The Manor House Thurloxton

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (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 providing non-institutionalised care where people were treated with dignity and respect and their wishes were prioritised. It was evident the providers direction and culture were reflected within the service. Staff felt that the service was a "Home away from home" for people. People and their relatives emphasized that they were happy with the service. Person centred care was embedded within the service, and people’s strengths were celebrated. Staff felt supported by managers and provided good care to people.

Managers were inclusive, compassionate and embodied the culture and values of the organisation. However, they did not always understand the context in which they delivered care, and support. We found several shortfalls during the assessment which were not independently identified and addressed by the managers. This reduced assurance that leaders had effective oversight of the quality and safety of care and were identifying and addressing concerns in a timely way.

The deputy manager was in the process of completing a qualification in managing within health and social care and wanted to make changes within the service. However, the service did not have an action plan to monitor the progress with these improvements before our assessment. Therefore, the provider could not demonstrate any shortfalls they had identified and how they planned to action them.

However, people and relatives were positive about the managers who were clearly visible within the service. One person told us they were, “Very happy with [deputy manager].”

Managers were responsive and immediately began acting on our feedback during the assessment. However, improvements were still to be fully embedded and sustained.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of whistleblowing and provided consistent feedback about their ability to raise concerns. This meant there was a positive and open culture at the service.

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. Managers told us, “Staff all bring something to the table.” Staff were supported by managers. One staff member told us, "I think we are treated fairly."

The provider did not have clear responsibilities, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes as they did not analyse and learn from shortfalls.

Governance systems had not identified and addressed the safety and quality concerns we have reported on throughout this assessment.

A considerable amount of information within the service was conveyed verbally; therefore, it was difficult to evidence when concerns were followed up, and what outcomes were achieved. The provider could not be assured correct actions were taken to keep people safe and could not demonstrate a learning culture.

The provider did not assess some risks to people, such as those associated with choking and community access. Risks associated with health and safety were not identified and actioned. Actions following the fire assessment were overdue.

We found the provider did not notify the Care Quality Commission (CQC) of 2 notifiable events as required by law. When significant incidents happen, providers must send a formal report called a statutory notification to the CQC to enable oversight and regulatory action if required.

We found policies missing. This meant staff were unable to access necessary guidance to ensure people were cared for safely. Although the provider started to implement policies during our assessment, these would require time to become fully effective.

The provider did not have any auditing systems for the service. The provider did not identify and address concerns in a timely way. This placed people at risk of harm. The deputy manager told us they planned to introduce audits following the assessment.

The range of governance shortfalls identified across the service highlighted the provider did not consistently use information relating to risks, best practice and outcomes to drive improvement.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. One healthcare professional told us, “It really does feel like home from home for the residents, a very special environment.” The service worked in collaboration with external professionals and people were supported to attend regular appointments.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

We found several shortfalls during the assessment which the provider had not identified through their own governance systems. Although the provider began acting on our feedback during the assessment, they did not identify these concerns via their own governance systems. For example, following our first visit to the service, the deputy manager introduced an electronic medicines administration record (eMAR) system to improve safe management of medicines. This would require time to become fully embedded before its effectiveness could be established.