Manor Farm Residential 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 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 the governance at the service.

This service scored 54 (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 always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. We reviewed the service’s statement of purpose, which is a document outlining the types of services they offer. However, the service was not registered to offer support for some services. We raised this with the provider who submitted a notification to get these services added during the inspection.

Staff felt there was a poor culture at the service, due to staff being overworked and stressed, and by poor management. One staff member felt this had improved following recent changes in management but felt there were still improvements to be made. The nominated individual explained, "There has been regular sharing of the updates and sharing of key policies and procedures with the staff. There is a reading list which they are required to read and the manager follows this on supervisions. Dependency levels were reviewed continuously and changes are made if necessary."

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. For example, leaders had not notified us of all incidents which occurred at the service, which meant CQC did not have oversight of the service.

Staff felt some leaders were not compassionate or inclusive and told us they had been subject to bullying and harassment in the past. Staff also told us they had raised concerns to leaders which had not been appropriately addressed.

However, people and relatives felt the service was well managed and spoke positively about the new manager and the nominated individual. One relative told us, “The new manager is like a new broom. She seems to be popular with the staff and is very pleasant, I think she’s very experienced.” Another relative told us, “The owners are very nice, always available when I go in. I’ve always felt very welcome there.” Leaders had completed the necessary training to support their role.We saw evidence of some concerns being addressed by leaders.

During inspection, some staff told us of concerns about the culture at the service and leaders’ response to concerns. They told us they did not feel concerns would be addressed and did not feel comfortable speaking with some leaders. However, there was a new manager at the service who had introduced systems to support staff speaking up, including a feedback box where information could be provided anonymously. Staff felt able to raise concerns to the new manager. The manager told us, “I have emphasised to everyone we have an open-door policy.”
This still needed time to be embedded and we shall assess this during our next inspection.

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. For example, some staff raised concerns about being treated differently and discriminated against. One staff also told us they felt staff working in certain roles were treated favourably than other staff.The nominated individual told us they thought this was in relation to staff in more senior roles working different shift patterns, which suited the needs for the service.

However, the new manager had introduced ways to promote workforce wellbeing, such as by appointing a staff member to become an equality, diversity and inclusion champion at the service. The manager told us, “We are going to have international days, with different meals and different nationalities, so we are being inclusive of all ethnic groups.” This still needed time to be embedded and we shall assess this during our next inspection.

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. For example, the provider’s systems and processes for auditing had not identified issues in a timely way and were not acted upon. This meant the audit systems for identifying, capturing and managing organisational risk and issues were ineffective in identifying concerns.

The provider did not maintain oversight of staff training records. For example, they could not always identify when some staff had not completed all required training, in line with the policy. However, the new manager had introduced clearer auditing systems, such as daily walk-arounds of the service, and we saw staff training completion had improved throughout the inspection.

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. The service worked well with healthcare partners. The manager told us how they had recently arranged a summer fete, raising money for the service’s activity funds, following feedback from people requesting to go out for a Christmas meal. The manager also told us they had arranged charity events at the service to raise money and to promote community engagement.

The provider did not always focus on 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. For example, staff told us they had shared feedback and suggestions in the past, but these had been dismissed. They told us that as a result, they did not feel confident sharing feedback and ideas. This meant the service could not learn from feedback from staff. Additionally, learning was not always clearly recorded following incidents at the service, such as unwitnessed falls and physical abuse between residents. This meant lessons could not be learned to reduce the number of incidents happening in the future. However, the new manager was introducing new systems and processes to aid learning, improvement and innovation among the team.