People in Action - 132 Manor Court Road

Social Care Org · West Midlands

Overall Rating
Requires Improvement Last inspected 5 January 2024
Domain Ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

View Full CQC Report

8 must-do actions

Must-Do Actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
12(1) The provider had failed to ensure care and treatment was provided in a safe way for service users.
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service. This placed people at risk of harm. Staff made no attempt to encourage one person to wash their hands before eating their meal, repeating a failure from the …
Must Do
Safe
12(2)(a) The provider had failed to assess the risks to the health and safety of service users of receiving the care or treatment.
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Records did not contain detailed information about one person's medical condition (following surgery) to inform staff how to identify further risks or how to support the person with ongoing medical appointments.
Must Do
Safe
12(2)(b) The provider had failed to do all that was reasonably practicable to mitigate any such risks.
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Environmental risks remained, including incomplete legionella water temperature control tests (without evidence of new boiler system negating need), significant delay in fitting new fire doors (identified as non-compliant in Jan 2023), and staff leaving a paint pot propping open a fire door and cleaning chemicals in an unlocked cupboard. The …
Must Do
Safe
12(2)(g) The provider had failed to ensure the proper and safe management of medicines.
Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
Medicines were not always managed safely, with the medicine room and stock cupboard left unlocked. The system for booking medicines required improvement, lacking clarity on quantities for effective auditing. Medicine administration records were not completed in line with best practice, with handwritten entries often missing strength, form, dose, frequency, or …
Must Do
Well-led
17(1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.
Regulation 17 HSCA RA Regulations 2014 Good governance
The provider's systems and processes failed to assess, monitor and drive forward enough improvement in the quality of care to be compliant with the regulations. Quality oversight was reliant on staff experience rather than set standards, leading to un-identified concerns. Timely action was not always taken on identified concerns.
Must Do
Well-led
17(2)(a) assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services);
Regulation 17 HSCA RA Regulations 2014 Good governance
The provider's systems and processes failed to assess, monitor and drive forward enough improvement in the quality of care. Effective audit tools were lacking for high quality care, including checks on medicines and risks in care records. Quality oversight was inconsistent, relying on individual staff experience rather than provider standards, …
Must Do
Well-led
17(2)(b) assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity;
Regulation 17 HSCA RA Regulations 2014 Good governance
The provider failed to have a robust policy on the management of appointeeships, with records not supporting safe money management due to missing mental capacity assessments, best interests' decisions, or risk assessments. Effective audit tools were lacking for risks within people's care records, and quality oversight failed to identify some …
Must Do
Well-led
17(2)(c) maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided;
Regulation 17 HSCA RA Regulations 2014 Good governance
Records did not always show people's capacity had been assessed, with limited evidence of best interest decisions or family involvement. Information to support decision-making was not always provided in an understandable way, and staff did not always take practicable steps to support decisions on finances or health. Records lacked detailed …
Location Details
CQC ID: 1-111132796
Local Authority: Warwickshire
Region: West Midlands
Inspection Report
Type: Inspection report
Date: 5 January 2024
Rating: Requires Improvement
Actions: 8 must-do
AI-extracted 17 Feb 2026