Merlin Manor Care Centre

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 the last inspection we rated this key question requires improvement. At this inspection the rating has changed to 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 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager and clinical team promoted a person‑centred, rights‑based approach which was embedded into everyday practice. They promoted a culture based on kindness, dignity and respect, which was evident in feedback from people, relatives and professionals who consistently described staff as compassionate, approachable and supportive. The registered manager was described as approachable and visible, and had developed a learning culture where incidents and safeguarding concerns were reviewed to identify improvements. Staff felt valued within their immediate team and described positive teamwork and a sense of shared responsibility. Staff demonstrated a good understanding of people’s individual needs and worked in ways that reflected the provider’s values, including supporting people to make choices and maintain independence. However, the culture was not consistently embedded across all areas because staffing pressures affected staff’s ability to consistently deliver the provider’s values.

The provider had leaders at all levels who understood the context in which they delivered care, treatment and support. The new regional management team were in the process of learning about the culture and values of their workforce and organisation. The registered manager and clinical team were highly visible, compassionate and inclusive, and consistently demonstrated strong leadership that inspired confidence among staff, people and partners. They were described as approachable, responsive and supportive, with an open culture that encouraged staff, relatives and professionals to engage with them. Staff spoke positively about the team’s leadership, highlighting the managers listened to their views, provided guidance and recognised their contributions. Feedback from professionals described good relationships with the management team and confidence in their responsiveness when issues were raised. The registered manager and clinical team showed commitment to continuous improvement, including acting on feedback and addressing issues such as communication concerns raised by partners.

The registered manager and clinical team fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt able to speak up if they had worries about care or safety and knew who to approach. However, this was not consistently applied across the organisation. Since the change of regional managers staff found when they raised concerns, particularly about staffing levels, these were not effectively addressed. Staff also described limited opportunities to attend meetings or receive feedback on outcomes, which reduced their confidence that their views would lead to change. Feedback from relatives also indicated gaps in openness and communication. Some relatives said they were not always updated following incidents or investigations and had to chase information, which limited transparency. These inconsistencies meant the provider’s systems to support speaking up were not always effective in practice.

The provider and management team valued diversity in their workforce and ensured they followed best practices guidance. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Mandatory equality and diversity training was in place for all staff, with refresher training to maintain awareness of protected characteristics and discrimination. Staff told us they were treated with respect and that diversity was valued. The management team were aware of their responsibilities under equality legislation and aimed to make reasonable adjustments where required.

The management team 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 new regional managers had introduced new audits and governance systems, which they had recently started to use. These needed to be embedded into practice and tested to ensure they were effective. Currently these systems had not always been effective in identifying and addressing risks or ensuring consistent oversight of the service. For example, the oversight systems had not identified the dependency tool was not ensuring enough staff were on duty or the decrease in staffing levels had impacted the care being provided.

The registered manager and clinical team had quality assurance processes in place, including audits, incident monitoring and governance systems, which showed a clear intent to drive improvement. The audits had identified issues, for example in risk management, staffing and care records demonstrating the systems were working to some extent. However, recently they had lacked autonomy to make wider improvements such as ensuring the tools used to determine staffing levels were effective and staffing levels were increased to meet changes in people’s needs.

Staff worked collaboratively with healthcare professionals to support people’s needs. Staff clearly understood and carried out their duty to work in partnership and provide a seamless service. They shared information and learning with partners and collaborated for improvement. Visiting professionals praised staff knowledge and their communication with them. Relatives reported that staff were responsive and approachable, and the home maintained positive relationships with families. People reported they found the staff closely tailored their work to individual’s needs and had supported them to experience positive outcomes.

The registered manager and clinical team focused on continuous learning, innovation and improvement across the organisation and local system. Staff described a strong learning culture. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. One staff member said, “I feel my views are listened to and respected. Staff are encouraged to share ideas and suggestions, and management is open to feedback aimed at improving the quality of the service.”