Manor Support and Housing Limited Also known as Koala House Annex

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 good governance.

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 clear vision and values which were reflected in policies and understood by staff. 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 had an equality, diversity and human rights policy in place at the time of the assessment which set out the aims and objectives of the service. Staff told us about the values of the service. One person said, “A caring organisation, put our residents in the centre of their care. Believe in promoting their independence and dignity, inclusion. We support our residents in the best life. They are like part of our family.”
 

Leaders did not always demonstrate the provider's stated values in their interactions with people. One person told us they did not feel able to raise concerns with leaders and did not always experience interactions that were kind and compassionate. Staff spoke positively about management and leadership within the organisation. Staff told us they felt supported by leaders who led by example. However, we found not all leaders embodied the culture and values of the organisation to ensure people were consistently spoken about and treated in a kind and compassionate way. One person also told us they did not feel able to raise concerns with leaders.

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

Staff told us they felt supported to speak up. One person said, “I really believe that everyone is listened to, no one has to argue, you can speak to your opinions and don’t feel judged.” Another staff told us, “[Leaders] always say raise any concerns. If you want to help anyone you have to speak up.” The provider told us they have regular supervisions for staff and in addition they have informal supervisions during team meetings.
 

Leaders encouraged staff development and promoted a supportive working environment.

Staff told us there was a positive culture of kindness within the team. One person said, “I feel comfortable as management is there to assist us. I feel supported as we work together like a family. Any time I have an issue I feel comfortable talking to management.” The registered manager explained to us how they encouraged and supported staff to develop within the service.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on information about risk, performance and outcomes to drive improvement.

The provider could not demonstrate they had established robust systems and processes so they could assess, monitor and mitigate all risks relating to the health, safety and welfare of people using the service, staff and the operation of the service. The provider’s quality assurance systems did not identify concerns we found during this assessment which are described throughout this report. The registered manager did not ensure medicines audits were always effective. For example, these audits had failed to identify concerns we found with topical administration of medicines and ‘as needed’ medicine protocols.
The provider did not always maintain effective oversight of the quality of care being provided, risk management and mitigation, staff practices, knowledge and competency to support people. The provider could not demonstrate that staff undertaking competency assessor roles had themselves been assessed as competent to perform those duties. Lack of competency assessments for all tasks meant staff did not always have the necessary skills or knowledge to deliver safe care, placing people at risk of harm. Gaps in recruitment checks meant all required information was not gathered to ensure there were suitable staff to work with people.
The provider did not always effectively review incidents, accidents and complaints to identify themes, trends and learning opportunities. This limited their ability to identify emerging risks, take timely action and reduce the likelihood of similar incidents occurring again. Where actions had been identified, these were not always completed or appropriately recorded, which reduced assurance that improvements had been implemented and sustained.
 

The provider worked collaboratively with partners to support joined-up care and positive outcomes for people.

The registered manager told us, “We have a very good relationship with all the families...The social workers are always there as well. So, collaborative work with all parties. We have a good relationship with commissioners as well, they are here all the time. The GPs are there as well. So, we can all try the best way to ensure the quality of support is good.”

We contacted professional partners for feedback. One said, “The staff have engaged professionally with our Community Mental Health Service and have demonstrated a good understanding of the needs of people with complex mental health conditions. They have communicated concerns appropriately, sought clinical advice when required, and worked collaboratively with health and social care professionals to ensure individuals receive safe and person-centred support.”
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider did not always have effective systems to support continuous learning, improvement and service development. The provider did not demonstrate they completed audits across all areas of care delivery and management to ensure learning areas were identified and used to drive improvement. Audits which were completed had failed to identify the concerns addressed in this report.Some audits were effective in driving improvement such as health and safety audit. However, the provider had failed to drive improvement through ensuring the care records were accurate and up to date with information.

The provider told us they used questionnaires to seek feedback. However, we found limited evidence that feedback, including concerns was analysed or used to improve how the service was managed.

The provider shared their themes and trends analysis with us during the assessment. This demonstrated how they reviewed incidents and accidents for learning. The provider was responsive to issues raised when we highlighted them. The registered manager told us they would implement new training and competency processes and review secondary dispensing practices to ensure feedback was addressed following our visit.