Meadowyrthe

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.At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights.

Relatives told us the staff team always respected people’s dignity and respect.

All staff told us the best part of working for the provider was spending time with the people living in the home. Staff told us they valued people’s rights and promoted people’s rights to privacy and dignity. One staff member said, “We always make sure people's dignity is respected, such as covering the body when carrying out personal care, and closing doors and curtains.”

The service apologised to people, and those important to them, when things went wrong

The manager told use about how they valued a culture of reflection and learning positively from mistakes. For example, they told us if staff made a medicine error, then this should not be about blame, rather encouraging the staff member to reflect on their error and sharing lessons with the team to encourage team learning. This demonstrated a positive and open culture.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Relatives told us the registered manager was visible in the service and involved them in their family member’s care.

Staff told us the registered manager was supportive. One staff member said, “The registered manager is approachable. They are easy to go to if you have concerns.”

Management were visible in the service, approachable and took a genuine interest in what people, staff and relatives had to say.

The registered manager notified us of all significant events which had occurred in the home in accordance with their legal responsibilities.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they could speak up and raise their concerns openly with the management team. One staff member said, “I would report any concerns to the registered manager. I can also use the whistleblowing number.”

A whistle blowing policy was in place, this was accessible to all staff and staff told us where it was located.

The provider told us they valued equality and inclusion diversity in the workforce. However, some staff told us they did not always feel their wellbeing was always considered by the provider.

We received mixed feedback from staff regarding feeling supported and treated fairly by the provider. Some staff told us they felt supported. However, other staff told us the provider needed more flexibility to support staff to manage issues in their personal life and more discussions were needed on an individual level.

The provider told us staff had access to the provider’s occupational health services and welfare review meetings were completed to review reasonable adjustments. There was also mental health first aid trainers available who ran support sessions for staff, employee wellbeing advice lines and other resources available to support staff. The provider also stated where staff experienced personal issues, help and support is offered, although staff needed to consider the needs of people requiring support and the staffing levels on duty.

Recruitment files contained employee health questionnaires which reviewed any existing health conditions and whether reasonable adjustments were needed. However, staff who had been employed for a prolonged period, where the provider had changed hands, did not have their employee health questionnaire stored in their employment file.

The provider responded to our feedback by recompleting the relevant questionnaire with the staff member and ensuring these were in place for all staff.

The provider did not always have clear responsibilities, roles or systems of accountability in certain areas.

There were checks and audits in place to monitor quality and safety. However, these had not identified some gaps in health and safety monitoring, incorrect medicine fridge readings or conflicting information in care plans. The provider was very responsive to our feedback and shared their new systems to monitor health and safety checks and updated the relevant care plans.

The provider had already identified areas of improvement which we also highlighted and was in the process of improving the environment, recruiting activity coordinators and updating risk assessments. These improvements were all action planned with set target dates.

Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. Incidents and accidents were analysed for trends or themes. When things went wrong, lessons learnt were shared openly with the staff team. Where people required their health monitoring, quality audits were in place to ensure care tasks were not missed. Call bell audits were carried out to ensure people received prompt care when required and the provider carried out regular spot checks on staff practice such as safe medicine administration, supporting people to eat and moving and handling.

Staff and relatives told us they had faith in the registered manager’s ability to lead the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Relatives told us they felt included in their family member’s care. One relative told us, “The provider provides regular updates. They [the provider] is a very respectful service.”

Visiting professionals told us the provider effectively communicated with them. The provider shared feedback from another visiting health professional where they praised the provider’s partnership working. The provider kept the professional updated with all changes in a person’s health and made appropriate health referrals on the person’s behalf. The visiting professional praised the provider, stating, “This is what I call teamwork.”

Records showed collaboration with numerous health and social care professionals.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The provider had a clear vision for the direction of the service which demonstrated ambition and a desire for people to achieve the best outcomes possible.

The provider shared recent questionnaires which they sent to people and relatives asking them for suggestions and feedback into the service.

The registered manager was involved within several registered manager networks where they shared good practice and was in the process of introducing new initiatives, such as an oral care initiative in the home.

Staff told us they had seen improvements to people’s wellbeing due to the recent employment of additional activity coordinators. One staff member said, “I've seen quite a few improvements recently. The new activity coordinators are fantastic."