Newhey Manor 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 assessment we rated this key question good. At this assessment the rating has changed to requires inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance at the service.
 

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.
The registered manager said the aim was to “Provide quality care based on person centred care”, but care practices in the home did not align to this, due to extremely poor care planning systems; the homes vision was not shared within any strategy or discussed at team meetings.

Staff feedback from June 2025 did show that 100% of staff said they knew what the service was trying to achieve. The registered manager was involved in people’s care and knew the residents well, however the necessary processes and documentation were not in place to enable staff to provide person centred care. A new member of staff said the registered manager did speak to her about the values of the service when she first started, however the vision and culture of the service was not shared with staff consistently from the start of employment and throughout, in staff meetings or in supervisions.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.
Whilst the registered manager had the relevant qualifications and experience and a desire to provide high quality care, we found this was not the case. There were seniors within the service who had ideas and identified areas where improvements could be made however, they did not always feel comfortable and empowered to be able to action these ideas.

There was a reluctance for the registered manager to delegate tasks; more effective, streamlined processes, combined with training and supervision of senior staff was necessary to ensure a much higher standard and continuity of care. This would enable senior staff to develop their skills and experience.

Accidents and incidents were not always documented within notes or reported to the relevant people, such as CQC. There was a lack of transparency, which is an essential characteristic in order to have the right support and ensure lessons are being learned to reduce the risk of further incidents.  

The registered manager said he understood his responsibilities; however, we identified a recent incident where the police had been contacted; this had not been reported to CQC as is the law. When this was highlighted to the registered manager, the relevant documents were submitted retrospectively. In addition, care plans were not person centred, medicines audits were not completed in a timely and effective manner and instructions from a physiotherapist were not followed.

The registered manager no longer attended registered manager forums. We saw no evidence that the registered manager currently attendeds any training or networking to ensure awareness of relevant changes in guidance and legislation and good practice.
 

People did not feel they could speak up and that their voice would be heard. The registered manager said he encouraged a culture of openness by “building trust between (himself) and the staff in a professional way” and making sure that when incidents occurred, they were transparent with the next of kin and the residents. Staff we spoke to said they felt comfortable to speak up and raise any concerns however, we saw no evidence of staff raising concerns.
A senior carer explained to us how she had taken some of the people outside to sit on chairs or in their wheelchairs one evening; people had been able to enjoy some fresh air and sunshine, with views of the large, open field at the rear of the home. People had really enjoyed themselves, and she had told the register manager that it had been a positive experience, however this had not been developed to become a regular occurrence. When staff did speak up and suggest ideas to improve people’s lives these were not explored further.
A senior member of staff said the term freedom to speak up had been “spoken about in the past”, but there was nothing formally recorded within staff surveys. Nor did minutes from meetings include information about freedom to speak up directly.
 

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.
There was evidence of diversity in the workforce. The registered manager did his best to accommodate the staff and their individual needs. One member of staff told us they only worked certain days to allow them to attend University on other days; another staff member told us they worked certain shifts to fit around their childcare needs.

There was an equal opportunities policy and overseas staff were recruited on sponsorship with the relevant checks in place and appropriate hours scheduled. Staff reported that they felt they were treated equally and we observed fair and consistent treatment of staff both from seniors and between care staff.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
Audits were conducted in various areas including care plans, falls, mattresses and medications, however there were no clear processes in place to use this information to manage risk or improve outcomes for people.

The registered manager, who was also the provider, was reluctant to delegate aspects of care management to senior staff. Records and care planning systems lacked clarity, important detail and were not reflective of people’s current needs; management and oversight of the home was severely lacking due to the time spent by the registered manager on administrative tasks.

We saw no evidence of spot checks in order to manage current performance, despite the registered manager’s daily presence in the home. While the staff understood their roles, the relevant systems, training and supervisions were not in place to enable people to fulfil their roles to their full potential or provide sufficient oversight and help drive improvement.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.
We saw evidence of referrals being made to relevant services however more proactivity would ensure better continuity of care and outcomes for some of the people in the home. For example, one person had started to show increasingly aggressive behaviour and a referral to the mental health team had been made but not followed up accordingly.

The registered manager could demonstrate how he worked in collaboration with other services such as the diabetic team, district nurses and the local GP practice. The feedback from the GP practice confirmed that “(name) is responsive to enquiries for information” and that the relation they have with the home is “positive”.

There was some involvement in the community with local schools coming to the home at Christmas, however further development was needed, such as attending dementia cafes or events locally, in order to help people achieve better outcomes and quality of life. Whilst we found evidence of working with other healthcare professionals this was not always done in a timely fashion and did not always ensure seamless and appropriate care for people.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

We did not see evidence of continuous learning and striving for improvement in the home. We did see action plans and lessons learned as a result of the falls audit and the registered manager told us about how he had identified a pattern in someone’s falls and linked them to the medication they were receiving at nighttime. Through conversations with the GP the medication had been adjusted and the falls had stopped. Although other audits were completed, these were not consistently analysed, and action plans were not always created.

People using the service, their families and carers were not always involved in developing and evaluating improvement and innovation initiatives. Families and carers did speak positively about the registered manager however they had not been approached to participate in care planning reviews. Feedback was gathered through the use of surveys, and while this was positive, they were not very in-depth and did not involve questions about involvement in care and how improvements could be made in their relative's care. We did not see evidence of relatives and carers being involved to help to develop their loved one's care. A relative told us that they did not have relatives' meetings.

Staff were competent and delivered safe care however there was little time allocated for them to develop their skills, outside the training that was offered. Regular team meetings did provide opportunities for staff to give improvement ideas, however minutes from meetings did not indicate that this was encouraged.