Archived: Metchley Manor

Updated 24 October 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 2 inspectors, Specialist Nursing Advisor (SpA) and 2 Experts by Experience. Both inspectors, SpA and 1 Expert by Experience completed a site visit. The second Expert by Experience made telephone calls to people and relatives of people who used the service. 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

Metchley 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. Metchley Manor 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

This inspection was unannounced.

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.

We reviewed public information available on the Healthwatch website. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

During the inspection

We spoke with 11 people who used the service, 5 family members and friends. We spoke with the registered manager, deputy manager, 2 team leaders, 10 staff that included housekeeping, catering, activities and care staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed the care records for 5 people who used the service and a selection of medicines administration records for people. We observed the care and support provided by staff and the home environment was assessed for safety and suitability. We also looked at 3 staff recruitment records, the provider’s policies, quality assurance audits and action plans.

Updated 24 October 2023

About the service

Metchley Manor is a residential care home providing personal care to up to 98 people. The service provides care and support to younger and older people, people living with physical disabilities and/or sensory impairments and people living with dementia. At the time of our inspection there were 57 people using the service.

Metchley Manor accommodates people in a large, purpose built dwelling across three units, each of which has separate adapted facilities. One unit specialises in providing care and support to people living with dementia.

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

People received a consistently high standard of care because the staff and management team placed people at the heart of the service. People told us they felt listened to and staff were kind, caring and compassionate. There was a friendly, positive atmosphere throughout the service. Staff had a good knowledge of people's needs, values and beliefs. People were involved in activities that were chosen by them and were meaningful to them. People and their relatives were involved in community projects and charity events to enable them to feel part of the community and have a sense of purpose.

The registered manager and staff were focused on providing a person led service that promoted positive outcomes for people. This was recognised with the service winning recent national awards. There was strong, clear leadership in the service and the registered manager was a role model for the staff providing direction and encouraging personal development of their skills and knowledge.

The care model for the service focused on the people living at Metchley Manor and actively promoted their independence and safety. Staff were aware of the responsibilities to keep people safe from abuse. The service was proactive in identifying areas that could put people at risk of avoidable harm. There were sufficient numbers of staff on duty to support people safely. Appropriate recruitment processes were in place to employ suitable staff to support people. Systems were in place to manage medicines safely. People were encouraged and supported to self-medicate to maintain their independence. The home was clean and well maintained.

People were actively involved in their care. Staff received appropriate training to carry out their duties effectively and had excellent relationships with people. Staff used effective communication skills to promote choice and independence. There was a special focus on nutritional and hydration and ensuring mealtimes were enjoyable, providing a social experience for people. The service embedded best practice to meet people's individual needs and ensured they received good healthcare.

Systems were in place to ensure people were able to make day to day decisions about their care and encourage people to do so. 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.

The registered manager promoted a culture of being open and honest, so people and their family members had confidence in the service being provided. There was a robust quality assurance system in place. Actions were taken in response to findings and the provider had a clear accountability structure in place. Incidents were shared with staff and reflective practice was used at all levels to drive improvement. Where we identified minor shortfalls as part of the inspection these were acknowledged and promptly actioned by the registered manager and their management team.

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

The last rating for the service under their previous provider was good, published on 23 June 2018.

Why we inspected

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

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.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.