The Manor House 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

We assessed a limited number of quality statements in the well led key question and found areas of good practice. However, improvements were identified to auditing systems, such as health and safety checks and care plan audits. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. The manager responded to our feedback and introduced new quality audits to monitor health and safety checks and review care plans. We will review the success of these new systems in the next assessment. Staff told us they felt supported by the management team, and they felt they worked as a team in order to promote people’s health and wellbeing. Staff told us the new manager was approachable and led by example. The manager told us they were working closely with health and social care partners to continually improve the care and support provided to people.

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.

Staff told us they understood the providers direction and they felt supported within their roles. One staff member told us, “I feel really well supported. The management have been there for me. We share ideas, we help each other.” Another staff member told us, “Morale amongst staff was a bit low but it has come back now. We are all raring to go and want to get the place back up to where it should be. We all work together, we support each other.”

The provider shared their statement of purpose and action plans. They had recently experienced periods of change in the management team and had received concerns from visiting professionals. A relatives meeting was held during this assessment to review the concerns and to share the provider's future plans for the service. This demonstrated the provider used an open culture to discuss concerns and be receptive to feedback.

Staff told us the manager led by example and provided support when needed. One staff member said, “It is easy to approach [the manager] if I have concerns. If I need anything, I just pop up to the office. [The manager] will come and ask me if I'm OK and ask if there's anything they need to know.” Another staff member told us, “I do feel well supported by the new manager. They are approachable and I would be confident that they would address any concerns."

The provider was open about things which had gone wrong such as concerns raised from visiting professionals and incidents involving people. They shared their action plans and told us about the steps they had taken to reduce the risks to people. Minutes of meetings showed how risk were openly discussed and actions were recorded to reduce the risk and improve the quality of care provided to people. The manager understood the duty of candour and told us about the importance of being open and honest.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were very knowledgeable about their roles. They took responsibility and were accountable for their actions. However, we found gaps in recordings and staff had not always followed the care plan when supporting people. The manager told us how they had addressed these concerns with the care staff and implemented new auditing systems.

Some quality audits were taking place, although these had not always identified the discrepancies found during this assessment. Care plan audits had not always identified the outdated information found in care plans. Health and safety audits required improving to address the gaps in health and safety monitoring. The manager responded to all of our feedback and introduced new auditing systems.

Relatives told us the provider worked in partnership and kept them up to date with changes. One relative said, “[My family member] has CPN visits. The provider stays in contact with me.” CPN’s are Community psychiatric nurses who can help support people experiencing mental health concerns. Another relative told us, “There’s organised meetings if I chose to attend. We’ve got a talk about dementia coming up.” An additional relative told us, “Other medical professionals are involved in [my family member's] care when they need to be. I’ve no complaints, I would complain if I needed to, but I don’t need to.”

Staff told us they work alongside visiting professionals. One staff member told us how they had benefitted from a recent training course with an external dementia specialist who was working with the provider to promote awareness. Other staff told us about how the provider worked with other health professionals such as nurses and GPs.

Visiting professionals shared their concerns over how care was monitored and managed. During this assessment visiting professionals met with us and the provider. They confirmed the provider was working with them to resolve the concerns and there was improvement identified. However, further work was ongoing.

Care records showed joint working with other professionals such as GP, tissue viability nurses, opticians, and physiotherapists. We observed the provider working with other professionals to act on the concerns which had been raised and improve the care and support provided to people.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.