Shipley Manor Care 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. This was the first assessment of the service, and we rated the service good with 7 evidence categories in this assessment. The service has forged strong links with local community groups and has worked well with some external professionals. Staff felt confident to speak up and were positive about the support they received from the whole management team. The registered manager had fostered an open, inclusive workforce which promoted people and staffs’ equity and celebrated diversity. The provider had a robust and effective process for evidencing lessons learnt. Overall quality assurance processes and systems were in place to monitor and audit the quality in the service. However, we did find the provider did not have effective processes in place for monitoring, reviewing and actioning shortfalls found on assessment in relation to the safe management of medicine.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff explained their understanding of the culture and values in the service, and we observed this practice being embedded from all staff and leaders. Comments from staff included, “We are all family here, we help each other, staff are very happy.” “We all help each other; we work as a team. Its all about working together to make it better for the residents” and, “We are like an extended family.” The registered manager demonstrated their ability to promote and embed the values and culture of the service from recruitment of staff, through training, supervision and support. The registered manager has implemented a staff appreciation day, called ‘Wots it Wednesday.’ All staff get to open a box with a gift in for them as a thank you for everything they are doing. This is one way the provider promotes the vision and values in the service and promotes a good culture.

The provider has an effective system in place to ensure the management team lead by example embedding the values of the service into their work and promoting an open, honest culture. We have seen evidence of this in meetings which are in place to drive quality and maintain and share good practice. This was demonstrated through staff meetings which have been completed regular with good input from staff, group supervisions to promote speak up culture, as well as best practice sharing and group working. All demonstrating the promotion of visions, values and open culture in the home.

Staff were overwhelming positive about the registered manager and other management in the service. All staff told us they felt the manager was approachable, fair and supportive. Comments included, “[Registered manager] is brilliant, any issues you can go to them. They are approachable and they are there to lend you support. There’s an open-door policy, other managers are also supportive.” As well as “[Registered manager] is fair and approachable; they are always on call even when they’re not on call.” The management, especially the registered manager has thought carefully about inclusivity in the service and leads well by example. For example, the registered manager has ensured there is a prayer room on the top floor for staff or people in the service to use.

We have seen evidence the manager was recruited as they had the skills, knowledge and experience to lead effectively, and has been in the position since the opening of the service. During the assessment we saw evidence the registered manager has demonstrated openness and compassion within their role, which translates through the values and culture in the service. The provider has inclusive leaders at all levels who embody the culture and values of the workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Staff told us they felt confident to speak up should they need to and informed us they were happy to suggest changes or improvements where required. Feedback from staff included, “If I were to make a suggestion it would be listened to” and, “If we have had any concerns the [registered manager] will listen to what we have to say and acts on the feedback we give. [Registered manager] is very responsive.”

The provider had effective systems in place to ensure staff were provided with, and supported to implement the whistleblowing policy where necessary. Freedom to speak up was promoted by the registered manager and embedded into staff interviews, meetings and supervisions.

The provider is inclusive and has an effective process for promoting workforce equity. Staff feedback was positive, and staff told us they felt they were treated equally and fairly with respect being shown from all members of the management team and peers. Comments from staff included, “Everyone is treated the same. Wots it Wednesday is nice as it shows management care and show this to us. We feel appreciated and valued.” As well as “I went to speak with [registered manager] regarding Eid. I was authorised my annual leave immediately, the manager had remembered I mentioned this in my interview and gave me this.” One staff told us, “I feel I am treated equally and fairly. I have been trying for a senior role in my previous job for a long time but was never offered the opportunity. Here the manager has already discussed progression for me.”

The provider employed staff with diverse needs and we saw evidence equality and inclusion were promoted. They took the necessary steps to ensure staff were included and reasonable adjustments were in place where required. The service had a prayer room to support people with cultural needs, and the staff supervision processes showed that staff were engaged and involved in the day to day running of the home. There were clear processes to show staff were included fairly and equitably.

The registered manager had a good understanding of their role in managing, reviewing and driving improvement in the home. We received positive feedback from visitors regarding how the home is managed. One visitor told us, “The place is brilliant, exactly what we needed for our friend. They listened to our requests regarding our room preference when we looked round before bringing our friend to live here. We couldn’t be happier, I feel this is down to how the manager runs the home. She knows her residents, staff and visitors.”

Overall, the provider had effective management and governance in the service for management of but not exclusive to care documentation, pressure area care, falls, and weight loss. However, we did find some shortfalls in the audit process for how medication was being managed, however, when these medicine related issues were identified they were addressed quickly by staff.

People told us there were plenty of activities and things to do in the service. Daily activities and visitors from the local community frequented the service. We observed local college students came into the service on the day of our assessment and completed activities with people in the service.

Staff told us there were many links with the communities and when activities are happening in the service family, relatives, friends, and members of the community groups are invited to attend. Staff told us how they take people out to local shops and cafés, and how there is an open invitation for visitors. Comments from staff included, “[Activity co Ordinator] always has something going on, he goes above and beyond.” As well as “[Activity co Ordinator] does a lot of activities linking with the nursery school, local schools, charities in Bradford, Colleges, and he invites friends and families to activities in the home.” Discussions with the registered manager demonstrated processes were in place to work with external community and professional groups inclusive of West Yorkshire Police and the Veterans Group.

We did not receive any feedback relating to how the service worked in partnership with them and the community. However, we saw effective partnership working with other professionals prior to people being admitted into the service. In peoples care records we saw strong links with other professionals’ involvement in people’s care- covering all aspects of their holistic needs.

The provider had systems in place to promote partnership working and inclusion. This was embraced by the provider. Care records reflected a good level of involvement with people, their relatives, and their advocates. Records showed there was a good level of partnership working with health and social care professionals, including GP's social workers and other clinical professionals.

Discussions with the registered manager demonstrated their understanding of the importance of reflective practice. Discussions show a multi-tier approach to the learning and improvement practices and processes in the service and across the wider group

Lessons learnt were evidenced clearly and robustly and we also saw evidence of wider group learning when things went wrong. There was clear evidence of sharing of good practice between the wider provider group and the recording process was very contemporaneous.