Manor Park Care Home

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 inadequate. At this assessment the rating has changed to 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.

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 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 new manager said they wanted to ensure staff knew the value of their role in caring for people. They knew the values and vision for the service and were trying to involve staff in embedding these in shared and sustained ways, to promote positive and respectful relationships. The management team and staff told us they were working together and felt proud of the shared efforts made to make improvements since the last inspection. One member of staff said, “We know we’re not perfect yet, but we are all working so hard and things are changing for the better.” Relatives told us there were improvements in the quality of the service. One relative said, “I am here 6 days a week so I can see the improvement” and another relative told us, “I’ve seen what has been done and this place is completely different now. There are still some minor issues, but from where it was, we are happy.”

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 leadership team provided continuous support for the new manager in their role as well as the wider staff team. Staff told us the provider and senior managers were regularly present in the home and were helping to make improvements. The manager told us it was their number 1 priority to get to know all the staff and people who lived in the home, and listen to their feedback. Nurses communicated clearly with the care teams to ensure people’s needs were known and encouraged teamwork.

People, relatives and staff told us the manager was visible in the home. One person told us, "I don't know the manager’s name, but I know they haven’t been here long. The manager is good and has popped in my room for a chat. One relative shared, "The new manager seems good and I have found them easy to talk with and ask questions. Everyone here is trying their best."

People did not always feel they could speak up and that their voice would be heard.

We received mixed feedback from staff we spoke with about their confidence in speaking up. Some staff felt hesitant to raise concerns, particularly around staffing levels, because they did not feel this would bring about any change. Staff knew the processes to follow if they wanted to speak with the manager or the wider leadership team. The manager was committed to developing an environment where everyone felt comfortable sharing their views.

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 employed a diverse workforce from varying backgrounds and cultures. Flexible working was supported, and adaptations could be made to suit individual needs. Training was inclusive of all staff. The provider ensured all staff had access to appropriate support systems. For example, mental health first aiders were available to ensure staff felt comfortable accessing support, regardless of their background or identity. All staff were included in meetings and minutes were available where staff could not attend.

Governance systems and processes were in place but required further improvement. The provider had clear responsibilities, roles, and systems of accountability to support this.

Aspects of quality assurance systems and processes had improved. However, they were not always effectively implemented to ensure safety or to drive improvement. Shortfalls identified through the assessment process had not always been identified or sufficiently addressed through the management team’s quality checks. For example, a serious injury had not been picked up or reported, people’s pressure relieving mattresses were not set correctly and there were gaps in repositioning. In addition, the manager’s walkarounds identified concerns with fluid records for 2 consecutive months, yet we found continued concerns with these on our first site visit.

Audit tools were in use and covered many aspects of processes and practice. However, actions were not always completed within the provider’s specified timeframes, with some being significantly overdue. Furthermore, appropriate and timely action had not always been taken where concerns had been identified.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider was aware further improvements were needed to strengthen partnerships. For example, sharing concerns in a timely way with partners and being clearer about outcomes of complaints with people and relatives.

The manager was considering ways in which to collaborate with local communities, such as schools. The provider was continuing to work with the local authority quality team to address their action plan for improvement.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice.

The provider had made improvements to the service and was no longer in breach of 4 out of 5 regulatory breaches identified at the previous assessment. However, some improvements were still required, and we found some repeated concerns, which the provider was taking action to address following our assessment.