The Manor House Roundhay

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 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 79 (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.

The providers vision emphasised a commitment to delivering inclusive and person centred- care by empowering staff, engaging residents and families, and fostering a culture of transparency, learning, and continuous improvement.

The culture within the service felt warm, welcoming, and friendly. We observed natural, relaxed interactions between people and staff, with conversations flowing easily and good natured humour evident- throughout. People were encouraged to take part in activities, socialise with others, and spend time together in communal areas. We saw that people got along well with each other and had positive, trusting relationships with staff.

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 management team and staff we spoke with demonstrated a clear passion for the service and for what they were striving to achieve. Throughout our assessment, the focus on delivering high quality care and achieving positive outcomes for people was evident.

Although the manager was new to the role, they were already familiar with the service and demonstrated good oversight of day to- day- operations and quality monitoring.

Staff told us they felt fully supported at work and were kept up to date with any changes. They described communication systems and team working within the service as robust and effective. One staff member said, “I trust [Management].” Relatives also spoke positively about the leadership and the support provided. One relative told us, “Management have really helped with all my worries and concerns. They ring me and communication is very good. If there was anything at all wrong, I would say so.”

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

Regular supervisions, meetings and surveys are carried out to ensure ongoing communication and continuous improvement. Staff told us that management are accessible and supportive, with one member of staff explaining, “Every day we have a flash meeting with the heads of department, including management. They always ask if we are happy or if we have any concerns, which is good.” People living at the home and their families are also engaged through regular meetings and surveys to gather feedback and inform improvements. The manager told us they fostered an open-door 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.

The provider had a comprehensive equality, diversity and inclusion policy in place, and staff had completed the required training in these areas. Feedback from staff was largely positive, with many reporting that they felt treated fairly at work and confident that any concerns they raised would be addressed. During the onsite inspection we observed a positive and inclusive culture within the service.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Audits were completed regularly and fed into clear action plans, providing good oversight of the service. The transition to the new manager had been smooth, with systems in place to maintain continuity and oversight during the change. Daily walkarounds of the home were carried out to monitor both safety and quality; these identified concerns promptly, and appropriate action was taken to address them.

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

We saw evidence that people achieved positive outcomes through effective partnership working, including improvements in areas such as pressure sore reduction. External professionals told us the provider worked collaboratively with them, and that the new manager was actively building professional relationships to ensure clear communication and consistent, wrap-around support for people at the home.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider and management team demonstrated a commitment to continuous learning and improvement using lessons learned to drive meaningful change across the service. This included regular analysis of incidents to identify root causes to support positive strategies and interventions.

The provider actively implemented a sustainability strategy through onsite renewable energy, electric vehicle charging, wildlife and gardening initiatives, integrating environmental responsibility into daily practice while enhancing people’s wellbeing and community engagement. They valued the importance of continuous development from learning lessons from accidents, incidents, audits and listening to feedback from people, their families, staff and external professionals as an opportunity to improve quality of care and service.

Reflective practice was used effectively, and learning was shared with staff. The manager welcomed feedback during the inspection visit.