The 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 requires improvement. At this assessment the rating has remained 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.

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

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 provider’s aim was to provide people with high quality, individualised care, within a friendly, homely and supportive environment and staff provided care that reflected this. They understood the importance of treating people with dignity and respecting their wishes.

Leaders had created a positive culture of kindness and compassion at the service, where people’s views were sought, listened to and where they received individualised care. The atmosphere at the service was warm and welcoming, and people looked relaxed and comfortable around staff and management. Staff told us, “The culture is very homely. [Registered manager] is always there for the residents; she treats them like family” and “Staff know people. There’s a caring culture towards people and from staff to each other.”

The provider and registered manager did not always have the knowledge and skills to ensure the delivery of safe care and the effective governance of the service.

The provider and registered manager failed to demonstrate sufficient oversight or understanding of their responsibilities regarding safety. They failed to identify environmental risks, were unaware of the requirements for managing water safety, did not ensure the kitchen and garden areas were secure, and had not acted on necessary fire safety improvements in a timely manner.

However, we received positive feedback about management from people and relatives. They told us, “We could discuss anything with [registered manager and deputy manager]. Nothing was too much trouble. They feel like extended family.” The registered manager led by example. We observed her speaking with people and saw she was kind, compassionate and treated people with respect.

Staff felt well-supported. A staff member commented, “[Registered manager] is a good manager. She is very supportive about both personal and work-related issues. She’s always there if you need her.”

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

The registered manager held regular meetings and provided yearly satisfaction surveys, which provided the opportunity for people and relatives to discuss the service, raise any concerns and suggest improvements. People and relatives told us the registered manager and deputy manager were approachable and helpful. They felt they could raise any concerns and make suggestions. They commented, “We had a questionnaire recently but to be honest, we don’t need them, as we always see [registered manager] and iron out any concerns whilst we chat” and “This is like a big family home, and we can talk to [registered manager] about anything and everything.”

Management held regular staff meetings and issued yearly feedback surveys to staff, which they could complete anonymously if they chose to. The 2025 survey showed a high level of staff satisfaction and engagement. Staff told us the registered manager was approachable, and they felt able to raise any concerns.

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.

We spoke with several staff, including staff from ethnic minority backgrounds. They all felt valued and told us they were treated with respect. None of the staff had experienced discrimination and they felt confident this would be addressed appropriately by the registered manager if it occurred. A staff member commented, “Management are very good and supportive. It feels like we’re all equal.”

The provider did not always have effective governance processes. They did not always act on the best information about risk, performance and outcomes.

The provider had not ensured people were living in a safe environment or protected from the risk of avoidable harm. The audits completed by management and the visits by the provider had not identified the issues relating to safety found during the inspection.

Where improvements to quality and safety were needed, action had not always been taken in a timely way. The shower room and bathroom had been out of use for the same four-week period and necessary fire safety improvements had not been made within required timescales.

However, most people and relatives were happy with the management of the service. They told us, “I think the management work hard to do all the right things for people, and it is never ending. [Registered manager] asks every day if all is okay.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners. However, collaboration with other services did not always result in appropriate, timely improvements.

Staff worked in partnership with community agencies and made appropriate referrals to ensure people received any specialist support they needed. Community healthcare professionals who visited the service told us people seemed happy and were well cared for. They told us management and staff were friendly and approachable, and the quality of care provided was good.

However, engagement with the local authority contracts department had failed to result in necessary improvements at the service. In July 2024, the department issued the provider with an improvement plan, due to required fire safety actions from a risk assessment carried out in 2023 not having been completed in a timely way. Despite regular reviews, and a further two fire risk assessments being completed, at the time of our inspection, not all fire safety actions had been completed, and the improvement plan remained in place.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Leaders did not always have a good understanding of how to make improvement happen in a way which considered impact and outcomes. For example, there was a lack of understanding regarding the need for dementia-friendly signage at the service and the potential impact this could have on people’s ability to be more independent.

They did not always have consistent, effective systems for ensuring lessons were learned and improvements made when incidents occurred, leaving people exposed to the continued risk of avoidable harm.

Some relatives and staff felt the environment needed updating and we noted the provider had an improvement plan in place for redecoration and the replacement of furniture.