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 inadequate. At this assessment the rating has remained 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 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 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.
At our last inspection we identified a reluctance from the registered manager to delegate tasks. A home manager had since been employed and although some tasks had been assigned to them, the registered manager still retained oversight and control of most areas. This resulted in frustration for some senior staff and a lack of upskilling resulted in gaps in knowledge, experience and confidence. More effective induction processes, training, shadowing and a more proactive approach by the registered manager was required to ensure a higher standard of care.
Accidents and incidents continued to be inconsistently documented and reported to the relevant people. There was a lack of transparency, which was also identified at the last inspection, and is an essential element in creating the right culture within the home and ensuring that lessons are learned.
The registered manager said he understood his responsibilities regarding reporting events and incidents to the CQC, however, we were informed of a recent incident which had been investigated by the local authority safeguarding team. When this was highlighted to the registered manager, the relevant documents were submitted retrospectively, several weeks after the incident.
The registered manager did not have effective processes in place to ensure sufficient oversight.
 

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.
At our last inspection we identified a reluctance from the registered manager to delegate tasks. A home manager had since been employed and although some tasks had been assigned to them, the registered manager still retained oversight and control of most areas. This resulted in frustration for some senior staff and a lack of upskilling resulted in gaps in knowledge, experience and confidence. More effective induction processes, training, shadowing and a more proactive approach by the registered manager was required to ensure a higher standard of care.
Accidents and incidents continued to be inconsistently documented and reported to the relevant people. There was a lack of transparency, which was also identified at the last inspection, and is an essential element in creating the right culture within the home and ensuring that lessons are learned.
The registered manager said he understood his responsibilities regarding reporting events and incidents to the CQC, however, we were informed of a recent incident which had been investigated by the local authority safeguarding team. When this was highlighted to the registered manager, the relevant documents were submitted retrospectively, several weeks after the incident.
The registered manager did not have effective processes in place to ensure sufficient oversight.
 

People did not feel they could speak up and that their voice would be heard.
Staff we spoke to said they felt comfortable to speak up and raise any concerns however the opportunities to do so appeared to be limited. Supervisions had only recently started to be scheduled more regularly and minutes from meetings did not include information about freedom to speak up directly. In addition, where supervision records showed that senior staff had voiced their concerns about not being used to their potential, there was limited evidence to show that any changes had been made in response.
The staff, people living in the home and their relatives did mainly speak positively about the registered manager, saying, “I am comfortable talking to the manager”. However, one relative told us, “I asked about a ramp to get (them) outside but they refused” so we could not be assured that people’s voices were listened to.
 

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 some diversity in the workforce and staff reported that they were treated fairly and equally. Some of the staff had been promoted to seniors since our last inspection and nobody reported any discrimination
 

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.
The provider had failed to ensure staff maintained accurate, complete and contemporaneous records. This placed people at risk of not receiving care in line with their assessed needs. This was also raised at the last inspection and there was a lack of urgency to address this issue. Care plans had been migrated to an online system since our last inspection however they continued to contain inaccurate and contradictory information.
During our assessment, we found shortfalls in the way the service was led. Effective processes were not in place to ensure good governance and oversight. This had led to multiple breaches of regulation, including safe care and treatment and good governance. These failings potentially place people at risk of avoidable harm.

Some audits were completed but they did not identify areas where improvement were needed or issues existed. Systems to monitor and improve the quality and safety of the service need to be significantly improved in areas such as risk management, medication and staff training and development, helping to identify, learn and drive improvements.
We saw no evidence of spot checks in order to manage current performance, despite the 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 staff to fulfil their roles to their full potential or provide sufficient oversight and help drive improvement.
Daily walk arounds which had not previously been taking place had recently been implemented, however there were areas of the environment which still required improvement.
In addition, care plans were not person centred, and audits were not effective in identifying issues and driving 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.

The staff worked in partnership with external organisations helping to provide suitable care and support. However, the provider did not have the necessary systems and documentation in place to facilitate moving between services. Information was shared as needed between the staff and other services but there was not a holistic approach where learning and information was shared to drive improvement.
The home supported people with dementia and the provider had not taken action to access the necessary dementia support to ensure that good and safe care was provided in line with best practice.
 

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. Meaningful audits were not completed and areas where improvements were needed were not identified by the provider.

People and their families were not involved in evaluating the home and the service it provided, and there were limited opportunities for feedback due to the absence of regular meetings.

People and their relatives mainly spoke positively about the management and the staff. However there was no evidence queries or suggestions made had been given appropriate consideration or used to improve the service.

Staff did not receive adequate training or inductions and there was no time allocated for them to develop their skills. Regular team meetings did provide opportunities for staff to give improvement ideas, however minutes from meetings did not indicate that this was encouraged. The lack of oversight from the provider meant the home did not have a culture of learning and striving for improvement