The 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 assessment for this service registered under different legal entity/provider. This key question has been rated 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 governance and oversight.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager and the provider had a shared vision, strategy and culture that was based on transparency, engagement, and understanding challenges and the needs of people and their communities. People and relatives noted staff were kind and reasonable, followed people’s wishes, and they did not observe any animosity between the staff. We observed the staff were smiling, welcoming and spoke to the inspection team. Overall, during the inspection it was observed staff worked collaboratively as an effective team. They demonstrated understanding of people’s needs and responded to them appropriately. Staff communicated with people and with one another in a respectful and positive manner. The people and relatives mostly spoke positively about the provider and the management of the service. Some people recognised there had been some changes in the service that affected staffing. They agreed that the staff and the management team worked in a positive and compassionate culture that supported them and each other. They said, “It’s lovely and the staff seem happy” and “I think so, yes [it is managed well]. I just feel that they could do with one or two more staff. The door is always open if you need to talk to someone”. The manager said, “I really love what I do, and I really care about it, and I hope it transmits to the team.”One professional added, “The type of positivity, calmness and caring culture can only come from the top and is fed down to give the lovely residents the best care and experience.”The manager and the staff team demonstrated a shared responsibility for promoting people’s wellbeing, safety, and security. The staff team and the manager used regular communication to share and discuss any information or changes. One staff member told us, “I feel supported by the current management team. There were lots of changes which was unsettling, but already the new team has helped with this. The manager is open and transparent and is approachable…It is more than a professional care, it is [manager’s] personality, and [the manager] operates a truly open door policy.” Another staff member said, “I am very happy with [the manager], who is nice and approachable…[The manager] has an open door and really makes time for us. [The manager] is on the floor a lot, mixing with the residents.”

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 managed the service with integrity, openness and honesty. The manager understood the requirements of how to deliver care, treatment and support and embody the culture and values of their workforce and organisation. The manager worked with the staff team to support their professional development to ensure they had the skills, knowledge, experience. Staff felt listened to, supported and that the manager was approachable. They said, “The manager has an open door policy and is very welcoming. [The manager] respects confidentiality, and the fact that [the manager] listens make me feel confident that [the manager] will try to resolve my concerns” and “The current manager really listens and respects me for the work I do; we are all treated as professionals.”Staff worked together well and were positive about the leadership in the service that contributed to better outcomes for people, their relatives and the staff team. The management team were visible to the staff team, people and relatives, and professionals. They praised the staff team saying, “My team are a great support to me. I have taken time to learn about the challenges and barriers to understand it. I look forward to coming to work, I love what I do and I love my team.”We observed staff and the managers were respectful and kind towards people and each other. The manager promoted a positive, caring, transparent and inclusive culture within the service. The staff team were motivated to provide care and support to people as their needs and health were changing.

The provider fostered a positive culture where people, their relatives and staff felt that they can speak up and that their voice would be heard. The management team encouraged staff to raise any concerns and promoted the value of doing so. Staff were confident that their voices would be heard, and they were happy to approach the manager or senior staff for support. There was a culture of speaking up where staff could raise concerns and would be supported without fear of detriment. The provider investigated any concerns that had been raised and responded appropriately. The staff added, “I can definitely voice my views without being fearful of any consequences to myself and it would be addressed in the appropriate manner. There is an open culture within the whole service, everybody strives for perfection and I believe this is respected” and “I have no doubt that what I may have to say is taken seriously. We are also reminded about the importance of whistle blowing; the level of awareness has been raised and there are posters up everywhere.”

The provider worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them. The provider valued and respected diversity in the workforce. They knew how to take action to improve if there were any disparities in the experience of staff with protected equality characteristics. Staff received training in Equality, Diversity, and Inclusion in Health and Social Care to support their roles. The manager also spent time on the floor with staff and people to pick up on any inequality issues. Staff felt positive about the manager and their support. Staff felt supported and treated fairly by the manager. Staff said, “I believe that people are treated equally, there is no sense of discrimination towards skin colour or religion here” and “The provider recognises cultural differences and no matter what race or colour, everyone is respected for who they are and as professionals. The activity team does a lot of work around diversity and cultural awareness.” The manager worked alongside staff delivering care so they could understand any issues staff encountered. This approach also encouraged an inclusive and equal workforce and mutual respect amongst staff. The manager used effective and proactive ways to engage with and involve staff, with a focus on hearing the voices of staff.The provider and the manager worked with staff to ensure equality and diversity were promoted, and the causes of any workforce inequality were identified, and action was taken to address these.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.The provider’s quality assurance systems did not identify concerns we found during this assessment.The oversight of the recruitment process was not robust. We found missing recruitment information for staff suitability, and the provider’s policy did not fully reflect the requirements of the regulation.The management team were not able to provide us with further evidence that the process of duty of candour was consistently followed. This demonstrated the provider’s lack of oversight regarding notifiable safety incidents, learning culture from such incidents and clear record keeping related to this process.The provider failed to maintain effective oversight of medicine management. The systems and processes in place failed to identify and address the medicine errors we found during our assessment, such as body maps not being used to confirm where topical medication should be applied to the body. This meant there was a risk of avoidable harm to people.Some responsibilities and tasks to monitor people's safe care and treatment were unclear. For example, the staff we spoke to were not aware who completed medicine audits and were not able to identify when medicine administration errors occurred. Additionally, staff were not able to confirm who had the responsibility of overseeing medicine stock, administration and discarding expired medicines within the service. The provider did not ensure there was a clear structure and strategy in place for staff to follow. The provider’s system did not always work as statutory notifications were not always submitted to inform CQC of incidents.We observed some activities taking place during our assessment, and people engaged well. But we also observed on both days, times when a lack of engagement was visible. This meant people could be at risk of social isolation and a lack of regular, meaningful engagement to support their wellbeing.The provider did not consistently review incidents, accidents and other events to help identify themes or trends that might require further action to be taken. It was not clear how this information was used to identify any specific causes or triggers to support more effective risk mitigation and reduce recurrence. This area needed improving to ensure there was effective and meaningful learning and impact of the services provided.Maintenance staff tested the call bells to check they were working. But the provider did not carry out any further audits to review response times for any risks to people’s safety and delays in supporting them.Information in people’s care records needed further review to support staff to ensure the right care and mitigation was provided consistently. For example, for one person, clear guidance was needed for managing their oxygen usage, including information such as the lowest readings for how long to monitor, and when to call 999. Another person could become upset and distressed but there was no specific care plan to describe how to support the person.All the queries were discussed with the registered nurses and shared with the management team to make changes. Staffing and deployment need to be reviewed. People told us there were not always enough staff to attend people. They said, “I think they’re short staffed personally. It’s in general, I feel it’s especially at weekends” and “They come and answer it and switch the bell off and say I’ll be back but sometimes they’re not back as quick as you wish them to be.”

For other areas of the service, the provider had oversight of the service provided and ensured people received the care and support they needed. There was an emphasis on continuously improving the service, and meaningful learning was applied to the staff team.

The manager and staff team 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 and positive outcomes for people.Where necessary, external health and social care professionals had been consulted or kept up to date with developments. The manager told us how they worked with people, their families, and professionals to ensure people received the care and treatment they needed.We received several responses from professionals, and they were all complimentary of the provider, the staff team and working relationships. One professional told us, “It is encouraging to work with services such as The Manor Care Home, which recognise the importance of [specific health aspect] support. Overall, staff appear responsive to residents’ needs, and the new manager shows a clear interest in residents’ welfare and continuous improvement of the service.”

The provider did not consistently demonstrate a proactive approach to continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The staff were mostly positive and complimentary about the new manager and the work they have been doing. However, staff told us consistently the one area they needed more support was reviewing and adjusting staffing numbers. The staff said, “I feel supported by managers except when I raised the issue of shortages of staff and the amount of support and assistance people need compared with the staff on the floor” and “The managers are very supportive and will often help out. I would say that when I raise a question about staffing, I do not feel heard. Staffing should not be about numbers of residents, it is about these resident’s dependencies, which can fluctuate.” Our observations confirmed staff’s feedback and this was raised with the management team. Although additional staff was added during our site visit, staff told us they were not sure this would be sustained.

The manager was not able to provide any recent surveys demonstrating how the provider regularly engaged and gathered feedback from different stakeholders to review and understand any issues the service had, as well as, gather positive feedback to support continuous learning, service development and any innovation. We asked the manager to provide us with information on any improvements, achievements or changes as a result of surveys or feedback, but we did not receive any further information. The manager told us they used a few methods to engage with people and relatives such as regular relatives’, residents’ and staff meetings. The manager also noted they promoted the use of independently verifiable feedback through trusted public channels. There was a notice board called “You said - we did” noting a few requests from people and relatives and progress of it. The manager said this helped channel and share information with people and relatives. The manager also told us how they worked well with the local safeguarding team which they felt was a highly collaborative approach. The manager said from reviewing the safeguarding information proactively, it gave them the opportunity to look into provider’s processes regarding safeguarding. Staff had meetings with opportunities to discuss items, issues or feedback arising from the running of the service. This meant staff were able to discuss important aspects of the service and identify areas needing attention together with the management team. Staff added, “Every 2 weeks we have a risk meeting going through all of the residents. We can dial into this meeting and contribute to it even if we are not on duty. Our contributions are really valued, it gives people a chance to have a voice” and “I feel the work I do is very well recognised and valued. My opinions are asked for and respected.” The manager oversaw and managed behaviours and performance of staff as and when needed. Where we identified shortfalls during this assessment, the provider was responsive to our findings and started working on areas of improvement.