Manifolds care Also known as Regus

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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. However, more work was needed about how they shared this with the people they supported and staff.

Systems to promote shared values and positive culture were not fully embedded. Whilst in practice the registered manager shared their vision, improvements were needed to document this.

Staff were positive about working at the service. A staff member told us, “I do feel supported and valued by Manifolds as they never fail to recognise my hard work and progress with [client they support]. Overall, the team have taken good care of me as a carer, and I believe they have mine as well as my client’s best interest at heart by ensuring we have everything we need.”

Leaders did not consistently understand the context in which the service delivered care, treatment and support. They did not always demonstrate the skills, knowledge, experience or credibility required to lead effectively.

More learning was required to ensure the registered manager had all the appropriate skills needed to assess staff competency and develop a more robust quality assurance process.

Despite this all feedback we received about the registered manager was positive. A relative told us, “[Registered manager] is a lovely fella, does regular spot checks.” A staff member said, “I would describe the management team as approachable, supportive and responsive. Communication is generally good and managers are available when advice or guidance is needed. They encourage staff to provide safe, person-centred care and work to maintain standards across the service. In my opinion, the service is well managed.”

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

Relatives and staff told us the registered manager was approachable and encouraged open communication and acted promptly when concerns or issues were raised.

However, further work was needed to strengthen and embed formal systems for gathering and acting on feedback, such as surveys and consistent recorded spot checks. Improving these processes would support the provider to more effectively capture experiences and drive continuous improvement across the service.

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 treated fairly and with consideration, and the provider sought to ensure staff had equal access to opportunities, support and development. This approach helped to foster a positive culture where differences were recognised and valued.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Quality assurance systems in place had not identified all of the concerns found during the inspection. These included issues relating to monitoring documentation, mental capacity assessments and recruitment processes. We discussed the existing quality assurance arrangements with the registered manager, who acknowledged improvements were required to strengthen oversight and ensure the quality and safety of the service could be effectively monitored. The need for more robust and embedded systems was highlighted, particularly in the context of any future expansion of the service and workforce.

While these issues had not resulted in a direct impact on people at the time of our inspection, they demonstrated gaps in governance and oversight which required prompt action to mitigate potential risks.

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.

Staff liaised with relevant professionals when people’s needs changed and prompted referrals to occupational therapists, community nurses and GPs when required.

The registered manager engaged with a local network of registered managers as a way to share knowledge and best practice.

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

While there was some evidence of good practice, systems to evaluate, learn from and share this consistently across the service were not well established. Improvements were needed to strengthen how learning was identified, shared and embedded to drive sustainable improvements and ensure people experienced equitable outcomes.