Salisbury 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 good. At this assessment the rating has remained 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 75 (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 provider values were available on posters at the service and on the provider website. Staff had training at their inductions on the values and there were ongoing discussions in supervisions and meetings. This meant staff had clear guidance and an understanding of the expected standards of care.

The registered manager told us they were working towards a culture of trust and transparency, addressing all issues and concerns when raised and sharing findings with staff. All heads of departments were involved in shaping the culture and made themselves available to people, relatives and staff. Staff were encouraged to share their feedback and areas for improvement. We saw examples where staff had made suggestions which had been used to develop the service. For example, staff suggested a more robust induction system which had been used to improve new staff inductions. Staff suggested changes to how people’s personal mail was managed and delivered. This had been implemented and improved outcomes for people.

Staff enjoyed working at the service. One member of staff said, “It is a good place to work, I would recommend it as a home.”

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 service had a registered manager who had registered with CQC in November 2025. They had previously worked as the deputy manager which meant they were familiar with the provider policies and the service. There was a new deputy manager who had started prior to this inspection. The service also had a clinical lead who took oversight of clinical governance and outcomes.

Feedback about the leadership was positive. People, relatives, staff and professionals described the registered manager as approachable and caring. Comments included, “[Registered manager is excellent, has a very good understanding of everything that is happening in the home” and “[Registered manager] will help out where needed. They work on the floor with us and we learn from them.”

A regional director visited the service regularly to support leaders and be available for people, relatives and staff. If needed the provider had other managers who could step in and offer support at the service which meant the service always had some management cover.

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

The provider had procedures and systems for staff to use to report any concerns or share any ideas for change. The registered manager shared examples of how they had acted on information of concern from staff to address allegations of abuse. They told us how important it was for them to be addressing any concern from all sources.

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 had training on equality and diversity which was regularly refreshed. The provider had a range of policies and systems to support staff with equal opportunities, diversity and inclusion. The registered manager told us they had a diverse workforce with staff from a wide range of backgrounds and cultures. Staff all worked together to welcome others and learn about each other. They shared examples of support that had been provided to staff who were going through changes in their lives and facing personal difficulties.

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.

Systems were effective in assessing and monitoring quality and safety. There were many different quality checks being completed by different staff which reduced the risk of complacency. The provider employed a quality team who helped monitor risk and performance as well as completing quality audits. Performance ratings were shared with the registered manager monthly and used to improve outcomes for people. For example, checks on people’s weights, falls, infections were all completed monthly which helped monitor risks and ensure action was taken.

The registered manager told us they completed various managers audits which could be on different areas of care delivery. They told us about a recent audit completed on choking and hydration. Actions had been identified and shared with the staff. Monitoring was being completed to make sure actions were being implemented.

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 had good links with their community. For example, local schools visited the service for activities and events, and the service supported local veterans. Veterans were invited into the service to link up with people living at the service who were also veterans or had links with the military. The service had completed the ‘Veteran Friendly Framework’. This was a scheme designed to help care providers support veterans in a variety of ways.

Staff worked well with local healthcare professionals. Feedback about the service from professionals was positive. Comments included, “They [staff] update me regularly and they know when to seek further help. I do feel the service is well-led” and “There is good communication, I have a good relationship with staff. In terms of dementia care, the staff are empathetic and understanding of people’s needs.”

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.

Leaders created a culture of learning and making changes to improve outcomes for people. Staff were encouraged to share ideas for change, and all feedback was listened to and acted on when appropriate.

The provider was trialling new electronic systems to improve care planning, risk management and quality monitoring. This would merge a number of electronic applications into 1 bespoke care management system. This would provide the service with better recording for care planning and be easier for the staff and leaders to access and use information. The regional director told us it was hoped the service would get this system later in 2026.