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 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.

Previously the provider was in breach of legal regulations in relation to good governance. At this inspection, enough improvements had been made, and the provider was no longer in breach of regulation.

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.

At our previous inspection we had identified significant shortfalls in relation to the culture of the service and how people had been treated. At this inspection, we found significant improvements had been made. However, time was still needed to embed and sustain those improvements. The provider told us they were committed to embedding good practice within the service and continuing to improve the care and treatment people received.

Staff told us the culture of the service had now improved, and they felt part of a team. The provider introduced additional training to prioritise safe and compassionate care and continued to work with the staff team.

One staff member said, “I feel my voice matters because it directly impacts the quality of care we provide. Open communication within the team helps ensure the people we support receive safe and person-centred care.” Another staff member told us, “The manager has also introduced new ideas and practices that have made the home more successful and emotionally connected with our residents. For example, the manager has encouraged more person-centred activities, greater involvement of families, and meaningful engagement tailored to residents’ individual histories and preferences. There is a strong focus on dignity, respect, and emotional wellbeing, not just physical care. These initiatives have strengthened relationships between staff and residents and created a warmer, more homely atmosphere.”

The service 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.

The service had a new manager who was committed to making improvements within the service and felt supported by the provider to do so.

Staff spoke positively about the manager and the wider management team. Staff told us they felt able to ask for support if needed.One staff member said, “I do know the manager, and I’d say they are very approachable. As a carer, I feel comfortable speaking with them about both professional concerns and personal matters that may be affecting my work. They make time to listen and don’t make you feel rushed or dismissed. I do think they model inclusive behaviour. For example, they actively encourage input from all staff during team meetings, regardless of role or length of service.”

Another staff member said, “I know the manager and feel they are approachable. They maintain an open-door policy and are available to discuss any concerns or ideas. I feel comfortable speaking with them both formally in supervision and informally when needed. I believe they model inclusive behaviour consistently.”

Relatives were complimentary about the manager and felt included in the care of their family members. A relative said, “The service standards come from the top. The management is inclusive, very approachable and take every issue, no matter how minor, seriously. They keep me as next of kin fully informed. The relationship between management, nurses and carers appears balanced, solid and respectful.”

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

At our previous inspection we found staff did not feel able to speak-up. At this inspection we found the provider had worked with staff to ensure they now felt confident to speak-up about any concerns.

Staff told us they knew how to whistle blow, and report concerns to external organisations, such as CQC and the local authority. A staff member said, “There is a clear whistleblowing policy in place and staff know how to report concerns safely if needed. Contact details for senior management and safeguarding teams are available in the office and in policies, so we can seek advice or escalate concerns if required.”

The provider displayed a whistleblowing poster which contained contract information for the safeguarding lead within the service, as well as the wider management team, including the nominated individual. This helped promote a culture of openness and encouraged staff to report concerns confidently.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Since our previous inspection, the provider had made changes to ensure staff felt respected and valued. Staff told us they now felt listened to by the senior leadership team.

Staff told us they were treated fairly by their managers and protected from discrimination. One staff member said, “I do feel valued at work. The manager thanks staff for their work, acknowledges when shifts have been difficult and recognises good practice. Feedback is given positively and staff are praised in team meetings and supervisions.” Another staff member told us, “I believe the manager models inclusive behaviour. The manager treats staff fairly and with respect, regardless of role or background, and ensures everyone’s views are considered. When support is needed, it is provided in a compassionate and understanding way. If a staff member is going through a difficult time or feeling under pressure, the manager takes time to check in, offer reassurance, and, where possible, make reasonable adjustments or provide additional support. This approach helps staff feel valued, respected, and supported.”

The service 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.

At our previous inspection we had identified systemic shortfalls in relation to the culture and management oversight of the service. At this inspection while we found improvements had been made further improvements were needed to ensure consistency.

The provider had not always used their checks and audits effectively to identify shortfalls. For example, in relation to MCA assessments, medicine management and end of life care plans.

The new manager, with the support of the provider, had introduced a wide variety of audits and governance processes to ensure effective oversight of the service. The provider had a plan in place to ensure continued support of the service to ensure changes made were embedded and sustainable. This included working from an established action plan and the provider undertaking unannounced monitoring visits of the service. The provider had also engaged an external consultant and was working with external professionals to ensure ongoing improvement.

The service held weekly clinical risk meetings. The manager and staff discussed key areas including incidents and accidents and safeguarding. The meetings supported management to have effective overview of the service and respond to concerns without delay.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service. Notifications were submitted, as required.

Staff and relatives spoke positively about the manager and the changes within the service. One relative said, “The management has changed frequently over the period, but we now feel able to identify and speak to the management.” Another relative told us, “Since [the manager] has taken over, it has been very good.”

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Since our previous inspection improvements had been made and staff now worked in partnership with stakeholders to ensure positive outcomes for people.

Health and social care professionals were complimentary about working with the service. One health and social care professional said, “We enjoy a good working relationship with the service.” Another professional told us, “I have consistently found the team to be highly professional, responsive, and committed to delivering safe and effective care to residents.”

Staff told us they shared information and learning with external professionals and collaborated for improvement. Processes were in place to ensure effective communication and partnership working was established between the service and health and social care professionals. This ensured people received joined up, effective care.

The service 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. They actively contributed to safe, effective practice and research.

At our previous inspection we found lessons were not always learned and timely improvements were not always made when things went wrong. At this inspection we found systems and processes had now been implemented to support learning and continuous development.

The provider had implemented an action plan in response to concerns we identified previously. The action plan was a ‘living document’ which was continuously updated and changed to reflect improvements made and changes introduced. This supported the provider to understand what improvements had been made and what still needed to be completed.

The provider was committed to making long lasting changes and improving the service. They were aware of the need to embed the changes already made and sustain the changes long-term. Processes were in place to ensure learning happened when things went wrong, and from examples of good practice. The management encouraged reflection and collective problem-solving. Staff told us they were supported to learn and improve in their role.