We carried out a review of the data available to us about Middlesex Manor Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Middlesex Manor Care Home, you can give feedback on this service.
Middlesex Manor is a 'care home.' It provides nursing care and accommodation for a maximum of 83 people across three units in a purpose-built home. People using the service have a range of needs. Most are older people, some of whom are living with dementia. At the time of this visit there were 81 people living at the home.
People’s experience of using this service and what we found
This was a targeted inspection that looked at safety in relation to concerns we had about the home’s high reporting of pressure area sores. Based on our inspection, we found there were no concerns. Where people required support with pressure area care, treatment was provided appropriately and in partnership with their GPs and other health professionals, such as tissue viability nurses (TVNs). People had pressure relieving mattresses and were regularly repositioned to ensure pressure on vulnerable parts of their bodies was reduced. Regular monitoring of people’s treatment and progress had taken place, and actions had been taken to address concerns found during the monitoring process.
At this inspection we also looked at the home’s infection prevention and control measures. All visitors and staff were required to wash and sanitise their hands, have their temperature taken and complete a personal Covid-19 risk assessment before entering the home. All staff and visitors were required to put on personal protective equipment (PPE) such as face masks, and disposable gloves and aprons, where appropriate, before entering any part of the home. This had helped to minimise, prevent and control the risk of infection.
People and staff had participated in regular testing for COVID-19 in accordance with government guidance. Staff were provided with lateral flow test kits so they could undertake tests at home prior to commencing their shifts. Visitors were required to show evidence of a recent negative lateral test or were offered one prior to entering the home.
Staff members received full pay to ensure they were not financially disadvantaged if they needed to isolate following a positive COVID-19 test. The provider had a welfare fund that staff members could apply to should they require additional financial support.
An infection control lead worker was rostered on to each shift in each unit at the home. They were responsible for checking policies and procedures were always followed.
Posters and reminders of safe infection prevention practice were displayed in the home’s reception area and at the entrance to each unit. Wall-mounted hand sanitisers were provided throughout the home. Members of the housekeeping team and care staff cleaned frequently touched surfaces, such as light switches, lift buttons and door handles throughout the day. Posters and notices were laminated and cleaned regularly. This helped prevent and control infection within the home.
People and staff were ‘cohorted’ which meant they always stayed and worked in the same units at the home. Activities were repeated in each unit so that small groups of people could participate with their regular staff members in a socially distanced way. Where people had been confined to their rooms, for example, due to a need to isolate, staff provided personalised activities for them, such as videos, music and chats. The registered manager told us that, during the summer months, some activities would take place in the garden to enable safe, socially distanced mixing.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 31 March 2022).
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We undertook this targeted inspection to check on a specific concern we had about the high level of notifications we had received about pressure area sores.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe key question section of this full report.
The overall rating for the service has not changed following this targeted inspection and remains good.
We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Middlesex Manor Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
We found the following examples of good practice.
Everyone entering the home was required to wash and sanitise their hands, provide evidence of COVID-19 vaccination, where relevant, a negative COVID-19 lateral flow test, and receive a temperature check before being allowed to leave the reception area. Visitors were required to complete a personal Covid-19 risk assessment. All staff and visitors were required to don personal protective equipment (PPE) such as face masks, and disposable gloves and aprons, where appropriate, before entering any part of the home. This had helped to minimise, prevent and control infection.
People and staff had received regular testing for COVID-19 in accordance with government guidance. Staff were provided with lateral flow test kits so they could undertake tests at home prior to commencing their shifts. They were required to show evidence of a negative result before commencing work. Lateral flow tests were provided to all visitors prior to entering the home.
Staff members received full pay to ensure they were not financially disadvantaged if they needed to isolate following a positive COVID-19 test. The provider had a welfare fund that staff members could apply to should they require additional financial support.
An infection control lead worker was rostered on to each shift in each unit at the home. They were responsible for checking policies and procedures were always followed.
Brightly coloured posters and reminders of safe practice were displayed in the home’s reception area and at the entrance to each unit. Wall-mounted hand sanitisers were provided throughout the home. Members of the housekeeping team cleaned frequently touched surfaces, such as light switches, lift buttons and door handles throughout the day. Care staff carried out these cleaning tasks during the evenings and at weekends. Posters and notices were laminated and cleaned regularly. This helped prevent and control infection within the home.
People and staff were ‘cohorted’ which meant they always stayed and worked in the same units at the home. Activities were repeated in each unit so that small groups of people could participate with their regular staff members in a socially distanced way. Where people had been confined to their rooms, for example, due to a need to isolate, staff provided personalised activities for them, such as videos, music and chats.
We found the following examples of good practice.
• Everyone entering the home was required to wash and sanitise their hands and received a temperature check before being allowed to leave the reception area. All staff and visitors were required to don personal protective equipment (PPE) such as face masks, and disposable gloves and aprons, where appropriate, before entering any part of the home. Visitors were required to complete a personal Covid-19 risk assessment. This had helped to minimise, prevent and control infection.
• An area of the reception had been specifically allocated for staff to change from the clothes that they had worn whilst travelling to work into a clean uniform. Staff uniforms were laundered at the end of each shift. A manager or senior staff member sat in the reception area during each shift change and monitored and recorded staff member’s adherence to this practice. This supported infection control in minimising the risk of cross infection.
• A gazebo was provided in the garden so that friends and family members could spend time with their loved ones by appointment. The provider was taking action to ensure that screens and other safety measures were put in place in a communal room to enable indoor visits to people as the weather became colder. Staff used a laptop computer to enable people to keep in touch with family members who were unable to visit. These arrangements enabled people to stay in contact with their loved ones, whilst keeping other people and staff safe.
• People and staff had received regular testing for Covid 19. The provider had a welfare fund for staff which they have used to ensure that staff members were not financially disadvantaged if they needed to isolate following a positive test. Designated trained staff had carried out testing to ensure that this was done in a consistent, safe way. An area of the home had been allocated and used specifically to isolate and care for people diagnosed with Covid 19.
• All staff had received training on Covid 19, infection control and the use of PPE. During each working shift a member of staff demonstrated to other staff the correct way to don and doff (put on and take off) PPE. The home had made a video of safe infection control practices and this was played on a loop on screens in each unit of the home. Brightly coloured posters and reminders of safe practice were displayed in the home’s reception area and at the entrance to each unit. This helped staff remain familiar with the correct procedures to keep people safe.
• Members of the housekeeping team cleaned frequently touched surfaces, such as light switches and door handles throughout the day. Care staff carried out these cleaning tasks during the evenings and at weekends. This helped prevent and control infection within the home.
• ‘Bubbles’ had been created for activities. Special activities, such as music in the garden were repeated so that small groups of people could participate with their regular staff members in a socially distanced way. Where people had been confined to their rooms due to a need to isolate, staff provided personalised activities for them, such as videos, music and chats.
Middlesex Manor is a residential care home providing personal and nursing care to 77 people with complex needs at the time of the inspection. The home can support up to 83 people in three separate units, each with their own communal areas. Many people at the home are living with dementia or other conditions associated with ageing.
People’s experience of using this service and what we found
People told us they felt safe and staff were kind to them. Engagement between staff and people using the service was caring and respectful. Staff provided people with personalised care that met their needs and preferences.
People's care plans and risk assessments were up to date and personalised. They included information about people’s individual needs and preferences. Guidance was provided for staff to ensure people received the care and support they required.
Staff were caring and treated people with dignity and respect. People’s differences including cultural, religious and relationship needs and preferences were understood and respected by staff.
People were supported to maintain good health and to eat and drink well. People were supported to access healthcare services when they required.
People’s independence was promoted and supported by staff. Staff recognised and respected people’s abilities.
Staff knew what their responsibilities were in relation to keeping people safe. They understood the importance of reporting any concerns they had about people's safety and how to protect them from harm or abuse.
Arrangements were in place to ensure that people received their prescribed medicines safely. Medicines were safely stored and recorded.
The provider recruited staff carefully to ensure that staff were suitable for their role. Staffing numbers were flexible and decided by the home’s evaluation of people’s needs.
Staff had the skills and knowledge to provide people with the care and support that they needed. They received the training and support that they required to enable them to carry out their roles and responsibilities effectively.
People had opportunities to participate in a range of social and leisure activities. People were supported to maintain relationships with family and friends. Faith representatives visited the home to support people’s religious preferences.
People were supported to have choice in their daily lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
The home was clean and safely maintained.
The registered manager showed effective leadership and the home was well run. Staff felt supported. Systems were in place to assess and monitor the quality and delivery of care to people and drive improvement. Actions had been taken to ensure that concerns arising from quality monitoring were addressed.
Rating at last inspection:
The last rating for this service was Good. (Report published 6 January 2017).
Why we inspected:
This was a scheduled planned comprehensive inspection.
Follow up:
We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
At our previous inspection of Middlesex Manor in September 2015 we found that the service was not meeting the requirements of the law in relation to the assessment and management of risk for people who lived there. During this inspection we found that the provider had made improvements in order to meet the requirements identified at the previous inspection.
Middlesex Manor Nursing Centre is purpose built and consists of three units of single rooms with ensuite facilities. The home provides nursing care for up to 83 people. At the time of our visit there were 67 people living at the service. Most were older people, some were living with dementia or with other conditions associated with ageing. Other people had significant physical disabilities.
At the time of our inspection there was no registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. However, a new manager had been appointed and had started full time working during the week of our inspection. They had commenced the application process to become registered with CQC.
People who lived at Middlesex Manor told us that they felt safe. Staff members had received training in safeguarding, and were able to demonstrate their understanding of what this meant for the people they were supporting. They were also knowledgeable about their role in ensuring that people were safe and that concerns were reported appropriately.
We observed that people’s medicines were stored, managed and given to them appropriately. However we found that the number of stored medicine to be administered as required did not always match the service’s records.
People had up to date risk assessments to ensure that they were kept safe from avoidable harm. Risk assessments contained detailed guidance for staff on how to manage identified risk to people. Care plans were also detailed and up to date and included information about how people wished to be supported. We saw that care plans and risk assessments were reviewed regularly and amended where there were any changes in people’s needs.
There were enough staff members on duty to meet the physical and other needs of people living at the home. Staff supported people in a caring and respectful way, and responded promptly to needs and requests. People who remained in their rooms for some or part of the day were regularly checked on. People told us that they were happy with the support that they received from staff.
Staff who worked at the service received regular relevant training and were knowledgeable about their roles and responsibilities. Appropriate checks took place as part of the recruitment process to ensure that staff were suitable for the work that they would be undertaking. All staff members received regular supervision from a manager, and those whom we spoke with told us that they felt well supported.
The service was generally meeting the requirements of The Mental Capacity Act 2005 (MCA). Assessments of capacity had been undertaken and applications for Deprivation of Liberty Safeguards (DoLS) had been made to the relevant local authority. Staff had received training undertaken training in MCA and DoLS, and those we spoke with were able to describe their roles and responsibilities in relation to supporting people who lacked capacity to make decisions. However records of best interest’s decisions did not always meet MCA guidance.
Meals that were provided to people were varied and met individual health and cultural requirements. Alternatives were offered where people did not want what was on the menu. People appeared to enjoy their meals. Drinks and snacks were offered to people throughout the day. People’s nutritional needs were recorded in their care plans and risk assessments with guidance for staff. Health professionals were involved where there were concerns about people’s weight.
Procedures to reduce the risk of infection were in place and we observed that these were followed by staff members. However, we identified infection control risks in relation to the lack of ongoing maintenance to communal bathrooms. We saw that this had been identified as a concern by the provider and that plans had been made to refurbish the bathrooms,
People told us that staff members were caring and we saw a number of positive interactions between people and their care staff. People told us, and we observed that they were offered choices and that their privacy was respected. However we observed that a small number of staff did not always interact in a positive way with people.
The service provided and group activities for people to participate in throughout the week. However, these were limited and some people chose not to engage with these. We were told that this had been recognised and that changes to the activities programme were planned. People’s cultural and religious needs were supported by the service
People and their family members that we spoke with knew how to complain if they had a problem with the service. The records showed that actions to address complaints effectively had been put in place.
Care documentation showed that people’s health needs were regularly reviewed. The service liaised with health professionals to ensure that people received the support that they needed.
There were systems in place to review and monitor the quality of the service, and we saw that action plans had been put in place and addressed where there were concerns. Policies and procedures were up to date and staff members were required to sign that they had read and understood any new or amended ones.
Our inspection of Middlesex Manor Nursing Centre took place on 28 and 29 September 2015. This was an unannounced inspection.
At our previous inspection of the service in October 2014, we found that the service was not meeting the requirements of the law in relation to the following: management of medicines; staffing; nutritional needs; safeguarding people who use services from abuse; assessing and monitoring the quality of service provision. During this inspection we found that the provider had taken significant steps to improve the service in order to meet the requirements identified at the previous inspection.
Middlesex Manor Nursing Centre is purpose built and consists of three units of single rooms with en suite facilities. The home provides nursing care for up to 83 people. At the time of our visit there were 63 people living at the service. Most were older people, some were living with dementia or with other conditions associated with ageing. Other people had physical disabilities.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People who lived at Middlesex Manor told us that they felt safe, and this was confirmed by family members whom we spoke with.
Staff members had received training in safeguarding, and were able to demonstrate their understanding of what this meant for the people they were supporting. They were also knowledgeable about their role in ensuring that people were safe and that concerns were reported appropriately.
People’s medicines were stored, managed and given to them appropriately. Records of medicines were well maintained.
People had up to date risk assessments to ensure that they were kept safe from avoidable harm. Most risk assessments contained detailed guidance for staff in managing risk to people. However, we were concerned that some risk assessments had not been completed which meant that we could not always be sure that people were safe.
There were enough staff members on duty to meet the physical and other needs of people living at the home. Staff supported people in a caring and respectful way, and responded promptly to needs and requests. People who remained in their rooms for some or part of the day were regularly checked on.
Staff who worked at the service received regular relevant training and were knowledgeable about their roles and responsibilities. Appropriate checks took place as part of the recruitment process to ensure that staff were suitable for the work that they would be undertaking. All staff members received regular supervision from a manager, and those whom we spoke with told us that they felt well supported.
The service was generally meeting the requirements of The Mental Capacity Act 2005 (MCA). Assessments of capacity had been undertaken and applications for Deprivation of Liberty Safeguards (DoLS) had been made to the relevant local authority. The majority of staff had received training undertaken training in MCA and DoLS, and those we spoke with were able to describe their roles and responsibilities in relation to supporting people who lacked capacity to make decisions. However the risk assessments for people regarding use of bedrails did not show that this was the least restrictive option available to meet their needs which is a requirement of the MCA.
Meals that were provided to people were nutritionally balanced and met individual health and cultural requirements. Alternatives were offered where people did not want what was on the menu. People appeared to enjoy their meals. Drinks and snacks were offered to people throughout the day. People’s nutritional needs were recorded in their care plans and risk assessments with guidance for staff. Health professionals were involved where there were concerns about maintenance of weight.
People’s care plans were person centred and provided guidance for staff about how people wished to be supported. The plans were updated regularly to ensure that they addressed people’s current needs.
People told us that staff were caring and we saw some positive interactions between people and their care staff. People told us, and we observed that they were offered choices and that their privacy was respected. However we observed that a small number of staff did not speak with people when they were providing support at mealtimes.
The service provided a range of individual and group activities for people to participate in throughout the week. People’s cultural and religious needs were supported by the service
People and their family members that we spoke with knew how to complain if they had a problem with the service
Care documentation showed that people’s health needs were regularly reviewed. The service liaised with health professionals to ensure that people received the support that they needed.
There were systems in place to review and monitor the quality of the service, and we saw that action plans had been put in place and addressed where there were concerns. Policies and procedures were up to date and staff members were required to sign that they had read and understood any new or amended ones.
People who used the service, their relatives and staff members spoke positively about the management of the service. We were told that the new manager had made a number of positive improvements.
We found two breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
This inspection took place on 2 October 2014 and was unannounced.
At our last scheduled inspection in July 2013 the service was not meeting the requirements of the law in relation to nutritional needs. We carried out a follow up inspection in September 2013 and found that the service was meeting the regulation and there were no concerns.
Middlesex Manor Nursing Centre is purpose built and consists of three units of single rooms with ensuite facilities. The home provides nursing care for up to 83 people. At the time of our visit there were 72 people living in the home, most people were older people, some people had dementia and other people had physical disabilities.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
During our inspection feedback from people, observation and most records we looked at demonstrated there were many positive aspects to the service including kind, well trained staff and skilled, experienced leadership. However, it was evident that the registered manager had a significant number of management duties to carry out in this large service. There was not a deputy manager in post to assist her with some of the day-to-day duties such as record keeping, supervision of medicines, checking staffing levels and auditing. The registered manager had received some support from senior management but some failings in these areas had not been identified which effected the quality of the service. So we have asked that action be taken to address these matters.
People’s safety was compromised in the way some medicines were managed and administered. We found shortfalls in the recording and auditing of medicines.
People told us that they were happy with the service, felt safe and had their privacy and dignity respected. Our observations and discussion with relatives supported this. Conversations with people’s relatives indicated that there was general satisfaction with the service provided. However, we found that most people did not have much to do and we saw little evidence of people taking part in meaningful activities individually or as a group.
Staff were familiar with people’s needs and their key risks. However, it was not evident at the time of the inspection how the staffing numbers and skill mix had been determined to ensure people’s varied and at times complex needs were met at all times. We found that there was a lack of sufficient staff to ensure that people received their meals without delay.
Staff received regular relevant training, were knowledgeable about their roles and responsibilities and received support from the registered manager and other senior staff. Staff had the skills to provide people with the care and support that they needed. Appropriate checks were carried out when staff were recruited.
Staff had received training about the Mental Capacity Act 2005 (MCA). However, we found staff were not always following the MCA for people who lacked capacity to make a decision. For example, an application under the MCA/ Deprivation of Liberty Safeguards (DoLS) for a person using the service had not been made, even though their liberty may have been restricted.
We found most people’s health and care needs were assessed and regularly reviewed. Staff liaised with health and social care professionals to obtain specialist advice so people received the care and treatment they needed.
There was a clear management structure in the home. The registered manager was accessible and approachable. People who used the service, staff and people’s relatives felt able to speak to the registered manager and nursing staff when they had any concerns or other feedback about the service.
There were systems in place to monitor the quality of the service and make improvements when needed. Checks of some equipment and call bells had not been carried out at the time of the inspection. However, promptly following the inspection the registered manager ensured these checks were carried out.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.
During this follow up inspection we spoke to five people who used the service, but the main focus was on talking to staff and checking records to make a judgement as to whether the provider was compliant with Regulation 14 (HSCA 2008 Regulated Activities) Outcome 5 Meeting nutritional needs.
At this inspection we found that the provider had taken proper steps to ensure that people were protected from the risks of inadequate nutrition and dehydration.
People's health, safety and welfare were protected as they received the advice and treatment that they needed from a range of health and social care professionals. Staff knew about their roles and responsibilities in meeting the needs of people who used the service and they supported people in a friendly and respectful manner. People who used the service told us that they found that staff were very approachable and they felt able to talk to them and to management staff if they had any concerns.
Each person had a plan of care that had been regularly reviewed and included information about the individual support and care that people using the service needed. However, there was not evidence that people' nutrition and hydration needs were always monitored closely.
The inspection team was led by a Care Quality Commission (CQC) inspector joined by an Expert by Experience, (people who have experience of using services and who can provide that perspective) and a practising professional.
We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.
On the day of the inspection the home was warm, and had a relaxed and friendly atmosphere. We spoke to people using the service living in two of the three units in the home. We also spoke to visitors.
People who use the service told us that staff understood their needs and provided them with the care and support they needed in the way that they wanted. They confirmed that staff were kind, respected their privacy and promoted their independence. They told us their religious and cultural needs were met by the home.
People's comments about their experience of living in Middlesex Manor Nursing Centre included, 'it's very comfortable', 'it's like home', 'i did not expect it to be so lovely', and 'having my own space is a dignified way of spending my later life'.
People told us that they had sufficient and suitable food and drink which met their dietary needs and preferences. We observed staff supporting people in a sensitive manner. We saw people using the service were offered choices of food and drink.
People told us; they liked living in the home, they had their health needs met, staff listened to them, and provided them with the care and support they wanted and needed. Comments included; 'I visited before moving in', 'staff help me in the way that I want', and 'I get things done the way I want'.
People informed us they had the opportunity to participate in a range of activities, and were positive about the care, and support they received at the home. Comments included; the staff 'ask me what I want to do', 'I like doing puzzles', 'I like music', 'It's fine here, staff are really nice, I like doing something', ' I like my TV, it's very important', and 'I do something every day'. A person spoke very positively about the support she received from an activity worker.
People spoke of the staff being 'kind', 'friendly',' nice', and approachable. They told us they felt safe living in Middlesex Manor Nursing Centre, and knew who to talk to if they had any worries or concerns. People confirmed that they felt staff would respond to these in an appropriate manner.
People spoke about being able to make choices about their lives; 'I visited before moving in', 'I can choose to go out', and 'I can choose what to do'.
People confirmed that they attended healthcare appointments and saw a doctor when they needed to, and had contact with a variety of other health care and social care professionals.
People were positive about the environment of the home and were happy with their bedrooms. Some people told us they had personalised their rooms. Comments included; 'I have my room as I like it', 'my room is nice', and the home is 'clean and very cheerful'.
People's views varied when they were asked for feedback about the meals. Some people when asked if they had enjoyed their meal said 'yes', 'I liked it, 'I thoroughly enjoyed it',' it's good', 'I have drinks when I want', and 'I have enough to eat'. When asked the same question, others commented; 'not really', 'the food is not good, my (relative) brings in food for me', 'the food is awful, it's not fresh', 'my (relative) brings me fruit' and 'I don't get choice'.
A person told us that he sometimes receives meals that met his preferences and cultural needs. Another person spoke of positively of a relative who regularly brought in food for him to eat that met his cultural dietary needs and preferences.
Visitors told us they had visited the home before their relative moved in and had immediately 'liked the atmosphere'. Recorded and verbal comments from relatives and significant others included; 'the staff are very nice', 'they are friendly people', ' we are always offered a cup of tea', my relative 'has received excellent care from all members of staff', 'the care given to (my relative) is second to none', 'excellent care', 'I am pleased with the care my (relative) is receiving', staff are 'friendly', 'staff are caring and easy to communicate with', 'my (relative) is well looked after'. 'I am happy with the care'; 'staff ring me and talk to me about (my relative)'.
Staff spoke of enjoying their job, and told us 'everyone is friendly', 'the manager is approachable', and 'we receive regular supervision'.