Cliveden Manor Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first full assessment for this service. This key question has been rated Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

People, their relatives and staff felt leaders were approachable and responsive to concerns. A person told us, “If I had a problem, I can go to the manager.” Records evidenced an open culture where people were encouraged to provide feedback.

Staff reflected a positive and caring culture, with staff expressing pride in their work and describing strong relationships with people living at the service. A staff member told us, “Everyone here is very friendly, we take care of each other. Other agency staff [tell] me this is a good place to work. I feel that I already have a bond with [people] and they appreciate me.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff spoke positively about the visibility of local managers. Staff told us registered managers and nursing leaders regularly worked alongside them and provided support on the floor when required. Staff told us care plans and audits were reviewed by managers, with action plans provided where improvements were needed.

Leaders were observed to interact kindly with staff, people and their relatives. The registered manager knew people, their needs and their preferences well. Leaders within the service had appropriate clinical qualifications to support people’s medical needs, as well as supporting staff within the service. Leaders were open, honest and aware of areas of the service that needed some improvements, for example, hand hygiene, medicines management and record keeping. This meant staff were supported by leaders who promoted a positive, transparent, culture.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were able to raise concerns within meetings, and we observed updates provided in a “you said, we did” format. Records showed changes had been made where staff were struggling with their workload to assist them. People and their relatives all confirmed they would feel confident in raising concerns if needed. A staff member told us, “[Registered Manager] is down to earth and realistic and clear about what [they] can do within their remit. [They have] always been responsive to my requests.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff spoke positively about the culture of the service and described a caring and compassionate workforce. Several staff told us they were proud to work at the home and felt people received good-quality care from committed staff. Appropriate reasonable adjustments were in place for staff who required them to support them in their roles, demonstrating an inclusive experience for staff working in the service.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems and processes were not always effective and did not identify concerns found amongst records on inspection, for example, inconsistent information in care plans, people’s reviews not always being completed as per the provider’s policy, and medicines. We gave feedback to the provider, and they took action to rectify this.

However, leaders within the service carried out a variety of audits, for example, assessing health and safety, medicines, IPC, accidents and incidents, nutrition and hydration, and skin integrity. Leaders also undertook “Quality Walkarounds”, assessing areas such as dining experience, residents in bed, memory care, resident and colleague feedback. These quality walkarounds included assessments of people who had remained in bed for a prolonged period of time.

Actions were identified in walkarounds and follow up was clearly updated. Meetings were held regularly to discuss outcomes, lessons learned and actions put in place to reduce risk. These provided clear oversight of people’s care, wellbeing and experience of the service.

We gave feedback to the registered manager regarding inconsistent information held in care records. The provider took action to rectify this.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Where incidents had previously occurred involving the use of people's own equipment, records demonstrated appropriate involvement of relevant healthcare professionals. Professionals worked with people to help them understand how to use their equipment safely and provided guidance to reduce the risk of further incidents occurring. Care records evidenced a proactive approach to risk management, with support tailored to the individual's needs to promote both safety and independence. This helped ensure people were able to continue using their equipment while understanding the associated risks and the measures required to minimise them.

The provider focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The provider’s audit process resulted in actions added to a service-wide plan which helped to drive continuous improvement and innovation. Staff also recognised improvements made by the service, particularly in relation to medicines management and operational systems. This meant people’s care continuously benefitted from improvements identified.