Dorking 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.

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 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 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.

People and their relatives spoke highly of the service and said they were happy with the care and support provided by staff. We heard, “I am treated very well here” and “I like being care for and being cooked for”, “I have recommended it to anyone looking for a care home and will continue to do so”, “Everyone was welcoming and helpful. I am impressed with the activities, my (family member’s) room design and size and her care. It is now as good as it can be, and overall, my (family member) is happy and content, and I know she is safe and well cared for” and “[Family member] says he will be there until the end of his days and he is happy, feels safe, cared for and amongst friends. He loves family and friends visiting and feels proud of where he lives.”

There was a sense of community with people relaxed in each other’s company as well as with staff. A relative said, “It is extremely well-run and has achieved a real sense of community, not only for the residents but for their families too.” Staff did not wear a uniform and they told us, “The residents like it and it feels more like a family here and that’s down to not wearing uniforms.”

Staff were equally happy at the service with 1 telling us, “Really do feel valued. I feel appreciated, it’s very open here. If they are pleased with you, they tell you.” Another said, “We are here to support and promote independence and supporting the residents to live their lives. I drive 1 hour to get here so that’s how much I enjoy it here. I have a lot of other options but I want to be here, I like this place. The staff are lovely and managers are very supportive.”

The registered manager recruited staff based on the provider’s values of empowerment, creativity, commitment, dignity, collaboration and innovation. These were standards and expectations set out across the whole service to help ensure people received good quality care.

Leaders were experienced and understood the context in which the provider delivered care, treatment and support. However, there was some inconsistency in their understanding of their requirements of registration.

Although the registered manager was experienced and capable, we found that notifications were not always submitted to CQC in line with their legal requirements. This included an incident where 1 person hit another over the head with a magazine, a person presented with a bump on their forehead from an unknown cause, and another person punched others on 2 separate occasions. This meant CQC was not always informed of incidents and concerns that met the threshold for notification. However, this did not appear intentional as the registered manager had submitted other safeguarding concerns and notifications appropriately.

In other aspects the registered manager displayed a good oversight of the service, clearly knew people well and had a good rapport with people and staff. They participated in weekly manager’s meetings which enabled them to share news and ideas with their peers.

Staff spoke well of the leadership team, telling us, “She is great, all the managers are. It’s a great team and there is no one I don’t think doesn’t fit in. The residents tell me they feel loved and cared for” and “When I joined, I joined as a homemaker, in June last year. In November they promoted me to lead, I am supported my colleagues and managers. If I have any questions or any concerns they will support me straight away.”

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

Staff felt comfortable speaking up and told us, “We are encouraged, there is no culture of keeping quiet” and “We are encouraged to speak up and there are examples where staff have done that. We are here to protect the residents.”

Human resource sessions were held at the service where people could go and speak in confidence and without the registered manager present.

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 felt they were treated equally at the service and there was no discrimination. One staff member told us, “We are all treated equally, and fairly. For example, it doesn’t matter of you are [staff’s country of origin], team leader or home maker we are treated the same.”

Our observations during the day confirmed this as staff were spoken respectfully to by senior staff and their colleagues.

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.

The service ran a number of audits across the service each month. This included care plan, medication, call bells, catering, health and safety, housekeeping, night visit, maintenance, pressure ulcer risks, mealtimes, wellbeing/activities and lifestyle.

Where shortfalls were identified these were highlighted and actions were set for staff to address them. This included ensure medication temperatures were consistently recorded and body maps were set up for people who had a pain path. Some call bell response time analysis showed some calls were not answered within the recommended timescales and an action to follow this up and investigate was set for the registered manager. Housekeeping staff were reminded to clean light fittings, bed bases and mirrors as a result of an audit of these areas and following a night visit, staff were reminded to wear name badges and keep the medicines trolley in the clinical room.

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.

The service worked with external health and social care professionals as well as having links with the local area.

As well as professional relationships with the GP, district nursing team, physiotherapists and other health professionals, staff had developed relationships with local schools, toddler groups and the local church.

The service had invited 3 schools to participate in a competition to suggest names for each floor at the service and through the National Youth Harp Orchestra of Great Britain people had benefitted from hearing young musicians practice their repertoire on several occasions and in particular just before they headed off abroad for a competition.

Staff had a good relationship with the local church and in particular the pastors. Monthly services were held at the service and Holy Communion offered to those who wished to receive it. This enabled people to continue to practice their faith.

The service also hosted a monthly dementia café in partnership with the dementia coordinators from NHS Surrey Downs. This meant people had a place for people living with dementia, their families and carers to come together. People were encouraged to join in helping to make the café feel like a genuine part of life within the service.

The provider 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 contributed to safe, effective practice and research.

The provider took time to review CQC reports to identify what made services good or outstanding and then shared this information with their locations for their learning and encouragement.

The registered manager had ongoing plans for the service to help ensure that people received consistently good-quality care. They told us, “Our focus is to get our staff more and more specialised in dementia care. Our dementia specialist is providing additional training to staff and everyone will be trained. We also want to have a medicine champion on each floor and we are providing additional training to kitchen assistants so they would be a position to take over the kitchen in the absence of a chef. It is important to give staff opportunities. We want them to think of this as a long term place to work.”

Long term the registered manager wanted to change the external area of the home to create a dementia-specific area which could be used by people living at the service as well as the local community.

The registered manager held a service improvement plan which recorded actions, deadlines and person responsible for these. This helped them keep track of shortfalls, areas for improvement and good oversight.