We undertook an unannounced focused inspection of Manor Care Home on 18, 20 and 22 February 2019. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection date inspection had been made. The team inspected the service against three of the five questions we ask about services: is the service well led, safe and effective. This is because the service was not meeting some legal requirements.

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.

Manor care home is a care home with 34 people living at the home at the time of this inspection.

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. The care home has two floors with ensuite rooms and a passenger lift. The majority of people living at the home were living with dementia.

There was no registered manager present in the home at the time of our inspection. 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. There was a new manager who had taken up their position as manager from October 2018. The new manager had applied for registration with the Care Quality Commission and was going through the registration process at the time of our inspection.

When we completed our previous inspection on 10 and 11 July 2018 we found concerns relating to staffing in the home and also governance. On this inspection we found a continued breach of the regulation in relation to good governance and we made a recommendation regarding staff deployment within the home. We also found the provider was in breach of regulations in relation to consent, safe care and treatment and the premises.

We undertook a tour of the premises and found numerous health and safety concerns not being addressed by the provider such as an uncovered hot water pipe which was 75 degrees Celsius and fire doors not all staff could open in the event of a fire.

The provider was not always following the Mental Capacity Act (MCA) 2005. A best interests process was absent in the records for one person. Staff were administering prescribed medication to manage their behaviours without evidence of lawful consent.

There was no evidence of behaviours which were challenging being analysed for triggers to always show people were being supported in the least restrictive way.

Safeguarding processes were not robust enough. There was no evidence of trends or themes being analysed by the provider.

Care plans were not up to date with accurate information. Person centred care was not being delivered.

People’s nutritional needs were not always being met as we observed people struggling to eat and drink or sitting with food in front of them not being supported to eat. We made a recommendation about staff deployment.

The emergency call bell system was not robust. Emergency pull cords were seen tied up and some sensor mats/door alarms were unplugged/switched off.

Quality checks and audits had not identified all of the issues we found on this inspection. The provider had not demonstrated they had taken robust action since the last inspection.

The home had a 5 star rating for food and hygiene. The rating was displayed in the main entrance of the home.

Prescribed medicines were being managed safely.

This inspection was carried out over two days on the, 10 and 11 July 2018. Our visit on the 10 July was unannounced. At our last inspection in June 2016 the service was rated ‘Good.’

Manor Care Home is a ‘care home’. 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.

Manor Care Home provides accommodation and personal care and support for up to 44 older people. The accommodation is provided over two floors in a large listed building and a large purpose-built extension attached to the main building. The home has 44 bedrooms of varying size, 34 of which have an en-suite facility. There is a range of communal spaces including: lounges; dining rooms and sitting areas. Toilet and bathroom facilities are dispersed throughout the building. There is a car park provided for visitors and staff. The home is situated in a quiet residential area of Middlewich. At the time of our inspection 32 people were living at the service.

The home has a manager and they have applied for registration with CQC. 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.

The registered provider had systems in place to monitor the quality of the service provided. Some areas needed improvements. For example, such as out of date health and safety checks had not been identified within the services own monitoring procedures. Some areas needed improvements such as environmental risk assessments, kitchen maintenance, updates needed for record keeping and repairs had not been identified within the services own monitoring procedures.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated activities) regulation 2014 Good Governance.

Staffing levels had been recently revised by the registered provider. On occasions staffing levels had been lower than the levels stated by the provider due to short notice of staff sickness. This puts people at risk of not being provided with appropriate support due to less staffing than would normally be in place.

This is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated activities) regulation 2014 Staffing.

‘You can see what action we told the provider to take at the back of the full version of the report.’

Since starting in post 10 weeks earlier, the manager had introduced regular supervision sessions and training for the staff team. The manager was clear in explaining that staff had been out of date with various training when she commenced in post.

Procedures were in place to minimise the risk of harm to people using the service. Staff understood how to recognise and report abuse which helped make sure people were protected. Monitoring checks needed review to show better governance of their records in analysing and reporting events.

Risk screening tools had been developed to reflect any identified risks and these were recorded in people’s support plans. The risk screening tools gave staff instructions about what action to take in order to minimise risks e.g. for falls.

Staff were recruited following a safe process to make sure they were suitable to work with vulnerable people.

Staff had access to personal protective equipment (PPE) to help reduce the risk of cross infection for example disposable gloves and aprons.

The service had policies and procedures relating the Mental Capacity Act 2005 and deprivation of liberty safeguards. Staff had recently completed training in this topic and staff understood the needs of the people they supported who lacked capacity.

Staff had good relationships with the people they were ca

The inspection took place on 30 June 2016 and was unannounced. At our previous inspection in March 2014 we found that the provider was meeting the regulations in relation to the outcomes we inspected. There were 41 people living in the home at the time of our inspection.

Manor Care Home provides accommodation and personal care and support for up to 44 older people. The accommodation is provided over two floors in a large listed building which has been converted and adapted for use as a residential care home. The home has 44 bedrooms of varying size, 34 of which have an en-suite facility. There is a range of communal spaces including: lounges; dining rooms and sitting areas. Toilet and bathroom facilities are dispersed throughout the building. There is a car park provided for visitors and staff. The home is situated in a quiet residential area of Middlewich.

The home has a registered manager. 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.

People who lived in the home and their relatives spoke of the quality of the care delivered. They told us that the staff of the home went above and beyond to ensure they received a person centred service. Staff maintained people’s privacy and dignity ensuring that any care or discussions about people’s care were carried out in private. We saw that interactions between staff and people who used the service were caring and respectful with staff showing patience, kindness and compassion. We observed that staff knew and understood the people they cared for and ensured that people were provided with choices in all aspects of daily life. Comments made included; “The care she has received has been second to none; the staff are incredibly attentive and genuinely create relationships with the residents. Whenever issues have arisen, for example when (name) was diagnosed with pneumonia this year and was subsequently hospitalised, the staff and management alike have been quick to respond and help. Lines of communication have always been clear and open”.

Staff were well trained and used their training effectively to support people and assist them with their daily life and help them wherever possible to retain their independence. Staff told us that the provider had developed some extra training events for staff to enable them to gain knowledge and skills to enhance the lives of people who were living with dementia.

Staff understood and worked within the requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards. Staff were able to demonstrate an excellent understanding and knowledge of people’s support needs so as to ensure people’s safety and protect their human rights.

Staff were recruited through a rigorous procedure. Staff went through a robust recruitment process before starting work. As part of the recruitment process the provider used value based recruitment techniques, a clearly defined culture statement and staff competency assessments.

People received their medicines as prescribed by their GP. Medicines were managed safely to ensure people received them in accordance with their health needs and the prescriber’s instructions. A GP was assigned to conduct weekly visits to the home to take a proactive approach to healthcare. Staff told us that this assisted them to discuss any issues relating to people’s health and well-being and to assist with regular health checks such as blood pressure readings ‘without fuss’.

Staff were attentive to people’s appetites and ensured that people were provided with a meal of their choice. We saw that special diets were catered for. Staff told us that menus were not provided because people were not always sure what they wished to eat pr

Prior to our visit to Manor Care Home we had received some expressions of concern about staffing levels, care and support and the general environment within the home. As a consequence we undertook an inspection of the service on 5th June 2014.

During the inspection we spoke with the home manager, the clinical lead nurse, six staff members and a director of the company. We also spoke with eight of the people who lived in the home and four of their relatives.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The home was well maintained and we noted that the security of the premises had been enhanced and a programme of refurbishment was taking place in order to ensure the home was pleasant and safe for people living and working there.

Training records highlighted that staff were up to date with all mandatory training needed to support people living at Manor Care Home. This helped to ensure people that were supported by staff who were fit to carry out their roles and responsibilities and were suitable to work with people who lived in the home.

The manager advised us that appropriate procedures, including review were in place should anyone need to be subject to a Deprivation of Liberty Safeguard (DoLS) application or plan. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.

Is the service effective?

We looked at six care plans and saw that people and their relatives were involved in the planning of their care. We saw that risk assessments were in place to support people's particular needs such as support with moving and handling. We saw that the care plans had been significantly improved over the past months. We saw that more robust evaluations were taking place and that care plans had been updated to reflect the changing needs of the people in the home.

Is the service caring?

We spoke with eight people who lived in the home and they all said positive things about the care that they received and the staff who supported them. Comments included; “the staff are very nice people”, “staff are kind and helpful”, “staff are fully committed to providing good quality care and support” and “cannot fault them”.

We observed that relationships between staff and people who lived in the home were warm and friendly and we saw that people were relaxed in the company of staff. We saw groups of people chatting to staff in a calm and friendly atmosphere. We saw that the staff were skilled in supporting people who had dementia whilst encouraging them to maintain their independence.

Is the service responsive?

The care plans looked at had been written in a person centred manner. This means that the individualised care plans focused on the person's individual assessed needs and on how they could be met. The care plans focused on providing support to an individual in different aspects of their daily life, for example how the person was to be supported with promoting their independence and any issues regarding their health so that they stayed as healthy as possible.

We saw that people were weighed on a regular basis and the results were recorded in a file in the main office as well as in people's individual care files. A recognised assessment tool was being used in the care plans and it was correctly used and recorded. We were able to see that these people were receiving the appropriate care and that people's weights were closely monitored and maintained.

Is the service well led?

We saw that quality audits were carried out by the provider. We looked at completed audits and saw that action had been taken in response to any issues raised. We looked at the manager's audit file and saw that the provider had put in place a monthly audit plan. The manager told us that they completed these each month and the information was reviewed and acted on where necessary. This showed that the provider ensured that there was an effective system to regularly assess and monitor the quality of service that people received. The staff members we spoke to said that the home was well managed and they enjoyed working there.

When we inspected Manor Care Home in October 2013 we found that improvements were needed to protect people from receiving inappropriate or unsafe care. Following our visit the provider sent us a detailed action plan which indicated that appropriate arrangements to protect and assure the health, safety and welfare of people living at the home would be in place by 31 January 2014.

We carried out this inspection to follow up on actions taken by the provider to ensure people were receiving safe and appropriate care.

We found that the home had a relaxed, sociable and welcoming atmosphere. Some of the people with were able to discuss the arrangements made for their care and support. They told us that they were happy and content and we saw that they were treated with respect and enjoyed good relationships with staff.

We looked at the personal care files for four of the people who lived at the home and saw that improvements had been made in the way care plans were written. Records showed that each person's health and wellbeing was monitored closely and where appropriate staff had sought medical attention or advice and guidance from the person's health and social care professionals.

We found that improvements had been made in each of the required essential standards including the provision of suitable numbers of staff and the assessment and monitoring of the service provision by the registered person.

We observed staff carrying out their work with care, sensitivity and skill.

Cheshire & Merseyside Health Protection Team, Public Health England recently identified a cluster of bacteria that was resistant to antibiotics. It appeared that some people living at the home had been infected by this bacterium. This resulted in visits made to the home by specialist staff in infection control. As part of CQCs collaborative work, we have liaised with other agencies that, over the last two months, have made very regular visits to the home and monitored changes and improvements. This inspection was conducted by two CQC inspectors and an accompanying specialist advisor in infection control.

The directors of the company operating the home, their management team and all the staff we met with on the day of the inspection were transparent, proactive and committed to securing the positive improvements recently made in the service the home provided.

People living in the home and people visiting the home made a range of comments. Some of which were very positive others were more neutral.

Staff comments voiced some concerns about staffing levels.

During our visit we saw that care was unhurried and that staff supported and encouraged people who lived in the home. We saw that staff treated people with respect and maintained their dignity.

One person visiting the home told us that during their visits “staff are always kind and caring to the residents”. A relative told us “staff always ring if my (family member) is ill or has an accident.

The relatives and other visitors told us they had no concerns or worries about the care and support offered to their family members who lived in the home. .

We saw that care plans were regularly reviewed and updated by staff. The provider may wish to note that there was little evidence to show that people who used the service and/or their relatives were involved in developing or reviewing the plans of care.

Information provided by the manager during this inspection told us there were policies and procedures in place to safeguard people who used the service from harm or possible abuse.

The manager provided us with a copy of the staff training record which showed staff had access to or had received appropriate training.

We saw records which showed that checks were carried out to ensure the health and welfare of people who lived in the home was maintained.

The provider told us that the manager would be submitting an application to the Care Quality Commission (CQC) by the end of February 2013 for the post of registered manager.

People we spoke with were happy with the support and care they received in The Manor Care Home. They told us that staff listen to any worries or concerns they may have and they were confident these would be listened to and acted upon. We were also told they were able to follow their daily routines as they wish.

People who use the service also told us they receive the level of support they require to live as independently as possible. They liked living in The Manor and liked the staff who support them. They also told us staff help ensure they were kept safe and that their health and social care needs were being met.

Overall people who use the service told us were satisfied with service they receive.

Information received from Cheshire East Social Services told us they had no recorded issues about the service. We were also told by a healthcare professional that they had no concerns about the care and support offered to the people who use the service.