Manor Lodge

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 did not look at all quality statements for Well-led at this assessment. The provider was previously rated as Outstanding in Well-led at the last inspection in 2018. Some scores in Well-led are based on the previous rating for this key question. We found a culture in which providing exceptional care whilst enabling people’s wishes and lifestyle was the core ethos of the service. The Registered Manager and Leadership Team were capable, compassionate and inclusive. Arrangements were in place to formally assess, review and monitor the quality of care provided at the service. This included regular audits of accidents and incidents, safeguarding, care plans and statutory responsibilities. Leaders and staff shared the goal of ensuring people received exceptional care. This was achieved through various initiatives, training and feedback opportunities, family meetings and the passion and ethos of learning from experiences. Robust governance systems were in place to identify areas for improvement, which was always followed by action to achieve this. Staff worked closely with external stakeholders to maximise people’s health and wellbeing and make a positive impact on their life.

This service scored 100 (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.

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.

The registered manager and staff were committed to ensuring, oversight and governance was well-embedded into the service. Staff were able to explain governance systems as team meetings, specific nurse led reviews of people’s health needs, case studies on wound management and use of medicines. Staff spoke about ensuring staff wellbeing and communication pathways worked well for them. Staff shared the management approach to learning and told us they use all opportunities to learn. The atmosphere between the management team and staff was good, staff told us they felt supported in their roles. People knew their individual responsibilities. One staff member said, “The management team and other staff are always willing to help, if I do not know something I can ask and I am supported, we work as a great team.” The registered manager felt the systems for auditing and governance were relevant, effective and useful in enabling them to monitor the quality of the care and support people received. They told us, “We complete audits for, infection prevention control, medicines, business continuity, health and safety, clinical reviews, weight loss and among other things I have just completed my winter plan. We run a daily report to check our systems for incident and lessons learnt.” A stakeholder from a medical background sent us exceptional feedback and described the care as ‘of the highest standard’.

Systems were in place to promote a positive culture, transparency, learning and improvement. This ethos was clearly embedded throughout the service and staff team. The provider had robust governance systems in place. A central quality assurance team visited the service regularly in addition to regional support. Audits were thorough and reflected the experiences of both people and staff. Action plans showed the management team responded promptly to any suggestions for improvements. Satisfaction surveys showed a satisfaction rating of 98 out of 100 for residents’ satisfaction and 87 percent for relatives’ satisfaction. The management and staff structure provided clear lines of accountability and responsibility, which ensured decisions about the day-to-day running of the service were made at the right level. An example of this is the different tiered levels in team meetings, ensuring the correct people with the skills would be able to share their knowledge and experience for better outcomes. Another example is staff were clear on their responsibility to report concerns and what action they should take if they do not feel listened to. Investigations of safeguarding’s were undertaken at appropriate management level and welcomed the involvement from external professionals to ensure all aspects were considered. Staff rights were respected through the inclusion of human resource teams. People's personal records were kept secured and confidential. Staff understood the need to respect people's privacy including information held about them in accordance with their human rights.

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.