The Manor House - Frenchay

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 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 outstanding. At this assessment the rating has changed to good. Leaders and the culture they created assured the delivery of high-quality care.

This service scored 71 (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. The provider had a mission statement and an organisational vision. These were underpinned by 5 core values of, ‘Valuing people, choice, participation, safety and working together.’ The vision and values were described on the providers’ website and in the induction programme. Staff reflected in their supervisions about how their practice had reflected the organisational values. A staff member said, “We know the organisational values. All the staff give good care.” We observed staff delivering care and support in line with these values. Staff told us they worked well together as a team and there was a positive culture. A staff member said, “It is a lovely place to work, a supportive environment.”

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. Managers demonstrated knowledge and compassion about the people the service supported and were dedicated to ensuring people received person-centred care. The registered manager attended local networks to gain insight into wider areas of health and social care. The registered manager had mentored a manager outside the organisation passing on their knowledge and offering support.

Staff and relatives told us the management team was supportive and approachable. A staff member said, “We are very well managed. [Names of managers] are very supportive, always there if we need.” A relative said, “Management are approachable. The management do a first-class job.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were in place to enable staff to speak up such as regular staff meetings, supervisions, surveys and whistleblowing policies. Staff told us they were comfortable in raising any concerns and reviewed evidence of this occurring. The provider took actions in response.

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. The provider had an up-to-date equality and diversity policy. During recruitment processes equality and diversity was monitored. The service currently did not have any male staff on the care team but had previously. Staff were encouraged to use their individual skills and interests to benefit people using the service. For example, singing and baking. Staff told us they worked well as a team. A staff member said, “We work really well together.” Religious practices of staff were respected. For example, ensuring staff could celebrate significant events and festivals.

The provider did not always have systems of good governance. They did not always act on the best information about risk, performance and outcomes. There were no provider level checks undertaken to support the development of the service. This meant for example, some environmental risks and incident form revision had not been identified. A service improvement plan contained areas identified in the environment but no other areas of the service provision had been identified for development. We identified where documentation required review to ensure consistency, completeness and relevancy. For example, accident forms, night check charts and daily planning sheets. As this meant information was specific, completed consistently and gathered the information that was needed to take positive actions.

However, the registered manager completed regular audits of the service which included reviewing areas such as staffing, training, safeguarding and care planning. Care plans and risk assessments were regularly reviewed. Medicines were regularly stock checked and staff competency checked. However, there were no checks on medicine management overall. The registered manager said this would be addressed and made amendments to include this going forward.

Notifications were submitted as required to CQC. The providers CQC assessment rating was displayed in the home and on their website as required. We highlighted the confidentiality of records as offices were unlocked and unattended at times. This had also been raised in staff meetings.

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 had positive working relationships with health and social professionals and other organisations. Managers and staff regularly liaised and shared information A health and social care professional said, “Staff know the people they support very well and will refer if they are concerned about a change in a person and are responsive in contacting other health services (GP's) if needed.”

The provider focused on continuous learning 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, effective practice and research. The service took advice on ways to enhance people’s physical and mental well-being. A health and social care professional said, “They are open to recommendations being made and responsive in their actions. They will try new suggestions even if they have been trialled before and seek further clarification if needed.”

However, internal governance systems needed to further demonstrate continual development and reflection of record keeping when accidents or incidents had occurred to ensure learning was fully effective.