Langham Manor

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 is the first assessment for this newly registered service. This key question has been rated Requires improvement: This meant the management and leadership was inconsistent and did not always support the delivery of high-quality, person-centred care.

The provider was in breach of the legal regulation relating to governance. Audits to monitor and improve the home were undertaken and included reports to the providers head office. However, these audits and checks were not always effective as they had not identified or always acted promptly on the findings. For example, we identified shortfalls in fire safety and staff training.

The registered manager had managed the service since it had opened in July 2023 and was supported by a deputy manager and a clinical lead. The registered manager was a visible presence undertaking daily walk arounds and overseeing the daily head of department meetings. The registered manager and regional manager responded positively to our feedback and immediately acted to address some of the areas we identified.

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.

There was a clear vision for the direction and development of the service and staff and management were proud of what had been achieved since the home opened. Staff intuitively knew what constituted good care and demonstrated a caring and compassionate approach.

The registered manager was supported by a deputy manager and a clinical lead oversaw nursing practice. The registered manager was a visible presence undertaking daily walk arounds and overseeing the daily head of department meetings and clinical meetings. A member of staff told us “It’s nice that a manager will come round every morning to check how the night went”.

Care delivery was driven by best practice and considered people’s needs. There were clear processes in place to provide leadership on each shift to oversee and direct staff.

The registered manager had been involved in the service prior to its opening and developed many of the internal processes. They were experienced in health and social care and significant numbers of staff had moved with them to the service from where they had previously been employed. While many staff described the registered manager as helpful, some feedback was inconsistent. We spoke with both the registered manager and regional manager about the feedback we received, and they assured us that they were addressing the concerns raised.

Both the registered manager and the regional manager were receptive to feedback and started implementing changes during the assessment.

There were clear management processes within the service which included quality assurance audits and oversight. The regional manager attended on the days of the assessment and told us that they made regular visits to observe and monitor the service and ensure good outcomes for people living there.

Staff meetings were scheduled but were not well attended; this was confirmed by records checked and by speaking with staff. Staff however said they received regular supervisions, which provided opportunity to discuss how they were doing.

Handover meetings were held at key points in the day to ensure that the staff coming on duty were made aware of any changes to people’s wellbeing however staff told us that these were unpaid and therefore voluntary, although they tried where possible to attend. There are risks that key information may not be passed on and we asked the registered manager to review this.

Staff told us they were aware of channels for raising concerns directly with management. However other staff expressed less confidence in the processes and were concerned about the impact on them as individuals.

The provider had policies in place to support staff to speak up, raise concerns, and keep people safe however we could not see that these were displayed. The registered manager told us that staff could access the polices on the providers policy portal but agreed that they would ensure that details of how to raise concerns would be displayed in staff areas. The registered manager was aware of their responsibilities under the Duty of Candor.

Staff felt that they worked well as a care team, ensuring that people receive safe, effective, and person-centred care. Staff told us that they were able to take breaks during their shift and had an appropriate place to do so. Recruitment records did not highlight any concerns about staff working patterns. However, some staff did not feel recognised for their hard work and were not aware of any initiatives in place to provide positive feedback or compliments to staff. We were told “We try to stick together and work as a team, I like the people I work with. There is not a lot of recognition from management”.

We discussed this with the registered manager, and they agreed to explore further with staff.

Staff said they received regular supervisions, which provided opportunity to discuss how they were doing and staff also felt that everyone had the same opportunities to learn and progress.

There were systems in place to enable the provider to identifying staff’s equality, diversity or inclusion needs. Training in equality, diversity and inclusion was available to staff to raise awareness of issues.

The registered manager and staff team at Langham Manor were aware of their roles and responsibilities and there was a quality assurance system in place to review and assess the service delivery. The provider had oversight of the service.

We saw records of audits to monitor and improve the home which included reports to the providers head office. These included audits of people’s care plans, medicines, the environment and infection prevention and control procedures.

However, the provider’s quality assurance audits and checks were not always effective as they had not identified or always addressed the findings. For example, they had not identified that the syringe driver needed servicing or that gas safety certificate had been allowed to expire. Concerns with fire safety had been raised for over six months but the provider had not acted on this, which could have placed people at risk of harm in the event of a fire. The staff training matrix showed significant shortfalls in the competition of training across a number of areas.

The shortfalls in governance arrangement are a breach of regulation.

People had access to social engagement. Visitors were welcomed and regular coffee mornings were held in the foyer to the home. People had visits from church celebrants as well organised events such as entertainers.

People also spent time in the community, alone or with their families and with staff. We saw that organised visits had taken place to for example the sports centre, the pub, craft centre and local beauty spots.

There was engagement and collaboration with other key organisations such as the local authority to support care provision and service development.

No specific concerns were raised by partner agencies.

Staff and leaders were unable to tell us about many local partnerships. However, they told us that they were exploring a number of opportunities for joint working. We saw that the provider had sponsored the local community business awards.

People’s needs were reviewed as part of the resident of the day reviews and regular audits are undertaken and overseen by the registered manager.

Formal quality processes to evaluate and learn from people, staff and relatives were not well developed.

Resident and relative’s meetings were held but not well attended. The registered manager told us that surveys were available, but we saw that only a very small number had been completed. There was no evidence that they had been analysed and used as part of the quality assurance system. When we raised this with the provider they agreed to immediately address and sent out questionnaires to key partners to ascertain their views. They told us that they would analyse the results and ensure the results were made available in a ‘we said you did’ format and they would ensure that this was accessible to all.