The Manse Residential Care 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 inspection we rated this key question requires improvement. At this assessment, the provider had made improvements and no longer in breach of regulation relating to good governance. 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 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 were supported to deliver high quality care and support to people in line with the provider’s vision and values for the service. Managers made sure staff had access to policies, procedures and systems, designed in line with the service’s vision and values, to help them provide care and support which met people’s individual needs.

Managers used audits and checks, supervision and staff team meetings to make sure staff understood how the service’s vision and values should be achieved through their working practices.

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 at the service were well regarded. A person described the service as, “very well managed. The managers are very approachable as well.” A relative told us, “The managers are great, very helpful.” Healthcare professionals told us they had a positive working relationship with the registered manager and the staff team.

The registered manager was experienced and had a good understanding of the needs of people and how these should be met through the provision of safe, high quality person-centred care. Staff told us managers were experienced and supported them in their roles. A staff member said, “I think [registered manager] is good and very approachable and you’re never worried about talking to him. He has an open door policy.”

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

People’s feedback indicated they had no concerns about speaking up if they needed to. A person told us, “I would tell them. I don’t hold back.” People were encouraged to share their feedback about their experiences of the service and provided a variety of ways they could do this.

Staff were supported to speak up if they had any concerns. The registered manager told us, “We talk about being open and not having a blame culture, to encourage the staff team to be open. It’s about reassuring the staff team that they shouldn’t be fearful of losing their jobs if they make a mistake.”

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 were valued and treated equally and fairly. Staff received the same opportunities to learn and progress in their roles. The registered manager told us, “The staff all get the same training and support. We have staff that need more flexible working due to their circumstances so we support them through this to make sure they are not discriminated against. In terms of vacancies we make sure opportunities are available to everyone. I haven’t had staff raise concerns with me about being discriminated against, but I would deal with this seriously and try to address their concerns.”

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. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had made improvements in this area. Governance systems were now more effective and used to regularly check and audit the quality and safety of care and support provided to people. Outcomes from checks and audits were used to make any changes required and support staff to improve their working practices. The registered manager understood and demonstrated compliance with regulatory requirements. They also understood their responsibility to provide honest information, suitable support and to apply duty of candour where appropriate.

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 collaborated with healthcare professionals on the delivery of safe, high quality care to people. They followed guidance and recommendations from professionals to support staff learning and improve the safety and quality of the delivery of people’s care and support. A healthcare professional told us, “They are responsive. We have worked with the home…and made many suggestions for improvement which the home took on board alongside their own improvements being made.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider had made significant improvements at the service since our last inspection. Managers had addressed the areas of concern to improve the safety and quality of the service. They made sure this was done in an open and transparent way so that people were involved and informed about improvements that were planned and made.

The registered manager told us the lessons learnt had led to positive changes at the service. They said, “I realised I needed to use our governance systems more effectively and in terms of our staff it has made them aware that we needed to do more and follow our systems and processes. I think we have a good service now because the feedback we get is good from people and relatives. The audits and checks we do gives us assurances that we are doing things right. The support and feedback from partners is good. As a manager it has made me appreciate how important it is to keep looking at all the areas and continuously working at ways to keep doing things better.”