Ealing Manor Nursing Home

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• 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 service since registered as a partnership in 2024. 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 relating to good governance (Regulation 17). Governance and quality assurance systems were not consistently effective in identifying, monitoring and addressing risks and shortfalls in the quality and safety of the service. Improvements identified through external scrutiny had not always been fully implemented or sustained.

This service scored 54 (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 always ensure its vision, values and culture were consistently understood and translated into person-centred, safe and high-quality care and support.

Some people described limited opportunities for social interaction and meaningful engagement. One person told us, "They can't come and chat with us." Other people described delays in receiving support and told us staff were often busy. These experiences did not consistently reflect the person-centred culture described by leaders.

The assessment identified concerns relating to staffing, responding to people’s needs, care planning and governance. These findings demonstrated the provider’s values were not always translated into consistently person-centred care and support.

However, leaders described a caring and family-orientated culture. The registered manager told us, "We care for them as we care for our parents." Staff and relatives generally spoke positively about the service and described it as caring and homely. Staff also described positive working relationships and a long-serving workforce.

Although there was evidence of a caring culture and positive relationships between staff, people and relatives, people’s experiences were not consistently aligned with the provider’s stated values and culture.

Leaders were approachable and demonstrated commitment to the service, but did not always provide sufficiently effective leadership and oversight to identify risks, address shortfalls and ensure improvements were sustained.

Management systems had not consistently identified or addressed concerns relating to fire safety, infection prevention and control, care records, medicines management, staffing, the environment and staff knowledge.

During the assessment, we found significant safety and quality concerns that had not been identified through the provider’s audits and monitoring systems. This reduced assurance that leaders had effective oversight of the quality and safety of the service.

Leaders had responded positively to recommendations from external agencies and developed action plans to address identified concerns. However, some improvements were not yet fully embedded in day-to-day practice, and governance systems had not always identified areas where further action was required.

However, leaders were visible and generally described as approachable and supportive. Staff spoke positively about management support and relatives described managers as responsive when concerns were raised. One relative said the manager "takes it on board" when issues were brought to their attention. Leaders worked with external organisations and healthcare professionals and demonstrated commitment to improving the service.

Leaders demonstrated commitment and compassion. However, stronger oversight was needed to ensure risks were identified proactively, improvements were sustained and people consistently received safe, high-quality care.

The provider did not always ensure staff understood and felt able to use formal speaking-up arrangements, including routes for escalating concerns outside their immediate management structure.

Some staff could not explain the procedures available for raising concerns or the routes they could use if they were unable to raise issues through their line manager. This reduced assurance that all staff understood how to escalate concerns or challenge poor practice when required.

Leaders had responded positively to recommendations from external agencies and developed action plans to address identified concerns. However, some improvements were not yet fully embedded in day-to-day practice. Governance arrangements had not always identified gaps in staff understanding or areas where further support was required.

However, most staff described managers as approachable and supportive. One staff member told us, "Yes, she listens and all the managers listen." Staff described using meetings, supervision, handovers and direct conversations with leaders to raise day-to-day issues. Most staff told us they felt comfortable speaking with managers and believed concerns would be listened to and acted upon.

Although there were elements of an open culture, understanding of formal speaking-up arrangements was not consistently embedded across the staff team.

The provider generally promoted an inclusive working environment where staff from diverse backgrounds felt respected, valued and supported.

Staff told us they felt respected and supported at work. They described positive relationships with colleagues and managers, and did not raise concerns about discrimination, bullying or unfair treatment. Many staff had worked at the service for several years, demonstrating workforce stability and retention. One long-serving staff member told us, "We work like a family."

The registered manager described a diverse workforce and told us, "The employment is diverse and we have everyone." Staff from different backgrounds worked together and generally spoke positively about the culture within the service. Staff also described managers as approachable and supportive when workplace issues were raised.

However, formal monitoring of workforce equality, diversity and inclusion was limited. Despite this, the feedback available to us indicated staff generally felt respected, valued and supported within their roles.

Overall, the evidence demonstrated a diverse and stable workforce where staff generally experienced an inclusive working environment.

The provider did not operate effective governance, management and quality assurance systems to consistently identify, assess, monitor and mitigate risks or drive sustained improvements in the quality and safety of the service.

Audits and monitoring systems had not identified several of the concerns found during the assessment. These included significant shortfalls in environmental and fire safety, infection prevention and control, medicines management, care records, risk management and people’s access to support. These concerns had not been identified or addressed through the provider’s own quality assurance systems.

Records were not always accurate, complete or consistent. Governance systems had failed to identify discrepancies between care plans, risk assessments, moving and handling records and Personal Emergency Evacuation Plans.

Staffing levels were not supported by a formal dependency assessment. Competency arrangements had not identified gaps in staff knowledge relating to fire safety, safeguarding, the Mental Capacity Act and Deprivation of Liberty Safeguards. Some concerns had previously been identified through external reviews but remained evident during the assessment. This demonstrated that learning and improvement were not always embedded into practice.

Leaders responded to concerns raised during the assessment and developed action plans to address identified issues. However, the scale and persistence of concerns that had not been identified or resolved through the provider’s own monitoring systems demonstrated significant shortfalls in governance and oversight.

The provider worked effectively with healthcare professionals, community services and external agencies to support people's care, treatment and wider needs.

Records demonstrated regular involvement from relevant health and care professionals. Staff sought professional advice when people’s needs changed and worked with external services to support ongoing care and treatment. Professional feedback indicated staff identified concerns, shared relevant information and escalated changes in people’s health when required.

Staff described established relationships with external services and shared relevant information when people transferred between services. The registered manager also described positive partnership working with community services to support people’s ongoing needs.

Leaders engaged with the local authority and other external agencies in response to identified concerns and improvement activity. They worked with relevant partners to support service improvement and emergency planning.

The provider did not always ensure learning and improvement activity resulted in effective and sustained changes to the quality and safety of care.

The provider had developed action plans in response to concerns identified through external reviews, audits and quality assurance visits. However, actions had not always been fully implemented or embedded into practice. During the assessment, we found concerns that had not been identified or effectively addressed through the provider’s own systems. These findings demonstrated that improvement activity had not consistently resulted in sustained change.

Leaders responded to concerns raised during the assessment and submitted further action plans relating to fire safety, staff competency, governance and record keeping. A leader acknowledged that some changes, including revised fire evacuation arrangements, required time to become established in practice. However, the provider could not yet demonstrate that recent improvement activity had resulted in better outcomes for people or reduced identified risks.

External professional feedback highlighted opportunities to strengthen staff training in areas including dementia care, recognising deterioration, advance care planning and end-of-life care. Healthcare professionals also identified the continued use of paper-based documentation as an area for improvement to support communication and multidisciplinary working.

Although leaders demonstrated a willingness to improve and engaged with external professionals and agencies, improvements were not always sustained and further evidence was needed to demonstrate that learning had been consistently translated into practice.