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.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained 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 provider was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation. The service was however, in breach of legal regulation in relation to the sending of statutory notifications.

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.

There was a positive culture at the service and staff felt positive about the direction of the service with the new management team in place. Staff felt supported by managers to deliver consistently safe, person-centred, and inclusive care. All told us they felt the service had significantly improved under the new manager. One staff member said, “The management are very approachable, as are the whole team.”

There had been 1 staff meeting since the new manager started in late December 2025, and further meetings were planned. There were additional daily meetings in place for relevant staff to share information around people’s care and support needs.

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.

The service had recently experienced a further management change and there was a new service manager in place who would be registering with CQC. Staff were positive about the new leadership style and approach of the new manager. We also received positive feedback about the deputy manager and senior staff. Staff said they felt the management within the service had a positive impact on the culture and atmosphere in the service. One staff member said, “The staff get on very well. We work together with the same goals.” Another told us, “[The] management are very supportive. You can go into [service manager and deputy manager] whenever you want. They support in any way they can and are really understanding.”

When we spoke with people and their relatives we received mixed feedback when we asked if they knew who the manager was. Some told us they knew the manager and spoke positively, others were unsure of the who the current manager was. We communicated this to the service manager and provider.

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

When we spoke with people and their relatives there was inconsistent feedback on how matters had been dealt with when they had raised concerns with staff. Although some of these concerns occurred prior to the new service manager taking up their post, there was no evidence to demonstrate that the provider’s complaints management system was fully effective. Whilst there was no significant impact identified, people and their relatives told us that opportunities to feedback were limited. The service manager told us that surveys and feedback systems were being reviewed and meetings for residents were being planned. There had been a date set for the next relatives meeting to allow people to meet the new manager and feedback their views.

There was a whistleblowing policy in place. Staff understood what whistleblowing meant, were aware of the provider’s internal processes and contact numbers and felt confident to raise concerns at any time.

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 valued and supported by the management team who treated them equally and fairly. Staff told us they felt they were treated with respect. The service manager understood the importance of having a fair and inclusive workplace environment for staff to work in.Staff were also supported through relevant training and supervision to inform their knowledge and understanding of expectations in the service. Staff were positive about the direction of the service under the new management, and no concerns were raised around inequality or inclusivity.

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.

At our previous assessment, the provider breached the regulation relating to good governance. At this assessment we identified improvements had been made and the provider was no longer in breach of regulation, however there were improvements still to be made. In addition to this, we identified a further breach in relation to the sending of statutory notifications.

The service had failed to send some statutory notifications to CQC as required by law. Whilst we identified most notifications had been sent as required, others had not been sent, and this had not been identified by internal governance arrangements and appropriate provider level oversight. This contributed to a breach of the regulation relating to the sending of statutory notifications.

We found that some aspects of record keeping relating to fire safety and evacuation procedures were not fully accurate. The log held within the service relating to safeguarding and complaints had not been effectively maintained to enable the service to use any findings to drive improvement in the service.

There were no effective systems or processes in place to ensure the service could seek and act on feedback received from people and their relatives as required by the regulations. However, had been identified prior to our assessment and processes were already in place to address this.

Improvements were evident in relation to the oversight of care planning documentation, medicines management and safeguarding processes. There were clinical audits in place together with environmental audits and infection control.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The registered manager and staff team had developed positive working relationships with services who supported people living at the home. This was demonstrated through the records we saw. Staff told us how they would contact relevant external professionals to help them meet people’s changing and ongoing needs. The healthcare professionals we spoke with spoke positively about the current working relationship with the service since the new management team were in place. However, they highlighted there were some areas for improvement in relation to clinical staff having a better knowledge of people’s clinical conditions, as this had led to occasions of inconstant communication with family members.

Links within the community were continuing to grow. The service manager told us a member of the local church attended Escan Manor to visit people, and local singers and entertainers had been to the service. The manager told us that they were exploring additional community options with local cafes to enhance community access for people.

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.

There were systems in place to learn from events such as accidents and incidents. We saw that care plans had been changed to reflect people’s changing needs which evidenced some learning and changes were made when the need was identified. However, the current systems and process in place to learn from complaints and safeguarding concerns were not managed in an effective way. Whilst it was evident concerns were recorded and escalated where required, the record did not show a conclusion to the concern or complaint. This would impact the ability to use the information to encourage change and improve outcomes for others using the service. We discussed this with the service manager and provider to highlight the need to ensure records were fully completed and contemporaneous.