CQC report explained · a residential care home, run by Sanctuary Care
The Manse Residential Care Home
11 South Norwood Hill, South Norwood, London, SE25 6AA
Rated Good: inspectors found the service performing well and meeting their expectations.
What inspectors found, January 2024
Rated Requires Improvement; inspectors found kind support but gaps in safety, staffing, dignity and care planning.
This was an unannounced inspection. It started by looking at Safe and Well-led, then widened to cover all five areas after inspectors found potential concerns. They visited on 31 October, 1 November and 29 November 2023, spoke with people, relatives and staff, and reviewed care, staff and management records.
Inspectors found risks were not always properly assessed or managed. Medicines records and instructions were not always safe. Staffing levels were not always enough to provide timely support, including at night. Some people's privacy and dignity were not respected, and care plans were not always up to date or personalised.
There were also problems with radiator safety, fire door repairs, staff training and the home's checks on quality and safety. Inspectors found no evidence that anyone had been harmed, but said the issues had put people at potential risk of harm. The home had previously been rated Good in 2017, but all five current ratings are Requires Improvement.
Kind staff
People and relatives described staff as friendly and supportive. Inspectors also observed kind interactions.
“Staff interactions with service users were friendly, caring, kind and supportive.” from the report
Food and drink
People were supported to eat and drink enough. They had dietary assessments, a varied menu and choices of meals.
“People were supported to eat and drink enough and maintain a balanced diet.” from the report
Activities and relationships
People could take part in activities, go out, see family and friends, and choose how they spent their time.
“People spent time with family and friends, participated in activities, went out into the community, and went on day trips.” from the report
Involvement in care
People and relatives were involved in planning and reviewing care and in decisions about support.
“People and their relatives were included in planning and reviewing their care and making decisions about their care and support, including any changes.” from the report
Risk management
seriousSome risks had no assessment or did not have clear, up-to-date instructions for staff. Inspectors found no evidence of harm, but said people were at potential risk.
“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.” from the report
Medicines
seriousSome people did not always receive prescribed medicines. Records, stock totals and instructions for medicines given when needed were not always reliable.
“Medicines management was not always safe.” from the report
Staffing
seriousThere were not always enough suitably qualified staff. During a night shift, one person needed immediate help but was left without staff support until inspectors raised the issue.
“The provider did not always deploy enough staff to meet all people's needs and health and safety requirements at all times.” from the report
Privacy and dignity
seriousInspectors saw two incidents where privacy and dignity were not respected. Two bedrooms also had carpets that continued to smell of urine.
“People's privacy and dignity were not always respected and maintained.” from the report
Quality checks
seriousThe home's audits and checks had not found several problems with care plans, medicines, staffing, training, safety and records.
“The provider's quality assurance systems and processes were not always effective.” from the report
Premises safety
seriousSeveral radiators lacked covers in areas used by people with limited mobility. The covers were still missing when inspectors returned four weeks later.
“During our inspection we identified a number of radiators without radiator covers in people's bedrooms and communal areas.” from the report
- 01What action has been taken to make risk assessments and care plans complete, personalised and up to date?
- 02How are medicines now checked, including topical creams, stock totals and medicines given when needed?
- 03How many staff are deployed on each shift, especially at night, and how is this matched to people's changing needs?
- 04Have all radiator covers been fitted, and have all fire safety and maintenance checks been completed?
- 05How does the home now check that people's privacy, dignity and personal hygiene are protected?
The inspection began as a focused inspection of Safe and Well-led, then widened to a comprehensive inspection covering Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 12 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of The Manse Residential Care Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Manse Residential Care Home →
- November 2020Inspected but not ratedSafe: Inspected but not rated
- December 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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Other services run by Sanctuary Care Limited
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