Manor Park 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The provider was in breach of legal regulations in relation to good governance of the service.

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Whilst the management team and staff expressed a commitment to person-centred care the shortfalls we found contradicted this.

There was a lack of engagement regarding organisational culture and core values. The provider failed to demonstrate that regular supervision and team meetings were used to reinforce the values of the service. There was also a lack of respect for maintaining a comfortable and safe homely environment. On both days of the assessment there was a hoover left in the corner of the lounge, the clinic room was cluttered, and people’s bedrooms had not been cleaned and tidied. This indicated a lack of respect for people’s home and a culture that did not embody strong and person-centred values.

Key governance gaps and incomplete monitoring records indicated cultural expectations were not consistently embedded across the service.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider did not demonstrate the required knowledge to lead and manage the service in line with requirements. There was a strong reliance on other staff and a lack of effective oversight over their work.

The provider and the registered manager were the same person. There was no evidence they had undertaken recent training to ensure they were competent to manage the service. The provider could not evidence how they actively sought staff feedback or created consistent opportunities for engagement. At our last assessment of the service, we recommended improvements be made to audits. Whilst there was an action plan in place, this spanned 2 years, and there was a lack of evidence to indicate shortfalls had been addressed or clear dates for completion. We found the service had deteriorated since our last assessment and the provider had not made the required improvements.

However, staff told us the registered manager and provider were approachable, and they thought the service was well managed. Staff comments included, “Management are understanding and supportive.”

The provider told us they planned to recruit a nominated individual and registered manager to oversee the service in the future.

People did not always feel they could speak up and that their voice would be heard.

The provider had a whistleblowing policy in place and staff said they understood how to raise concerns. However, the policy lacked detail. The provider and the registered manager were the same individual, and the policy did not contain clear guidance as to how staff could raise concerns outside of the service. There was no evidence of regular supervision which meant staff did not have formal opportunities to raise concerns, reflect on practice or seek guidance.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse staff team. However, there was a lack of evidence to indicate how staff routinely received support and guidance to carry out their role.

Not all staff had received up to date training in equality and diversity, which meant we were not assured their knowledge and understanding in this area was good.

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

Quality assurance processes to ensure the service was safe and effective were not in place. The provider did not have robust oversight of existing audits and there was a strong reliance on other staff to complete them. The audits in place were basic and did not provide effective tools to meaningfully assess the quality of the service. For example, the medicines audits did not cover key areas such as stock control, medication counts, temperature checks or reviews on completed MARs. This meant there was no oversight as to whether medicines were being administered safely.

The provider had policies in place, but we highlighted they had not always been adhered to.

Our findings at this assessment highlighted quality assurance processes were not effective at identifying multiple shortfalls across a range of areas, including staff training, supervision and the cleanliness and safety of the service. This lack of governance impacted significantly on the quality and safety of the service. As a result of our feedback the provider submitted an action plan, including timescales for improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider collaborated with the local authority who commissioned care and health and social care providers. However, their action plan highlighted they had not addressed shortfalls that had been identified. Whilst some people living at the home accessed local options, such as shops and the local park there was no evidence of wider community engagement or local connections.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research

There was not a culture of learning and improvement. The provider could not demonstrate their understanding of quality performance and regulatory requirements. The service did not use the tools available to them to learn lessons from routine events that occurred in the service. Audit processes were not used to drive improvement. The provider did not demonstrate innovation or proactive approaches to improving care for people.