Maesbrook Nursing Home

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 Inadequate .This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding of service users and governance.

This service scored 39 (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 did not always have a clear shared vision or culture that supported consistent, person-centred care. People and relatives frequently described a culture where communication was poor and concerns were not acted upon. One relative explained that communication issues, “let down the team as a whole” and contributed to their family member feeling “overlooked”.

Staff we spoke with also reported inconsistent practices across shifts, and we observed disjointed activity in the home with staff unsure of their roles or prioritisation. The registered manager was not consistently visible or engaged with people. A resident told us, “I don’t know who the manager is”. This demonstrated limited leadership presence and connection with people using the service.

Relatives expressed concerns about cultural inconsistencies, highlighting that standards declined when communication or staffing pressures increased. Some relatives felt welcomed and stated the home was “comfortable, nice and quiet.” This was not reflective of everybody’s experience, with frequent reports of people waiting for care, being distressed, and delays in essential support. These concerns indicated the culture did not consistently promote dignity ,responsive or shared expectations of high-quality care.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Leaders were not consistently compassionate, inclusive or effective in creating trust. Many people and relatives described the registered manager as distant or difficult to approach. One person told us they had never met the registered manager. Staff expressed uncertainty about leadership expectations, and inspectors observed a lack of coordination during busy periods, with staff showing they were unclear about their tasks. This lack of structure did not support confident care provision.

Relatives described situations where concerns about clinical deterioration, continence and medicines were not taken seriously. One relative said, “We should not have had to do that,” after taking their family member to AE because staff had not acted on their requests to continue observations. Some people and relatives described the registered manager as professional and “capable”.

The provider did not always foster an open culture where people, relatives or staff felt confident raising concerns. Evidence demonstrated repeated situations where families escalated issues because the service did not respond promptly or transparently. Relatives we spoke with described raising concerns “over and over”, including about continence care, communication, and dignity, without seeing improvement.

Staff reported conflicting information about medicines, risks and documentation, and inspectors found multiple governance failures, including incomplete ABC charts, the use of “as needed” medicines not documented with rationale, gaps in care plans and unreviewed incidents. These issues indicated concerns raised by staff did not result in effective or timely action. Some relatives felt able to speak with leaders, but people, relatives and staff told us it felt their concerns were dismissed, minimised or not followed through. One relative told us, “I don’t always feel concerns are treated with openness or compassion.”

Relatives raised concerns about the capability and communication skills of recently recruited staff.

People also highlighted discomfort with male agency staff providing intimate care when their care plans specified female carers, and these preferences were not always respected. One person said, “It’s not right being washed by a male carer.”

Although some longstanding staff were described as warm, experienced and supportive, there was limited evidence the provider ensured support, training or supervision across the whole workforce was in place .Instances of poor communication, lack of cultural sensitivity and inconsistent adherence to people’s protected characteristic related needs showed equality and inclusion were not embedded in practice.

The home employs a diverse workforce and is committed to promoting equality, diversity and inclusion across its staffing arrangements. The provider supports inclusive recruitment and employment practices and values the different experiences, skills and perspectives that staff bring to the service.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not effective and exposed people to ongoing risk. We found failures in care planning, medicine oversight, incident management, risk assessment, safety monitoring and record keeping. Examples included an “as needed” medicine administered without clear rationale, unreviewed ABC charts, unaddressed behaviour related risks, missing care plans for people at end of life, and unclear wound care documentation.

Environmental safety concerns were significant, including poor water pressures, hot water system limitations, unsecured wardrobes, cluttered laundry areas, and fire safety risks such as inappropriate storage in cupboards with electrical systems and inadequate evacuation signage. We raised this during our assessment, and the provider took action by having professionals review the system.

Leaders did notmaintaineffective oversight of GDPR compliance, with staff using personal phones to photograph body areas,ex staffretaining access to sensitive information and confidential documents left in accessible areas.Although the provider took some immediate actions after inspectors highlighted issues, these did notdemonstratesustainable or embedded governance. The extent of the failings and ongoing risk meant governance was inadequate andrequiredurgent improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Partnership working was inconsistent. While some relatives described positive communication with community professionals, we found cases where required external input was delayed or not coordinated effectively. For example, One resident transferred from their home had not received an adequate assessment, and staff we spoke with reported they were, “dependent on other agencies” and trying to chase updates.

Staff we spoke with reported difficulties securing timely GP reviews, SALT assessments and therapy input. In some cases, clinical concerns were escalated by families to external professionals because they felt the home had not responded adequately.

There were examples of positive partnership, such as involving families in palliative care decisions, and some relatives described feeling well informed about health changes. However, these examples were not consistent across the home.

The lack of reliable coordination, delayed referrals, and absence of systematic engagement with professionals limited the effectiveness of partnership working and meant people did not always receive integrated, seamless care.

The provider did not demonstrate a strong learning culture or consistent approach to improvement. Inspectors found repeated concerns across key areas which had not been addressed since previous inspections. Breaches in regulations 12 and 17 remained, and patterns of risk continued without evidence of learning or meaningful change. Incidents, complaints and behaviour related concerns were not consistently reviewed, analysed or used to improve practice. ABC charts were incomplete or lacked evaluative review; lessons from incidents were not documented; and staff escalation of risks, such as unsafe continence care or concerns about seizure medication administration, did not lead to timely action. Environmental issues, staffing pressures and documentation failings persisted over time. Although immediate actions were taken during inspection, these reflected reactive responses rather than sustained learning or innovation. The provider did not demonstrate systematic quality improvement processes, staff learning pathways, or innovation to address recurring problems. As a result, improvement was not reliable or embedded.