Manordene

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 changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the lack of robust governance at the service.

This service scored 29 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, and engagement. They did not understand the challenges and the needs of people and their communities.

The leadership team had not identified the institutionalised practices in the service. There was a blanket approach to providing care including the ‘shower’ list, all people having to use plastic 2 handled beakers, bed rails and people placed in chairs and restricted from moving. We found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights. One member of staff told us, “I feel it's lost its spark here over the last few years. Staff morale is really down, and I think that does create all over bad feeling.”

We found the leadership team was not always open and transparent with stakeholders in relation to all allegations of abuse. This meant professionals and people’s representatives were not always in receipt of information to make an accurate judgement about the quality and safety of the care provided, which put people at risk.

There was a lack of transparency in relation to 2 people being required to share a room. The registered manager told us they were not aware of why the 2 people were sharing. They said, “I don’t like it because I believe in maintaining privacy and dignity. I don’t make decisions for residents as a I believe they had a mind of their own.” However, a representative of the person told us the registered manager had spoken to them about moving the person into a room with another person as they had a male resident moving in and needed the person’s room. There was also a lack of openness about the cleanliness of the service we observed as this would have occurred over a long period of time. However, the registered manager told us, “I was quite taken back to walk in here Tuesday, to be honest with you and to see the state of the home because that is not how I'd left it on Thursday.”

When we asked the registered manager whether it was dignified to put a sign up on the wardrobe about staff being particularly mindful of washing their hands when they had attended to that person’s care they said, “(Person) cannot see in the sense to say (person) doesn't want that sign up because (person) hasn't got that capacity.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders had not considered the impact on staff of not taking action when they are raising concerns about staff levels. We saw from staff meetings they were not always given an opportunity to feedback on any improvements that might need to be made. Staff fed back that when they tried to suggest improvements were made, they did not feel listened to. One told us, “I’m not really supported and actually sometimes even stopped (from trying to make changes).”

There were incidents of high levels of distress by people where staff were impacted. The registered manager told us, “I do say to them (staff), don't take it personally and we remind them that this person has dementia.” However, there was no evidence of any debriefs with staff on the incident report and it was not clear what action had been taken to support staff wellbeing after these incidents had occurred.

Staff told us they did not feel able to speak up as no action was taken. One told us, “I've reported it (their concern) and it's been constantly ignored.” Leaders did not role model a shared vision, strategy or positive culture to staff. This had a major detrimental impact across all areas of people's lives. We found the leaders had not encouraged a positive culture where people or staff could feel they can speak up, that their voices will be heard, and their concerns and suggestions listened to. Staff told us they did not always feel they could escalate their concerns if they had already raised this with their seniors. This resulted in unsafe care and poor care to continue with people. The leaders failed to recognise they had developed a closed culture that did not promote or uphold people’s or staffs’ rights.

We saw from a staff meeting in August 2025, where staff had raised concerns confidentially to the registered manager, whilst the staff name who reported this was not mentioned, the concerns were discussed openly in a staff meeting.

The service failed to work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had not received appropriate training in this area and failed to demonstrate good values in relation to equality and diversity.

There were agency staff that had worked at the service for a long period of time. However, they were not given the opportunity to attend staff meetings or have supervisions with their senior.

The leaders did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. They were unable to provide evidence of an effective system to assess monitor and improve the quality and safety of the services provided, and to ensure they had met the requirements of this regulation.

There were very few audits taking place and these were only undertaken by the registered manager. We asked the registered manager whether any audits were undertaken by the provider, or their representative and they said, “(Provider) is here regularly and they will do their own audits, I don’t have any audits from (Provider).” However, when we asked for any audits from the provider, none were provided.

The providers electronic care system was able to produce reports to identify the safety and quality of care, however these were not being utilised. We were able to identify using this system, the lack of fluid intake, staff not supporting people with regular showers and staff not repositioning people with another member of staff. However, none of this had been identified by the leadership team. This meant they could not be assured that all areas of service delivery were monitored and that actions were taken to improve poor practice. Leaders were unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the service which resulted in people having poor outcomes.

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

Whilst external professionals fed back positively about the leadership, leaders did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. Where advice had been provided by stakeholders, this was not always being followed. Where safeguarding concerns had been raised, these were not always reported.

Leaders did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcomes and quality of life for people. There was no analysis of the overall incidents to look for trends, themes and triggers to try and reduce the risk of incidents which placed people at risk. By systematically reviewing incidents services can implement changes that lead to continuous improvement. This might involve revising protocols, enhancing staff training that reduce the likelihood of future incidents. We found this was not taking place.

Whilst the registered manager told us they were already aware some of the shortfalls we identified, there was no evidence of any action plan to confirm this.