations.

On the day of our inspection staff interacted well with people and people were cared for safely. People and their relatives told us that they felt safe and well cared for. Staff knew how to keep people safe. The provider had systems and processes in place to keep people safe. Medicines were administered safely but the provider did not follow their policy for covert medicines. Medication administration sheets (MARS) were completed fully however information sheets did not include people’s allergies.

The provider acted in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. If the location is a care home the Care Quality Commission is required by law to monitor the operation of the DoLS, and to report on what we find.

Risk assessments were not consistently completed. We found that people’s health care needs were assessed and care planned and delivered to meet those needs. People had access to healthcare professionals such as the GP and also specialist professionals. People had their nutritional needs assessed and were supported to eat enough to keep them healthy. People had choices at mealtimes. Where people had special dietary requirements we saw that these were provided for.

There were sufficient staff to meet people’s needs and staff responded in a timely and appropriate manner to people. Staff were kind and sensitive to people when they were providing support and people had their privacy and dignity considered. Staff had a good understanding of people’s needs and were provided with training on a variety of subjects to ensure that they had the skills to meet people’s needs. The provider had a training plan in place and staff had received regular supervision.

We saw that staff obtained people’s consent before providing care to them. People were provided with access to activities and leisure pursuits.

Staff felt able to raise concerns and issues with management. Relatives were aware of the process for raising concerns and were confident that they would be listened to. Audits were carried out but action plans were not always in place to address any issues which were identified. Accidents and incidents were recorded. The provider had informed us of incidents as required by law. Notifications are events which have happened in the service that the provider is required to tell us about.

When we last visited The Manor Nursing Home on 09 April 2014 we found that people were not protected from the risks associated with unsafe or inappropriate care and treatment because accurate care records were not being maintained.

We re-visited the service on 11 August 2014 to check if the provider had made any of the required improvements to the issues we had previously highlighted. A single inspector carried out this inspection.

The following summary is based on a review of the action plan sent to us by the provider after our last inspection, our observations during our visit, our discussions with people who used the service visiting relatives and staff who supported them. We also looked at people’s care records, management records and other documentation.

At the time of this inspection our records were in the process of being updated to reflect the acting manager had successfully completed the process to become the registered manager for the service.

The focus of our inspection was to answer a key question we always ask; is the service safe?

We saw care records were up to date, accurate and they reflected people’s needs and abilities. Where risks had been identified; care plans detailed how the risk was managed in order to keep people safe and promote their health and wellbeing.

The summary is based on our observations during the inspection, speaking with people who used the service, their relatives and the staff who supported them. We spoke with two staff members, one person who used the service and a relative during our inspection. We also looked at three care records and other documentation.

We considered the findings of our inspection to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found-

Is the service caring?

We observed care and saw how members of staff treated people. We saw care was delivered well and in a respectful way. We saw that staff were kind and attentive and encouraged people to be independent. We saw that care workers showed patience and gave encouragement when they supported people. During our inspection we observed staff spoke with people on an individual basis and understood their particular needs. For example, one person enjoyed drawing and staff spoke with them about this and provided support.

We observed when staff supported people they did so at their own pace and reassured people if they were upset.

One person said, “Brilliant here".

Is the service responsive?

We saw that people's individual physical, mental and social care and support needs were assessed and met. This also included people's individual choices and preferences as to how they liked to spend their day. During our visit we saw staff asked people what they would like. For example where they wanted to eat their meals and whether they wanted to join in activities or not. We also observed a person requested a drink and staff responded. One person we spoke with told us they chose not to go out of their room but this was respected and staff came throughout the day to make sure they were alright.

We observed staff usually obtained people's consent before they carried out any care. For example, they asked people if they wanted to go to the hairdresser and where they would like to eat their lunch.

Is the service safe?

Risk assessments regarding people's individual activities for example falls and mobility were carried out and measures were in place to minimise these risks. The service did not have risk assessments in place for areas such as the use of bed rails and refusal of care.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards in place. We saw an application had needed to be submitted to assess whether a person was being deprived of their liberty. We observed this was granted and safeguards put in place. Mental Capacity Act (2005) and Deprivation of Liberty Safeguards is law protecting

people who are unable to make decisions for themselves.

Relevant staff had been trained to understand when an application should be made and how to submit one. This means that people will be safeguarded as required.

The home also had policies in place regarding the safeguarding of vulnerable adults and when we spoke with staff they were able to tell us about this. The person we spoke with told us they felt safe and the relative said they felt their relative was in a safe environment.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk. We observed regular maintenance was carried out, for example on electrical and fire equipment.

Recruitment practice was safe and thorough. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

When we looked at records we found gaps in people's repositioning records. These gaps meant it was difficult to monitor what care people had received and would put people at risk of having pressure sores.

Is the service effective?

Our observations found that members of staff knew people's individual health and wellbeing needs. We saw that people responded well to the support they received from staff members.

When we spoke with a relative they told us the staff had supported their relative and understood the support they required to help them to settle into the home.

We observed staff responded to people's needs and requests in a timely manner.

Is the service well led?

Staff said that they felt supported and trained to safely do their job. Training plans were in place to ensure staff had the appropriate skills to meet people's needs.

Quality assurance arrangements were in place and people were listened to.

At the time of our inspection the home was without a registered manager. We spoke with the acting manager about this and they told us they were in the process of completing the application for registration to become a registered manager. We observed they had arrangements in place to provide leadership and support in the interim period.

You can see our judgements on the front page of this report.

People we spoke with told us that they liked living at The Manor Nursing Home. They told us that the Manager and staff team provided the support and care they needed.

One person told us that, “They (staff) are good to me and I can’t speak highly enough of them.” Another person said, “It doesn’t matter what you ask for or want they get it.”

During our visit we looked at records, including personal care plans. We also spoke to the manager and staff who were supporting people on the day of our visit, and we observed how they provided that support.

We saw that staff communicated in a way which people said they understood. One person said, “The staff are respectful and know my ways. When I get upset they understand me and listen.”

We spoke with two visiting professionals who told us that the service offered personalised support for people, and were responsive to people’s needs.

People said that they happy with the care and support they received and felt the home was a safe place to live. They told us that staff respected their decisions and including them in the planning of their care. One person explained to us how staff discussed things with them, adding, “but in the end I make my own decisions”.

One person told us that although she could mainly look after herself she valued the support staff gave her, which she felt was at the right level to maintain her independence.

We were told that people enjoyed the meals provided and we received no negative comments about the menus. They said things like, “the food is lovely, they ask me what I would like and offer me a choice” and “good food, I like it all”. We saw care staff helping people to eat their meal in a relaxed manner; they appeared unrushed and interacted well with the people they were assisting.

People told us they were happy with their rooms and the general facilities provided at the home.

The people we spoke with praised the staff saying things like, “the girls are very good” and “they look after us really well”. They said they could talk to the manager or any of the staff if they had any worries and no-one raised any concerns with us during our visit.

In this report the name of the registered manager appeared. They were no longer in post or managing the regulatory activities at this location at the time of our inspection. Their name appeared because they were still the registered manager on our register at the time of our inspection and have not taken the necessary steps to deregister. We are aware that a new manager would take up the post on 2nd October 2013.

Due to the needs of people who lived at The Manor Nursing Home we used different methods to reach a judgement on the quality of the service. We spoke with three people and three relatives about their views. We also spoke with two nurses, a care assistant and a maintenance person.

We looked at records and information about how the service was managed. We conducted a tour of the building and observed interactions between the care staff and people residing at the home.

Records we saw showed Mental Capacity Act assessments were inadequate and ‘best interest’ procedures were not in place. We also found that people’s needs had not always been adequately assessed and people did not always receive care, treatment and support which met their needs.

We saw people being offered choices and opportunities which were respected and responded to. We observed staff offering a person a choice of drinks and sweets. They showed respect, good listening skills and sensitivity.

Relatives we spoke with said, “It is very homely here, like a family”.