Meadway Court

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 remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders and staff demonstrated a clear understanding of the importance of providing person-centred care. One staff member told us, “When we support people, we try to tailor this support to them.” We found that improvements had been made to people’s care plans since the last inspection. However, further development was needed to ensure all care records consistently contained detailed, personalised information that fully reflected people’s individual needs, preferences, and wishes. Leaders were aware of these areas for improvement and had plans in place to address them. Staff spoke positively about the culture within the organisation. One staff member told us, “We do get a lot of support now. I can now go the new manager and speak to them. I couldn’t do that in the past.” Another staff member told us, “We all work as a team.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had a good understanding of the issues and priorities within the service. There was evidence that concerns and instances of poor practice were addressed promptly. People and staff spoke positively about the registered manager highlighting their visibility within the service, being approachable and open to feedback. One relative told us, “The manager is very approachable.” Another relative told us, “The manager is friendly and easy to talk to, you don’t need to make an appointment, they will chat with you anytime and I’m comfortable talking to them.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. However, there was no evidence to demonstrate how feedback was gathered from people who require support to express their wishes and choices.

There were policies and procedures in place to support speaking up. People and staff told us they knew who to speak to if they needed to raise any concerns and felt these would be followed up.

There was evidence of regular touch points with people and staff, providing opportunities to raise issues and discuss concerns. However further work was required to ensure this feedback was effectively used to drive improvements within the service and improve outcomes for people. This included feedback from people who may need support to express their wishes and choices.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. However, staff were not always supported to fulfil their aspiration and progress in career development.

The provider demonstrated a commitment to equality, diversity and inclusion and employed a diverse workforce in line with the principles of the Equality Act. Staff spoke positively about the registered manager and consistently described them as open, visible and approachable. Staff told us they received support and guidance when needed and felt comfortable raising concerns or discussing issues with the registered manager. This contributed to a positive and supportive working culture.

However, there was limited evidence to demonstrate the provider actively supported staff to undertake additional training and develop their careers.

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

There was a registered manager in place at the time of the inspection. They were actively involved in the day-to-day running of the service and were visible to both people and staff. The registered manager demonstrated a good understanding of the service’s priorities and recognised that further improvements were required.

Governance systems and oversight arrangements were in place. However, these were not always fully effective. Audits and quality checks did not always identify the issues we found during this inspection. Lessons learn were not always used to drive improvements, reducing the opportunities for the provider to learnt from incidents or actively identify emerging risks. Further work was required to ensure lessons learnt were consistently used to drive improvements and to ensure people experienced safe care and positive outcomes.

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.

The provider worked collaboratively with a range of stakeholders and partner organisations to help ensure people’s needs were met. Feedback received from stakeholders and professionals was positive and indicated they valued their working relationship with the service. This demonstrated the provider’s commitment to partnership working and achieving positive outcomes for people.

However, we found that support, guidance and advice requested from external professionals were not always sought or acted upon in a timely manner. As a result, people did not consistently benefit from the established relationships the provider had with stakeholders and partner agencies. This meant opportunities to improve outcomes and support people's needs were sometimes missed or delayed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There were policies and procedures to support continuous learning within the organisation. However, these were not always effective. We saw some evidence that lessons learnt were identified when things went wrong, and actions plans were put in place. However, some audits did not always include meaningful analysis to drive improvements within the service or identified the issues we found during this inspection.