Manor Hall Nursing 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 Requires Improvement. At this assessment the rating has changed to 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.

Staff said that the management team were approachable and keen to listen, and that they feel well supported and there was a lot of good natured humour, which made things go well. The management team understood and supported people’s (and staffs’) cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences. The management team knew people well and also worked alongside staff to support and promote good practice. All the staff were positive and proud of the care delivered to people who lived at Manor Hall.

Feedback from staff was consistently positive and enthusiastic when we spoke with them. The service aimed to give people consistently good care and staff worked together to try and achieve this. Individual staff supervision and group team meetings were used by the provider to remind staff about their organisations underlying core values and principles.

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.

Staff told us the management team were approachable, supportive and promoted an inclusive work environment.

The deputy manager told us they operated an open-door policy and ensured that the management team spent time on the floor meeting people and staff. The management team had a good knowledge of all the staff and knew their strengths and weaknesses.

There were systems and processes in place to support staff development and progression within their roles. Staff talked of how they were supported to gain qualifications and extend their role, for example, becoming Care Home Assistant Practitioners (CHAP) CHAPs works alongside nurses in a care home setting, taking on certain clinical and leadership tasks such as dressings. We saw evidence that staff received regular supervisions, spot checks, competencies and values-based supervisions. The provider’s senior management team visited the home regularly and provided support and supervision to the registered manager and deputy manager. There were organisational management meetings which enabled learning across the organisation to be shared and relevant lessons learnt implemented within the home. The provider supported the registered manager and staff to attend external training and meet with other providers and managers to network through various forums.

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

Staff told us that felt able to raise concerns. One staff member said, “I think our culture here is to be open, mistakes can happen but we have to own it and learn,” and “We get reminded at meetings and supervisions of safeguarding procedures, raising concerns and whistleblowing options, I would proudly speak up for our residents.”

The provider and management team understood their responsibilities under the duty of candour. The Duty of Candour is to be open and honest when untoward events occur.

We have received notifications as required. During our assessment we found that the management team were open and transparent about recent safeguardings and wanted to improve relationships with their GP surgery and seek solutions. They admitted when things had gone wrong and demonstrated how they had used these to make improvements.

Staff were supported and enabled to voice their views and concerns. They were aware of the whistle blowing policy but felt that they could raise them and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. People and their relatives confirmed they knew how to complain, and a copy of the complaints policy was available in the home and on the service website. Relatives told us; they would make a complaint if they needed to but would talk to staff first. A record of complaints was held in the service. These included the information on the complaint and how this was responded to. We saw complaints had been responded to and actions taken as necessary.

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 told us they felt they were treated equally and that there was a supportive culture at the home. Staff were given opportunity to give their feedback and to discuss any issues or concerns at staff meetings or on a one-to-one basis during supervision.

Staff felt they were treated as individuals and their needs were taken into consideration, such as shift times being re-arranged to fit in with family commitments if required.

The provider had procedures in place to promote staff well-being and worked to provide flexible working conditions if required. There were robust measures in place to monitor, maintain and promote good mental well-being across the staff group. There was a formal recruitment process and equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. Staff were encouraged to undertake training in equality and diversity.

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.

Quality assurance systems were in place and used effectively to improve the service. The management team had worked hard to ensure there was robust oversight and effective governance at the service. There were computerised and paper systems and processes, to assess, monitor and improve the quality and safety of the service provided. Governance meetings were held regularly and minuted. These were used to monitor effectively and pick up trends/concerns early, such as repetitive falls. However, we found some areas regarding the management of medicines that needed to be improved, and not all behavioural charts were completed in full following administration of PRN medicines. Peoples mental health was not always monitored and evaluated in daily notes. These areas were acknowledged as areas they had identified as needing development.

Staff told us about their duties and responsibilities, they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. There were checks and audits in place to monitor quality and safety. Action was taken when audits identified areas for improvement.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partner agencies and collaborate for improvement. Staff built relationships with community groups. The activity coordinator told us they had arranged for a choir to visit to sing carols. Other entertainers were invited to the home. Staff liaised with local GP’s and other healthcare providers when appropriate.

The deputy manager told us how they worked with other healthcare professionals to ensure continuity of care. Health and social care professionals visited the home regularly and were able to assess people following their admission to the home from hospital or home. Staff had access to the tissue viability team, falls team, dieticians and other specialist services as necessary. Staff told us of how they monitored people and used risk assessments to ensure they requested referrals in a timely way. One staff member said, "If someone is having lots of trips or falls, we contact the GP for a referral, also we work closely with the tissue viability nurses, we do have a few people with complex wounds

We spoke with one health professional that work alongside staff at the service. They told us, "They keep good records and that also helps us to treat appropriately," "Staff do contact us when needed, and work with us."

Staff supported people to give feedback and opportunities which they had to drive improvements and encourage learning from any incidents which occurred. The provider and registered manager had oversight of accidents and incidents. Trends and patterns were identified and addressed. We saw example of lessons learnt following incidents which occurred within the service. For example, introduction where appropriate of crash mats and sensor alarms. Reflective meetings were held with staff to give opportunities to discuss development points to encourage improvement in practice, following safeguarding outcomes. Learning was, where appropriate, also shared across the providers other services. The management team encouraged staff to speak up about ideas and supported them to make positive changes.