Martlet 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 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.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

The provider’s policies and procedures reflected best practice in care and support. Staff demonstrated a clear understanding of the service’s values, culture, policies and procedures.

Leaders and staff demonstrated a clear focus on supporting people to live comfortably and make choices about their care. This was reflected in the calm and welcoming atmosphere observed throughout the home and in the way staff consistently prioritised people’s needs during daily interactions.

People and relatives spoke positively about the culture of the service and felt confident approaching staff and managers if they had concerns. One relative told us, “Staff are very approachable and easy to talk to if we did have any issues”

Staff worked collaboratively across roles and were observed supporting one another to ensure people received timely and attentive care. Staff were provided with opportunities to discuss best care practice and regulatory requirements during regular supervision sessions and team meetings. Records of staff supervisions and meetings demonstrated that equality, inclusion and the needs of people and their communities were considered.

The service 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.

Leaders were visible, approachable and well‑known to people, relatives and staff. The registered manager and senior staff were actively involved in day‑to‑day oversight and responded promptly when issues were identified. During the inspection, leaders took immediate action to address environmental risks, demonstrating accountability and a willingness to learn.

People and their family members commented positively on the support they received from the management team. One family member said, “The manager has been very helpful and supportive.” Staff described leaders as supportive and accessible, and we observed managers providing guidance and reassurance to staff during the inspection.

The provider had created an open culture where people, relatives and staff felt able to raise concerns. People told us they felt safe and confident to speak up if they were unhappy. One relative explained, “I think she would be comfortable speaking up if needed to staff or the manager if she was unhappy about anything.” A staff member told us, “I have no concerns that if I raised something with my managers I would be listened to and actions would be taken.”

Staff responded positively when issues were highlighted during the inspection and escalated concerns appropriately to managers. Leaders encouraged reflection and discussion, and concerns raised were acted on without delay. This demonstrated that feedback was welcomed and used to improve practice.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider supported an inclusive workforce and respected people’s individuality. Staff treated people with dignity and adapted their support to individual preferences and needs. People’s rooms reflected their personalities and life histories, and staff were knowledgeable about people’s interests and choices.

Staff records showed a diverse workforce, and there was evidence of fair recruitment, induction and ongoing support. Staff had all received equality and diversity training and felt they were treated fairly and equally. They told us they felt valued and had opportunities to develop within the service. This contributed to positive morale and continuity of care for people.

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 provider had systems in place to monitor quality and safety. These were regular and detailed, and actions identified had been promptly addressed. However, these were not always effective in identifying and addressing risks promptly. During the inspection, we found environmental risks that had not been identified through routine governance processes. These issues were addressed immediately once highlighted, and managers took swift action to reduce risk. Although we found no immediate risk to people, the fact that these risks had not been identified through regular audits indicated gaps in oversight. This demonstrated that governance systems needed strengthening to ensure consistent risk identification and sustainability.

The provider was aware of their responsibility to share any information of concern where appropriate, with, for example, Local Authorities and the CQC.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service worked in partnership with families and external professionals to support people’s wellbeing. Relatives described positive communication with staff and managers and felt involved in discussions about ongoing care and future arrangements.

Staff supported people to access health services when needed, including GP support, and worked flexibly to accommodate relationships that were important to people. One family member described how the home supported two people to have bedrooms close together so they could spend meaningful time together.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The provider demonstrated a willingness to learn and improve. When issues were identified during the inspection, leaders responded immediately and used these as learning opportunities. Staff were receptive to feedback and adapted their practice following discussions with managers.

The service showed a reflective approach, with leaders acknowledging areas for improvement and considering how systems could be strengthened. Staff and people described how they were involved in discussions about the service. This supported continuous improvement and helped embed safer practice across the home.