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.

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

This service scored 57 (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. However, they did not always understand the challenges and the needs of people and their communities. The provider had failed to comply with a condition of their registration when they admitted a person with learning disabilities to live at the service. The service was not designed to support the individual needs of people with learning disabilities or Autistic people and staff were not sufficiently trained to meet these needs. A quality audit of the service had already found some shortfalls that we identified at this assessment. A service improvement plan was in place to drive forward necessary changes and developments. This was described as work in progress and changes were not yet fully implemented and embedded within the service and care practice. Staff told us the culture of the service had improved since the new manager arrived. One staff member said, “The culture here has changed, it’s much better.” Another staff member said, “There have been improvements. Communication with managers is getting better.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and their relatives spoke positively about the management of the service. One person told us, “The manager and deputy appear to work well as a good team. They are both responsive and helpful.” Staff told us they felt well supported in their roles. One staff member said, “The managers are very supportive, that's why I'm still here.” Staff told us the registered manager was approachable. One staff member described the registered manager as “Lovely, friendly and kind.”

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

Staff told us they felt able to raise any concerns and had opportunities to express their views about the service. One staff member said, “I can say what I think could change and what’s important.” The registered manager had introduced changes which provided staff with additional opportunities to discuss practice and speak up.

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 had developed a diverse staff team and staff said they felt included and involved in the service. One staff member spoke about team members for whom English was not their first language. They described how they were included and supported and said, “The staff have adapted well.”

The provider did not have defined responsibilities, roles, systems of accountability or good governance processes in place.

Systems for governance and management oversight were not robust. Shortfalls in the assessment, monitoring and management of risks had not been identified and addressed through the provider’s auditing systems. Management oversight had not identified that some staff did not have a firm understanding of safeguarding. There were shortfalls in providing care in a personalised way to meet people’s individual needs. This had not been identified and addressed through the management and quality assurance systems. The registered manager accepted shortfalls that were identified and took immediate action to ensure people’s safety. The registered manager was responsive to feedback about the service and provided information following this assessment about improvements that were being made. The provider had undertaken an initial audit of the service which had identified shortfalls across the service. The registered manager was implementing an improvement plan, but these changes were not yet fully embedded and sustained in practice. A more recent audit had noted improvements in some areas including medicines management.

The provider understood their duty to collaborate and work in partnership with external agencies, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff gave examples of how they worked effectively with partner agencies including support with end of life care, managing tracheostomy care and enteral feeding. Records showed staff were proactive in contacting partner agencies when people’s needs changed to ensure they received a seamless service. For example, a referral was made to the Speech and Language Therapist (SaLT) when a person was noted to have difficulties with swallowing.

Feedback from a health care professional was positive and described how staff worked collaboratively.

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.

Systems to identify learning and make improvements were not always effective. The provider had not identified shortfalls in the skills and knowledge of staff for example, in relation to supporting people with a learning disability.

The provider had a service improvement plan in place to drive improvements they had already identified. This was work in progress and changes were not yet in place, embedded and sustained. People, their relatives and staff spoke positively about the management of the service and described an improving situation. A staff member told us, “Things are definitely improving.” The registered manager was open and transparent about work that was still needed. They acknowledged the concerns raised at this assessment and were proactive in taking immediate action to ensure people’s safety.