Clifton Manor Nursing 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 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 86 (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 described a positive culture with a strong focus on providing high-quality care in a calm, supportive environment. They understood their roles and responsibilities and told us they felt well supported through induction, training and ongoing guidance. Staff spoke positively about working at the home and were committed to achieving good outcomes for people. One member of staff told us, “[The leaders] are good managers. I wouldn’t be here if it wasn’t nice. When I’m at home, I can’t wait to get back to work.”

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Leaders remained actively involved in the service and worked alongside staff to support people when required. Staff described managers as approachable and available when support or guidance was needed. Comments from staff included, “Whenever I shared my concerns, [the managers] were there to support me”, “I had fantastic support from [the managers]”, and “I feel I’m able to go to the [registered manager] and tell her how I’m feeling.”

The service benefitted from strong clinical leadership. Leaders demonstrated a detailed understanding of people's increasingly complex needs and ensured staff had access to the knowledge, guidance and support needed to provide effective care. They monitored people's needs, responded promptly when these changed and worked closely with staff to ensure people received appropriate care and support.

The registered manager actively encouraged people and those important to them to share their views and influence the development of the service. They maintained an open-door approach. People and their relatives spoke positively about the leadership within the service, and the culture leaders had created. One relative told us, “I think the [registered manager] is brilliant. Any issues, they’ll sort it.” Another relative told us, “We think they do a great job.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

A comprehensive programme of audits, reviews and meetings enabled leaders to monitor quality, safety, performance and people's experiences of care. Audits covered areas including care planning, medicines, infection prevention and control, staffing, the environment, health and safety and meal experiences. Regular governance meetings, daily oversight and action plan reviews ensured areas for improvement were identified and progressed.

The provider used detailed analysis of people’s behaviour to identify patterns and trends over time. This information was used to inform care and identify themes across the service. Leaders used information from falls, incidents and clinical monitoring to identify patterns and opportunities to improve practice. Where issues were identified, additional checks were introduced and followed up to ensure changes were effective and sustained. The provider maintained clear records, policies and guidance to support effective governance. Leaders demonstrated a good understanding of their regulatory responsibilities, including duty of candour requirements, and used governance systems to maintain high standards of care and support.

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.

Staff made referrals when required, acted on professional recommendations and maintained positive working relationships with partner agencies. One professional told us, “Communication with staff is very good. They were busy but still able to answer any questions I had. Really good risk assessments and care plans."

Leaders encouraged people to contribute to their communities. For example, people were supported to participate in fundraising and charity initiatives, helping them to remain connected to the wider community and maintain a sense of purpose and belonging. The registered manager told us, “I want my residents to feel empowered."

The provider recognised the importance of maintaining meaningful relationships. Relatives were welcomed into the service, encouraged to remain involved in people's lives and supported to maintain strong connections with their loved ones. For example, relatives were invited to share meals with family members living at the home, helping them spend quality time together and remain involved in everyday life. This helped people feel valued, included and connected to the people and communities that mattered to them.

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

Leaders used research and evidence-based practice to inform care and support. For example, the clinical manager had dedicated time to review emerging evidence relevant to people's needs and used this learning to influence practice within the service. This included reviewing evidence relating to medicines and other therapeutic approaches to ensure people benefited from current good practice. The activities coordinator also used research-informed approaches and regularly evaluated the effectiveness of interventions. They told us, "We constantly assess and evaluate who can benefit from [the activities]."

The provider sought opportunities to improve practice and achieve recognised standards. For example, the service achieved ‘Lifelong Smiles’ oral health accreditation and supported staff to develop their knowledge and skills in oral health care. Leaders also looked beyond routine practice and explored new approaches that could improve people's quality of life and experiences.

Learning directly informed improvements across the service. Information from behaviour monitoring, outcome reviews, audits and service analysis was used to understand what was working well and where changes were needed. The provider promoted a culture where learning and improvement were valued at all levels, resulting in improved experiences and outcomes for people.