The Manor House

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 remained 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 75 (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.

Staff told us communication between themselves, and the management team assisted them in providing effective support to people. They had regular opportunities to discuss people’s needs, this included handovers and huddle meetings. Staff comments included, “We get the chance to talk at huddles or with nurses if we have any concerns” and “It is good to talk through and raise any issues.”

People and their relatives were positive about the culture of the service. They told us communication was good, and they were happy with the staff and the service overall. Relative’s comments included, “Staff are friendly and chatty, all the staff know me and speak to me” and “Any concerns they speak to us, when we come in.”

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.

The provider and management team had a clear commitment to providing person centred care and valuing people who lived at the home and the staff team.

Staff said the management team were approachable, inclusive and supportive. Staff comments included, “They are very approachable and understanding” and “I feel very supported as an employee by management.”

Relatives gave positive feedback about the service and leaders. One relative told us, “The manager is approachable, the salt of the earth, they respond quickly to any issue.”

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

Staff understood the importance of speaking up and confirmed they were encouraged to speak up in team meetings and they had received relevant training to support this.

One staff member told us they had, “responsive carers and managers, I do not have any doubts all issues will be dealt with.”

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 told us they were treated fairly by the provider and enjoyed working with each other as a team.

Staff from different backgrounds told us they were well supported by their colleagues and the registered manager to feel included and part of the team. One staff member told us, “We respect each other and our cultures, we come from all different areas.”

We observed staff demonstrating respect for each other and the people they were supporting.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

The service had displayed its CQC assessment rating on their website and at the service as required. The provider had a business continuity plan, to guide staff in emergency circumstances. The registered manager understood their responsibilities under the duty of candour and had notified CQC of all reportable incidents.

Regular reviews of records, staff meetings and feedback from people were used by the management team to ensure the service was providing good quality safe care. Leaders shared any learning with staff members and looked at ways to improve the service.

The service had quality assurance systems including a service action plan. There were various areas the registered manager’s audits had identified where improvements were needed, and these had been transferred to the main action plan to monitor completion. However, the audits had not identified the shortfalls we found in relation to medicines administration and staff training. We fed this back to the registered manager to address.

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 provider had good relationships with general practitioners, and other community teams.

The registered manager and nurses regularly liaised with health professionals, to ensure people had the correct guidance for them to follow when providing care and support.

Health and social care professionals were positive about how the registered manager and staff team collaborated with them. They told us, “They are professional in their approach to their work” and “I can only praise the registered manager and her team for their effective communication and partnership working.”

The registered manager advised us local community links were being developed with local schools and colleges who had visited the home and spent time with residents.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice.

The service was focussed on learning and improvement, when areas were identified these were shared with staff and opportunities for staff to develop their skills were provided. For example, the provider had recently communicated to their team their plans to support people with other care and support needs. The staff team had recently completed a training course to ensure they were equipped to support new people who may live at the home.

The registered manager had an action plan they were working on with specific actions to drive improvements in the service.