Manor Field

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 the service has an inclusive and positive culture of continuous learning and improvement. At our last inspection we rated this key question Good. During our assessment of this key question, the provider failed to ensure quality assurance processes were effective and the governance and leadership in the service had been inconsistent. This resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A senior manager acknowledged the shortfalls and told us of their plans to make the necessary improvements to ensure people received safe and compassionate care that met their needs and preferences. A new manager had just started at Manor Field and told us they wanted to improve the service for the people living there. We assessed 4 quality statements in the well-led key question and found areas of concern. The provider had a governance structure in place to monitor the quality of their services. However, this had not always been effective in identifying the shortfalls found at this inspection and improvements were needed. People were not supported following ‘Right support, right care, right culture’ guidance. Systems were in place for staff to raise concerns, however staff told us they had felt that actions from the provider and managers had not always been carried out in a timely manner in response to their concerns. Managers did acknowledge that divisions amongst the staff team still remained at the service and that they continued to work to resolve and improve working relationships. Staff worked in partnership with external services to ensure people were in the best of health. Relatives were positive about their loved ones care and felt staff engaged with them about their loved ones care.

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 management team told us they promoted a positive culture within the home, however staff told us they did not always feel listened too and that there were divisions amongst the staff team. The regional manager acknowledged this. Work had started to improve relations during a change in management at the service, however further work was needed to ensure all staff felt equal at the service, listened to and trusting of one another. We were not assured that staff at all levels had a well-developed understanding of human rights at Manor Field due to the issues identified during this inspection. However, when speaking with staff, inspectors found them to be passionate about doing the best for the people they cared for.

The policies and procedures the provider had put in place was based on providing transparency and the needs of people. The services business plan and visions and aims placed people at the heart of the service. Service objectives were monitored through audits. However, we found that audit systems were not robust enough to ensure the visions and aims of the service was adhered to consistently and ensured there was an open and positive culture at the service where both people and staff felt safe and listened too to ensure feedback can be provided.

Staff were positive about the interim manager. However, we were not assured that the interim manager and staff had been consistently supported and the provider had a robust oversight of the service. Although we saw people cared for at Manor Field, with some good outcomes for achieved for individuals, some shortfalls required addressing with regards to dignity and good governance, which would require addressing to ensure people always received safe care and support.

At the time of the inspection there was no registered manager in post, however an interim manager was employed while the inspection was in progress. In the absence of a registered manager, the deputy manager was being supported by the regional manager to manage the service. Our findings show some shortfalls in meeting the legal regulations during this inspection. Although actions were taken in response to our concerns, this resulted from our assessment identifying these concerns rather than the provider having identified and managed these independently.

Staff did not feel confident their voices were heard. They had provided feedback about the service and gave examples where they had spoken up in the past to leaders about their concerns. This inspection was prompted due to allegations being made about staff and risks not always being addressed. In part, some of these allegations were investigated by the local council’s safeguarding team, following the providers internal investigation. These were dealt with willingly by managers as an opportunity to put things right, learn and improve. For example, you had increased out of hours spot checks on staff at the service. Managers told us they were surprised allegations had been raised at the service as they told us there had been a culture of openness, inclusion and trust by ensuring that all voices are heard at Manor field with the governance meetings and surveys. They told us staff are encouraged to challenge their colleagues’ discriminatory attitudes and behaviour if noted. Terminology is often discussed during supervisions and team meetings, setting standards for what is acceptable language to use when discussing individuals with protected characteristics. However it was acknowledged that improvements were still needed and work in particular with regards to staff relationships.

Policies and procedures were in place for people to speak up and training was provided to all staff. The outcome from the providers staff engagement survey 2024 was shared with CQC as part of the inspection and although some of the areas had seen an overall reduction in satisfaction at Manor Field, staff had reported feeling more confident in speaking up at the service, compared with the previous year. Monthly ‘Our Voice’ meetings take place with people and staff. Giving people the opportunity to tell managers what is working well, what needs improving, what they would like to do etc. At each meeting staff review what was said in the last meeting. The organisation holds an annual Positive Culture self-assessment, and staff are asked to evaluate their own performance, including how they promote dignity and respect, whether they care for people in a gentle and kind manner, and value people in terms of any protected characteristics. This discussion leads into any actions that need to be addressed within the team, with staff actively encouraged to challenge any practice that does not comply with these values.

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.

At the time of the inspection there was no registered manager in post, however an interim manager was employed while the inspection was in progress. In the absence of a registered manager, the deputy manager was being supported by the regional manager to manage the service. There was a management and staffing structure and staff were, aware of their roles and responsibilities and, the majority had confidence in the provider to support the service during this period of change. However not all staff told us they felt supported and felt there were divisions amongst the staff team which had not been addressed by the provider or visiting managers. The regional manager acknowledged there was still some work to be carried out to unit staff at the service as some staff actively disliked their colleagues. The regional manager told us they would support the new manager in their post and to performance manage staff where necessary.

During this inspection we found robust quality assurance systems were not always in place to identify shortfalls and take prompt action, the service is in breach in this area. Managers had not picked up on the issues we have identified via this inspection or issues had been identified too late. Notifications had not been submitted to CQC. Records were not always kept up to date. Staff had not followed the providers own policies or followed best practice guidelines. We found diet and nutrition management plans for people had not been reviewed in line with the provider’s policy. We also found annual review dates for people’s restrictive reduction plans had expired. Failure to keep updated records meant there was a risk that people may not receive safe and effective care consistently. Records showed there were discussions around how to improve people's care following audits and surveys as well as comments from meetings. The service is supported and to ensure sustainability of the service. Arrangements for the integrity, availability and confidentiality of data, records, and management were included in a business continuity plans. Workforce planning was considered to ensure the service has appropriate number of skilled and experienced staff. Digital records have been embedded at the service. Staff told us this has had a huge impact, giving time back to support and greater evidence of care, it also provides quality of legibility.

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

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.