Manor Lodge

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 requires improvement. At this assessment 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.

The provider had a person-centred culture that put people at the heart of the service. Staff had a good understanding of the ethos of the service and were clear about their responsibilities. They understood their roles and told us they were supported by the management team.

Staff told us the service was a good place to work for. A member of staff said, “The manager is very supportive and helpful.” Staff had access to a range of policies and procedures to guide them in their roles.

People and relatives told us that the service was good. They also mentioned that the management team were approachable and included them in discussions about the care and support being provided.

The provider had inclusive leaders at all levels who understood the context in which they delivered care and support.

The registered manager had an open-door policy where people, relatives as well as staff could raise any issues or concerns, they had, and this helped to ensure the service ran smoothly.

People, relatives and staff felt the registered manager was approachable and were able to discuss anything with them. People and their relatives mentioned that the management team were accessible and friendly.

Staff felt valued and supported by the management team and were included in discussions about the service. They told us the registered manager was very supportive and felt confident they would be listened to if they had any concerns. A member of staff said, “The manager is good. I can talk to them at any time.”

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

The provider had a whistleblowing policy, which guided staff on how they could raise concerns about any unsafe practice. Freedom to speak up is about creating an environment where individuals feel comfortable and safe to express their opinions and concerns.Staff were aware of the whistleblowing policy and knew how to raise concerns about any unsafe practice.

The provider had created a positive culture where staff were empowered to speak out, knowing that they were supported to do so and that their voice would be heard.

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.

The provider ensured people and staff had an equal opportunity and were not treated differently or discriminated against because of their characteristics. People and staff had equal opportunity to fulfil their potential.

There were regular meetings held for staff to share their views and experiences and for the registered manager to cascade information about things happening in the service. Staff told us they were encouraged to discuss any issues they might have or share ideas during these meetings. There were also regular meetings held with people who use the service.

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.

At the last inspection, we found the systems to assess, monitor and improve the quality of the service were not always effective. Daily records of people's care were not always complete. There was not enough time given for more group activities for people. The administration of people's medicines was not always being recorded accurately and staffing level needed reviewing.

During this assessment, we found improvements had been made around the concerns we identified at our previous inspection.

The provider carried out audits to monitor the quality of the service and to identify how the service could be improved. These included areas such as health and safety, care records, staff training as well as medicines records, to ensure they provided care and support to people to the required standard.

There were enough staff employed to meet the needs of the people using the service. Daily records had been improved. There was a number of activities people were able to take part into help ensure they were not socially isolated, and this was monitored by the registered manager.

The registered manager had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines and was open and transparent in responding to any issues raised. They kept CQC up to date with any changes that happened at the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The registered manager worked closely with health and social care professionals to monitor the health of people.

People’s healthcare needs were identified and managed to ensure that they received the necessary care and treatment to keep them in good health. For example, we saw staff contacted the GP to seek advice as 1 person was not well. The registered manager would liaise with the hospital team if there was a lack of information when a person was discharge from hospital to ensure people received the care and the support accordingly. They had regular contact with multi-disciplinary teams to discuss people’s on-going needs or any concerns they might have.

People had the contact details of their doctor recorded in their care plans. This helped to ensure staff could also contact them if they had concerns about a person's health.

Staff were aware of people’s needs and monitored people's health and welfare and made referrals to health care professionals where appropriate.

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

The provider had processes in place to ensure that learning happened when things could be improved; for example, following an accident or incident.

The provider also continually sought feedback from people, relatives and staff about the service through the use of satisfaction surveys. From the completed satisfaction surveys, we saw there were positive about the service. The registered manager acknowledged the feedback received and addressed any areas of improvement where needed for example, activities being offered in the service. This helped to improve the quality of service provided as needed.