Meadow Acres

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 inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was not always consistent. Leaders and the culture they created did always not support the delivery of high-quality, person-centred care.The service was in breach of legal regulation in relation to poor governance systems. This meant systems were not robust enough to demonstrate the service was consistently managed well.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team did not have a clear shared vision and culture which was based on transparency, equality and human rights. We observed staff interactions to be caring, however we found further improvements needed to be made to instil a culture of care in which staff truly promoted people's individuality, protected their rights and enabled them to develop and flourish. Some staff told us they felt well supported by the management team and the governance systems in place. However, a small number of staff expressed concerns that if they raised issues, these might not be acknowledged or appropriately acted upon. They also described past situations where concerns about colleagues had been escalated but were perceived as not being transparently managed. Although we could not verify these accounts, the perceptions reported by staff indicate a potential risk to the development of a closed culture if staff do not feel confident to speak up freely. The management team responded immediately to this and put together additional training and work around closed cultures. This reflected a growing sense of shared direction and a commitment to building a more cohesive and supportive culture across the service.

The service was manged by a leader who was keen to learn and develop the service to deliver person-centred care. There were elements of the service that required leaders to develop their skills in recognising where improvements were needed. The provider had not ensured they provided leaders with the skills to recognise where improvements were required to the culture of the support provided. We found that there were overall failing of the culture of the services. Despite this, the staff felt the leaders were present and supportive. A staff member said, “Management are very supportive”, Another staff member said, “The management team are very helpful from small help to major help, using training, informal and formal conversations, supervisions and annual appraisals.”

People and staff were regularly asked for feedback, which was used to shape service delivery. The provider encouraged relatives involvement where their voice could be heard and to share their views about how to make change either within the service or to enrich the lives of individuals.

The staff understood what to do if they needed to speak to someone about their concerns. The provider had a whistle blowing procedure in place.

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. Staff said they felt the leaders and the provider were fair and listened to them.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. The provider had a governance system, however it lacked oversight of certain aspects of the care and care records being completed for people using the service. As part of the inspection, we had identified areas of improvement, which had not been found as part of their governance systems. For example, risk management, medicine management and environmental risks.

The management team completed regular audits; however, where improvements had been identified, there was not always clear action plans or evidence to show actions were embedded in the service. This meant staff would not always be equipped with the knowledge to change their support practice for the better.

The provider lacked oversight of certain aspects of the care and governance systems were not robust enough to capture the significant risks identified during the inspection. Including the culture of the service, and the care records being completed for people using the service. The provider did not meet best practice guidance set out in Right support, Right care, Right culture. With in the report we have identified examples where people were not respected or had choice and independence over their lives.

The Registered Manager 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. The Registered Manager had established links with the local community.

The provider had system of sharing learning and improvements for the organisation which filter to the services. These shared lessons learnt from internal and external reports and intelligence. However, consideration to be taken to see how this valuable information and learning is embedded into the services.