• Care Home
  • Care home

Manor Court Care Home

Overall: Good read more about inspection ratings

Britten Drive, North Road, Southall, Middlesex, UB1 2SH (020) 8571 5505

Provided and run by:
Bupa Care Homes (CFHCare) Limited

Report from 11 May 2024 assessment

On this page

Safe

Good

Updated 8 July 2024

People using the service and their relatives said they felt safe. Staff understood how to protect people from abuse. The risks to people's safety and wellbeing were assessed, planned for, and monitored. People lived in a safe and well-maintained environment. People received their medicines safely and as prescribed. There were enough suitable staff to care for people.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning culture

Score: 3

People using the service and their relatives told us they knew who to speak with if they had a complaint. People who had raised a concern were happy with the way these had been responded to. One relative commented, ''When I had a complaint, I felt [ managers] listened to me.''

Staff told us the management team were good at sharing information with them. They explained that following incidents, accidents, complaints, or safeguarding concerns they had meetings to discuss this and had learnt from what had gone wrong. They also told us that the organisation shared learning from other services.

The staff recorded all accidents, incidents, and other adverse events. These records were appropriately detailed and included information about how they responded to the situation and the outcome of this. These records were analysed, and the management team had good oversight, identifying themes, and taking action to put things right. They shared learning with staff through meetings and written communication.

Safe systems, pathways and transitions

Score: 2

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safeguarding

Score: 3

People using the service and their relatives told us they felt people were safely cared for.

Staff told us they had undertaken training to recognise and respond to abuse. They were able to tell us about different types of abuse and how they would react if they witnessed or were made aware of this.

Staff supported people in a safe way. There was information on display about how to recognise and report abuse. People looked comfortable and relaxed with the staff. Staff regularly checked on them and asked them if they were alright.

There were procedures for safeguarding people from abuse. These had been followed and the provider had worked with other agencies, including the local safeguarding authority, to investigate allegations and to follow protection plans.

Involving people to manage risks

Score: 3

People using the service and their relatives told us risks were well managed. People were supported to take risks and be independent when they wanted.

Nurses and unit leaders explained they were involved in developing risk assessments. Other staff confirmed this information was shared with them. They told us they had relevant training to help manage risks and keep people safe.

We observed staff following good practice when supporting people to move and when people were eating and drinking. Staff were patient, explained what they were doing and encouraged people to be independent when they were able.

The staff had carried out risk assessments for each person. These included risks to their wellbeing, relating to their health, with eating and drinking, moving safely and risk of falls. The assessments were clear and included personalised management plans. They were regularly reviewed and updated. The staff reviewed plans and reassessed risks following accidents, incidents, and falls.

Safe environments

Score: 3

People told us they felt they lived in a well-maintained environment. Some people highlighted they wanted some areas repaired or redecorated. We told the registered manager about these comments. People told us they were able to personalise their rooms.

Staff told us they were involved in checking the environment for risks. They explained repairs were attended to promptly and there were good systems for reporting issues.

The environment was safely maintained. There was adequate equipment to help keep people safe, to reduce the risk of falling, to reduce risks of skin damage and to safely move people. There were call bells available in bedrooms and communal rooms, as well as other equipment such as sensor mats, when people had been assessed as needing this. The environment was generally well maintained and decorated. There was enough furniture and additional features to help create a homely atmosphere and pleasant surroundings. People had access to communal spaces including enclosed gardens for each unit.

There was a planned programme of refurbishment. The provider had designed refurbishments based on the needs of people living at the service. For example, there was an accessible kitchen for people with physical disabilities to use to make their own drinks and snacks. A dementia specialist had helped design features to help support people with orientation. They had worked with external agencies and had developed plans to alter the lighting, acoustics, decoration, and interactive features in line with best practice for positive environments for people living with dementia. The provider ensured there were regular checks on the environment, equipment, and safety.

Safe and effective staffing

Score: 3

People using the service felt there were enough staff. They said they did not have to wait for care. They told us call bells were answered promptly. They explained staff were knowledgeable and they felt they had the right skills and training to provide safe care.

Most staff felt there were sufficient staffing levels. They worked together as a team and were happy with the way tasks were delegated and they shared information. Staff felt supported by managers and told us there were clear lines of responsibility. Staff told us they undertook a range of training and could request support with qualifications and further training if needed.

Staff were available when people needed them. They were attentive and provided a good level of support. Staff did not rush people.

There were systems to help ensure only suitable staff were recruited. These included checks on their identity and right to work in the United Kingdom. The provider assessed staffing levels based on people's needs. People were cared for by the same regular staff who knew them well. The provider supported staff with a range of training, opportunities to meet managers and appraisals of their work.

Infection prevention and control

Score: 3

Two people raised a concern about cleanliness. We told the registered manager about this so they could address their concerns. Other people told us the building was kept clean. They were happy with the way laundry was managed. They told us staff wore gloves, aprons, and other person protective equipment (PPE) as needed.

Staff told us they undertook training about good infection prevention and control. They had enough PPE and were involved in checking procedures were followed.

The environment and equipment were clean. The provider employed a team of housekeeping staff who followed schedules to ensure all areas were deep cleaned.

The staff used systems to help prevent the spread of infection. They, and managers, carried out infection prevention and control audits and checks on cleanliness. When problems had been identified the staff took action to address these. There were suitable systems for food storage and preparation; as well as monitoring the temperature of food.

Medicines optimisation

Score: 3

People were given their medicines as prescribed, safely and in a timely manner. This was recorded on their medicines administration record (MAR) by the staff. Some people were prescribed medicines to be administered on when required basis. Guidance in the form of PRN protocols was in place to help staff give these medicines consistently. Care plans had the necessary information to guide staff to support people with their health needs.

Staff were trained in medicines administration and managers had assessed their competency and knowledge. This ensured staff could handle medicines safely. Staff told us they supported people and clinical healthcare professionals so that -people’s medicines were reviewed periodically.

Medicines were stored securely at appropriate temperatures. There was an effective system in place to order prescribed medicines. MAR were updated accurately and in a timely way when medicines were administrated, started, and changed. People’s allergies were accurately recorded. Regular medicines audits were carried out to identify gaps and make improvements. There was a process in place to report and investigate incidents. Medicines policies were in place to guide staff on how to handle medicines safely.