Marsh Farm Manor Care Home

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• 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 reviewed 7 quality statements in this key question. Governance systems were in place identify improvements needed. There was a service improvement plan which was monitored by the registered manager and provider to make sure actions were completed in a timely way. Staff were aware of the provider values and enjoyed their work. However, staff feedback raised concerns about some aspects of the leadership behaviour. Some staff had not felt listened to and felt their concerns had not been addressed. We shared all concerns received about leadership behaviour with the provider who told us they would investigate them without delay.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they enjoyed working for the provider and were aware of the provider values. The registered manager told us staff had opportunities to discuss provider values and expected standards of working in staff meetings and staff supervisions.

The provider had an induction process for new staff which included sharing information on the provider values. Information on the values was available on notice boards in staff rooms.

Feedback from some staff about one of the management team was mixed. One member of staff told us they had initially found the manager unapproachable, but this had improved over time. Another member of staff told us they found the managers approach unsupportive at times. Some staff told us they did not feel their ideas were listened to. Suggestions and concerns they had raised had not been actioned. All the staff we spoke with told us they felt able to approach the district manager who regularly visited the service. Staff told us they would share their feedback and any concerns regarding the management with the provider.

The service had a manager in post who was registered with Care Quality Commission (CQC). This meant in addition to the provider recruitment process the registered manager had also completed the CQC fit person process to become registered. The registered manager was completing an academic qualification in leadership. A district manager visited at least monthly to provide support for the service and to carry out quality and safety checks. There were 2 deputy managers in post. One deputy manager had commenced work prior to this assessment and was still completing their induction. Concerns about some leadership behaviour had been received prior to this assessment which we shared with the provider. The provider was in the process of investigating another concern we received during this assessment about the management approach.

Staff told us they knew how to speak up if needed and were aware of the whistleblowing policy. Some staff shared with us they had raised concerns with management but felt they had not been listened to. We shared this feedback with the registered manager who told us, “I am very surprised, people come and talk to me all the time. I do tell the staff to come to us, I do also encourage them to come with solutions. If we cannot change anything we will tell the staff why. We act on all concerns received.”

The provider had a whistleblowing policy and told us staff had telephone numbers of people to contact if they wanted to raise any concerns. We observed details on how to speak up were posted on notice boards in staff rest areas.

Staff did not share any concerns about equality, diversity and inclusion in the workplace. Staff told us the team was becoming more diverse with staff being employed from overseas. Staff told us they welcomed this and enjoyed learning about different cultures. The registered manager shared with us examples of reasonable adjustments made to staff working patterns in order to support them to work.

The provider had many policies, procedures, schemes and initiatives to support workforce equality, diversity and inclusion. Staff had various resources available to support them with different aspects of their lives both at work and their personal lives. We saw provider schemes available to staff were being advertised on the staff room notice boards.

The registered manager told us their approach to governance was to try and include all staff in the processes. The registered manager said they did not want staff to think that governance was an area only for management.

The provider had quality systems established to make sure regular checks were completed. Records of the audits carried out were kept and any actions identified were added to an over-arching action plan for the service. The district manager visited the service at least monthly to complete provider checks on various areas of quality and safety. The provider also had a quality team who carried out larger audits to identify compliance with various pieces of legislation and good practice guidelines.

People shared feedback that they could see various healthcare professionals and during our site visit we observed healthcare professionals visiting people in the service. For example, an optician was visiting and community nurses. People’s feedback demonstrated they consistently were able to see appropriate professionals in a timely way.

The registered manager told us they hoped to build more relationships with professionals from the local authority and join their framework for providers of adult social care. The registered manager said, “We need to build relationships and we need to get ourselves known locally. We are celebrating our first year opening soon. We will invite all the stakeholders to that.” Actions to improve relationships with stakeholders were added to the service improvement plan.

Professionals we contacted did not share any concerns about this quality statement.

The registered manager told us they had recently started a ‘blue light breakfast’ on a weekly basis. This scheme aimed to provide a rest stop for healthcare professionals working in the community. Professionals could visit the service for breakfast and a drink and take a rest. The service had offered the top floor of the service to local groups to use for their community events. Staff worked with a range of professionals to make sure people’s health needs were met.

The registered manager shared examples with us of how they had made improvements at the service. For example, the service was registered for the ‘Veterans Friendly Framework’. This was an accreditation scheme supported by 2 national veterans’ charities to help providers identify veterans and support their wellbeing. There were 8 standards to achieve as part of the framework and the service had so far achieved 2. The registered manager told us this work so far had helped them identify people who had served in the armed forces. Staff were able to think about any different types of support might be needed for veterans and their families. Staff told us the service had a puppy who was training to be a pet therapy dog. People living at the service had been involved with care of the dog and some aspects of training.

The provider had a quality team who regularly shared good practice and changes to ways of working with all the provider services. Registered managers attended regular manager meetings to receive updates and share good practice with peers. Local primary school children had been encouraged to visit and had been involved in activities and events with people living at the service.