Manor House Residential 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

At the last inspection, the provider was in breach of regulation 17 in relation to lack of effective quality oversight systems, monitoring staff training and policies and procedures promote good outcomes for people were not fully understood by staff. At this assessment, the provider had made enough improvements and was no longer in breach of this regulation. Improved oversight systems and processes were used effectively to monitor all aspects of the quality of care and safety within the care home including staff training and policies and procedures. The registered manager and staff worked collaboratively with external agencies to promote people’s quality of care and support. The registered manager welcomed feedback and acted on concerns. There was an open, inclusive and fair culture to improving equality and equity for staff and promoting people’s diverse needs and preferences.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager was open and welcomed feedback. Complaints and concerns were acted on and any lessons learnt was shared with staff.

There was a culture of speaking up. Staff felt confident to raise concerns with the registered manager and knew how they could raise concerns with external agencies.

The registered manager took action to continually review and improve the culture within the work place in relation to promoting equality, diversity and inclusion. Policies and processes in place supported the well-being of staff. For example policies detailed how the provider supported staff’s mental health and well-being in the workplace and staff confirmed this happened in practice. Posters were displayed to remind staff the deputy manager, lead for mental health well-being was available if they needed to discuss sensitive and confidential matters.

The registered manager told us there was fair and equitable treatment of staff and always considered staff’s individual circumstances wherever possible. Staff gave examples of how they were supported in the workplace. For example, reasonable adjustments were made to support staff with a change of shift and job role.

Staff understood their roles and responsibilities within the team and how these contributed to ensuring the safety and quality of the service. The registered manager was aware of their responsibility to maintain standards of governance and oversight of the service. During the on-site assessment, the registered manager was responsive and took action to mitigate risks in relation to fire safety.

Quality assurance audits had improved and were more robust following the previous inspection. For example, we reviewed medicine audits the previous 2 months and we saw action had been taken were shortfalls had been identified. The registered manager was responsive to the concern we identified and updated the fire safety audits to include checks on bedroom fire doors. There were a range of mechanisms to engage with people, their relatives and staff to seek their views and feedback. Systems and processes to ensure staff understood their role and responsibilities and had the skills, knowledge and training to meet people's needs. The registered manager and provider were responsive to feedback and took action to mitigate further risks to people. The registered manager was aware of their legal responsibilities to inform the care quality commission of statutory notifications.

There were processes in place for working effectively with other health and social care professionals. For example, audits were in place which also checked follow up health appointments had taken place or were entered in to the diary.

People were supported by a variety of health and social care professionals to ensure their needs were met. For example, care records showed referrals were made to the speech and language therapy team to undertake assessments when people had difficulty with swallowing or eating.

The registered manager and staff worked in an open and transparent, and they collaborated with all health and social care professionals who supported people in the home. One member of staff told us, “The GP or nurse will visit the home and they might ask us to monitor a person for a couple of days. We put a monitoring chart in place and feedback to the GP our findings.”

Feedback received from the local authority who monitored people's package of care, was positive. They told us all required actions had been completed. This showed a commitment to improve the service.

Staff told us the registered manager used team meetings and supervisions to share learning and to ensure the team understood the actions needed to improve practice. Staff were able to describe what had changed in response to learning from the previous inspection. For example, wearing 'do not disturb' tabbard when completing medication round.

People were actively involved in developing the service through engagement and seeking their views and feedback about the quality of care and service. The registered manager and staff team worked well together to keep people safe and cared for. The registered manager encouraged staff to share ideas for improvements and actively listened. Staff were positive about their work and felt involved, listened to and supported in their role.