Manor Barn Nursing 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 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.

The service was in breach of legal regulation in relation to governance of the service. This breach has been met.

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.

Leaders had created a positive culture focused on providing safe, person-centred care and achieving good outcomes for people. Staff described an open and supportive environment where teamwork, learning and continuous improvement were encouraged. Following previous concerns, the provider had strengthened systems and promoted a culture of openness, accountability and shared responsibility for quality and safety.

Staff understood their roles and responsibilities and were encouraged to raise concerns and contribute to improvements. Learning from incidents, safeguarding concerns and complaints was used to review practice and drive improvement. Relatives spoke positively about the culture within the home and described staff as caring, approachable and responsive. This helped create an environment where people felt supported and received consistent care from a committed staff team.

Leaders were visible, approachable and understood the needs of people living at the home. Staff, relatives and professionals spoke positively about the leadership of the service and described leaders who were supportive and responsive. Observations during the assessment showed leaders maintained a regular presence within the home and were engaged with people, relatives and staff.

Relatives told us they knew who the manager was and felt comfortable raising concerns or asking for advice. One relative said the manager was "always approachable and makes time to speak with us." This helped promote positive relationships, effective communication and confidence in how the service was run.

The provider promoted a culture where people, relatives and staff were encouraged to raise concerns, share ideas and contribute to improvements. Leaders described a deliberate focus on creating an environment where people felt comfortable speaking openly and where concerns would be listened to and acted upon.

Staff were encouraged to report incidents, accidents, safeguarding concerns and medication errors without fear of blame. Leaders consistently referred to the importance of openness and transparency and described systems which supported reflection, learning and improvement. Staff demonstrated an understanding that concerns should be reported promptly and discussed examples where lessons learned had been shared across teams.

The provider had formal arrangements to support staff who wished to raise concerns. This included a designated speaking-up champion, visible information for staff and opportunities to raise concerns during one-to-one discussions, supervisions and provider visits. Provider representatives also described holding informal opportunities for staff to speak confidentially if they had concerns regarding culture or practice.

The provider promoted equality, diversity and inclusion within the workforce and recognised the importance of creating an environment where staff felt respected and valued. Leaders described a diverse workforce and demonstrated how individual needs were recognised and accommodated. Equality and diversity training formed part of mandatory training arrangements and staff were supported to work within an inclusive culture.

Leaders provided practical examples of supporting staff with cultural, religious and personal needs. This included accommodating prayer requirements, supporting staff to observe religious celebrations and ensuring rotas considered individual circumstances wherever possible. Staff were encouraged to bring their experiences and perspectives into the workplace and leaders spoke positively about the contribution made by a diverse workforce.

The provider also demonstrated awareness of equality and diversity in relation to people using the service. Leaders described how care and support would be adapted to reflect cultural, religious or dietary requirements where required, helping ensure people received personalised and inclusive care.

The provider had effective governance arrangements which supported the delivery of safe, high-quality and sustainable care. Governance systems had been strengthened following previous concerns and leaders demonstrated clear oversight of incidents, safeguarding, staffing, training, complaints and quality assurance activity. Improvements made had been embedded into day-to-day practice and were supporting continued improvement across the service.

Comprehensive audits, provider visits and electronic monitoring systems enabled leaders to identify risks, monitor performance and track actions to completion. Information from audits, incidents, safeguarding reviews and quality monitoring was used to identify themes and drive improvements. Provider representatives described regular oversight visits, in addition to formal audits, to provide support and assurance that improvements remained embedded.

Systems were also in place to support sustainability, including central monitoring of training compliance, competency assessments, spot checks and regular review of service performance. Feedback from relatives and professionals reflected improvements in leadership, communication and oversight. This gave leaders assurance that quality improvements had been maintained and continued to deliver positive outcomes for people.

The provider understood the importance of partnership working and community engagement in improving outcomes for people. Staff worked collaboratively with families, community organisations and healthcare professionals to support people’s wellbeing and maintain important relationships.

The service actively promoted community involvement and opportunities for social inclusion. People were supported to attend local venues, church services and community outings, and leaders described plans to develop a dementia café in partnership with local services. These initiatives helped people remain connected to their local community, maintain meaningful relationships and reduce the risk of isolation.

The provider promoted continuous learning and improvement across the service. Lessons learned from incidents, medication errors, safeguarding concerns and complaints were reviewed and used to improve practice and reduce risk. Staff understood the importance of reporting concerns and described how learning was shared through meetings, supervision and provider-wide learning events.

The provider had responded positively to previous concerns by strengthening governance, safeguarding oversight, incident reporting and training monitoring. Leaders demonstrated how these improvements had been embedded into routine practice through regular audits, provider oversight visits and ongoing monitoring of service performance. This helped ensure improvements were sustained and supported people to receive safer, higher-quality care.