Muscliff 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 inadequate. At this assessment the rating has remained inadequate.This meant there were widespread and significant shortfalls in service 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 good governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.Staff told us the culture of the service was improving. Comments included, “I stand shoulder to shoulder with my colleagues” and “We are improving day by day and improving, following instructions and attending more training.” During a review, the provider had identified, ‘It is clear that the current practices are not delivering safe or competent care.” The provider was working with an external consultancy organisation to make and embed the changes needed to make further improvements. The provider was working to improve the culture of the service and embed a shared vision by working with all staff to implement a recently updated action plan. The provider was also supporting staff through additional training.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The leadership of the service was unstable, with a high turnover of managers and vacancies. The provider’s failure to implement a consistent leadership team had contributed to a continued breach of regulations. For example, new management staff did not always have the most up to date information, or access to relevant information required to make improvements. The provider had restructured the management team and was working more closely with consultancy staff to rectify this.

Records documented staff had continued to raise concerns relating to the care of people and insufficient staff on duty. Staff told us, “There are new rules and sudden changes. The managers are not ready to listen to us”, “The new management do not value us,” and “I am not involved in meetings.” A professional said, “It is often difficult to find or speak to a member of the management team to inform them of observations of the environment, such as the dementia signage displaying an incorrect date. This is confusing for people and may cause distress. The manager shared a staffing dependency tool they had created in response to concerns from staff. However, information including how many people were using the service, and what health conditions they had, was inaccurate. One staff member said, “We are often finishing late because we want to take our time and not sacrifice the quality of care.” This lack of oversight meant the manager or provider could not be assured corrective actions would be effective.

People and staff did not always feel they could speak up and that their voice would be heard. While the provider was working to make improvements, more needed to be done to ensure people and staff could speak up and feel listened to. People told us their concerns were not always responded to. One person said, “The new manager says they will make it better here, more things to do. We will have to wait and see I suppose.” There continued to be a high level of stress and anxiety within the staff team. A staff member told us, “Some horrible things happened in our home, it is not good, but I feel some of the changes have been discriminatory.”The lack of a consistent leadership team meant staff and people had to rebuild relationships and trust with new leaders. This undermined the speaking-up process.

The service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff surveys and staff supervision records recorded low levels of staff satisfaction. Staff did not always feel respected, valued, or listened to by leaders. A staff member told us, “We can talk to the manager, but we are not sure if they are listening to us.” Another staff member said, “We are feeling stressed and tense, always struggling to have our breaks because of cover.” The provider told us, “The closed cultural dynamic within the staff group remains a challenge, limiting openness to change and reducing the diversity of perspectives required for safe and effective care.” The provider stated the action taken regarding further training for staff in core care skills such as moving and handling, had still resulted in some instances of poor practice. When prompted to share what further action they planned to take to address this shortfall, the manager said, “I have recommended a full service reset to the provider."

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

The information that was used to monitor performance or make decisions was consistently inaccurate, invalid, unreliable or out of date. We found those inconsistencies throughout the provider’s systems. For example, the provider told us each person’s care plan had been reviewed and updated, except 1. During the inspection, we found 10 of the 12 care plans we reviewed, contained incorrect information relating to people’s health conditions, including risks of choking and risks to skin integrity. Therefore, the provider could not be assured staff had access to accurate information required to deliver safe care for people.The provider did not have oversight of accidents and incidents in line with their policy. The manager confirmed, “There is a backlog of accidents from May 2025, I need to make time to review them. I have been focussed on care plans and other tasks, so you won't see improvements…. for months.” This meant the provider could not be assured they would identify potential themes or trends and act to drive improvement without delay. We spoke with the provider who concluded, “There has been insufficient progress to demonstrate assurance.”

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. The provider informed us they did not always have effective working relationships with external professionals and services. People were not always supported to access their hobbies, interests and local community. Feedback from staff and professionals confirmed this duty was not being met. Comments from staff included, “We have planned things; we need to do more activities,” and “Activities are not happening.” The provider had engaged an external specialist service who was conducting a review of activities and opportunities for people to be active members of the local community. The leadership team told us they were developing a plan to address this shortfall by seeking views of people and their relatives, in addition to recruiting more staff. Following the inspection, the provider told us, “The service is disjointed, staff are not consistently accountable, and residents are not engaged in a way that promotes dignity, wellbeing, or safety.”

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe and effective practice. While the provider had implemented an action plan to improve care provision and regulatory compliance, they had not always monitored and checked if the plan was achieving positive results. The manager said, “There is too much to do, how do we show it's got better and stayed better? There are no systems in place and no access to information.” The provider’s ideas for improvement had not been translated into meaningful and measurable plans at all levels of the service. However, the provider was proactively working with a consultancy service to support them with making improvements. In response to our feedback, the provider implemented a new, more robust management structure at the service to address shortfalls we identified. The provider continued to engage with the local authority and care quality commission to share information and gain feedback.