Escan Manor

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.

This service scored 50 (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 a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. There was no evidence of learning from similar issues within the provider group.

Staff gave mixed feedback around leaders and whether there was a positive, compassionate, listening culture at the home which focused on learning and improvement. Staff reported morale had been low, however the new management team had begun to improve this, working on communicating a shared culture. Staff commented, “Some of us feel supported and valued and others they feel not motivated but the staff we have now are better.” The interim manager was aware there had not been a strong sense of teamwork between the staff group and there had been a lot of staff changes recently. However, despite the barriers they sometimes faced, it was clear staff prioritised safe and compassionate care and the present staff team was more stable. The provider had policies which supported equality and human rights, diversity and inclusion.

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. However, the management team was very new but had already found many issues relating to previous management at the service and were working towards improvements.

Staff generally gave positive feedback about the new management team at the home and confirmed they seemed to have the skills, knowledge and experience to lead effectively. There was a lot of input from head office including face to face which had not been evident previously. The new management team felt supported and were clear about what needed to change and were able to identify areas for improvement with knowledge and consistency.

People did not always feel they could speak up and that their voice would be heard.

Not all staff agreed they were encouraged to raise concerns or were confident their voices would be heard. However, they did feel the new management team seemed approachable and they felt able to raise issues with them. Staff confirmed team meetings had been infrequent but were now being arranged. We saw clear communication, for example, with care workers about what needed to be done and why to improve care and support. There was a freedom to speak up policy and whistleblowing policy.

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. However, this had not been the case previously and the management team in place were new. Staff said they had not been managed well, allowing some previous staff to dictate to others. This had been recognised by the interim manager and the current staff team was stable and working well together. There had been positive changes in the staff team working at the service. Staff said it was early days but they were seeing improvements and getting to know the management team. There were policies to support workforce diversity and inclusion.

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.

The new management team brought in to address concerns raised previously had started to measure staff competencies to ensure they were confident in meeting peoples’ needs and address the lack of governance and oversight. Governance records had been poor, and they had found it difficult to evidence audits and actions taken. There was a lot of work to do but the new management team were committed to improving the service and had started to put measures in place to address this. A new registered manager was being sought to maintain consistency going forward. The interim manager had drawn up a list of tasks required by management and this was being monitored.

Governance systems had not been effective at identifying or managing risk and overseeing performance and outcomes. There had been a high number of safeguarding alerts and medicine errors over several months. The provider was open and transparent and were acting promptly to address the issues. For example, care plan reviews were in progress, training had been completed other than face to face training in areas such as diabetes and dementia which were planned. Communication was improving. Evidence to show effective maintenance systems were in place was missing which made it difficult to assure safety in some areas, with fire training records not ensuring all staff had been trained and safety checks not up to date. A new maintenance person had been employed. We were not assured people and relatives were being listened to regarding their concerns about wider health needs being co-ordinated with external agencies, but this had been identified and was being addressed. Safeguarding management was not robust which had placed people at risk of harm. We were assured during our site visit this was now being managed more effectively and would be monitored. The new management team had put together a thorough action plan which was being reviewed regularly by different external agencies. The issues relating to oversight and governance was a breach in the legal regulation relating to governance.

The provider was committed to continuous learning, innovation and improvement across the organisation and local system. However, our findings at this assessment indicated the provider had not been proactive in identifying and addressing their own learning and improvement. They had not identified the issues raised by concerns prior to this assessment although they had responded promptly. There was now a new management team working to make improvements. There was now a comprehensive service improvement plan in place at the time of our site visit to drive continuous improvement which was being worked through. Provider oversight had improved with on site support from the quality assurance team. Although we had seen several areas recently improved, some improvements needed to be made still and embedded.

The interim manager was open to our feedback and had a desire to improve practices at the service. They provided us with details of the actions they planned to undertake to address the concerns identified and ensure ongoing monitoring and governance of these processes.

The provider was committed to continuous learning, innovation and improvement across the organisation and local system. However, our findings at this assessment indicated the provider had not been proactive in identifying and addressing their own learning and improvement. They had not identified the issues raised by concerns prior to this assessment although they had responded promptly. There was now a new management team working to make improvements. There was now a comprehensive service improvement plan in place at the time of our site visit to drive continuous improvement which was being worked through. Provider oversight had improved with on site support from the quality assurance team. Although we had seen several areas recently improved, some improvements needed to be made still and embedded.

The interim manager was open to our feedback and had a desire to improve practices at the service. They provided us with details of the actions they planned to undertake to address the concerns identified and ensure ongoing monitoring and governance of these processes.