The Meadowcroft Care 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 good. At this assessment, the rating has changed to requires improvement. This meant the service 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 remained in breach of legal regulations in relation to the way they operated their governance systems which had continually failed to pick up and/or take appropriate or timely action to address the issues we identified at this and their last assessment.

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 service 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.

Staff told us there was a positive culture within the care home and they all strived together to do the best for the people who lived there, despite the constantly changing management. One member of staff said, “We’ve had lots of different managers here in the last 6 months, but we continue to work well as a team. We just get on with things.” A second added, “I have worked here for many years and still enjoy it. We have a good team spirit, and the culture remains good here whoever is in charge.”

The service did not have a stable management team in place which meant the care home was not always consistently managed and nor did all its leaders understood the context in which they delivered care and support to people living there. Nonetheless, a new management team had now been appointed who had the right skills, knowledge, experience and credibility to effectively lead the service while embodying the culture and values of their workforce and organisation.

The service had not had a registered manager in post for the last 6 months and they continued to experience high rates of management turnover. In the first 8 months of the year [2025] 3 different people had been in day-to-day charge of the care home including, 2 interim managers. In addition, the services long standing deputy manager had recently left. This lack of stable management meant the care home was not being consistently well-managed and people living there were not receiving the continuity of care they should expect to receive.

We also received mixed feedback from people about the care home’s leadership. Typical comments included, “Changes in managers occurs far too often at the home. This negatively effects the standard of care people living at the home receive,” “There has been a lot of change in management over the last year which has likely made the staff feel unsettled. Staff have also had to get used to multiple interim managers and deputies recently” and “We have not seen stable management in place at the care home since the long-standing registered manager left in 2024. The deputy managers and 3 different managers have been in-charge since for relatively short periods of time, and the care home has felt unsettled ever since as a result”.

Staff expressed being equally concerned about the constantly changing management situation at the care home in the last 12 months. One member of staff remarked, “Having had so many different managers in-charge of the home this year it has made working here far more difficult that it should be. Most of the managers were great but they all had got their unique styles and personalities, so they kept changing how they expected us to work. This led to lots of confusion and inconsistent approaches. We desperately need some stable management here to get us back on an even keel and some much overdue consistency.”

We discussed this issue with the new interim manager at the time of the inspection who acknowledged that a lack of stable management at the care home in 2025 had hindered the various leader’s ability to consistently manage the service effectively. The provider confirmed a new home manager had been appointed and would commence in post by the end of October 2025

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

The care home had an open and transparent culture where people living there, their relatives, external health and social care professionals were all encouraged to raise concerns without fear. The provider used a range of methods to gather people’s views about what the care home did well or might do better. The provider received regular feedback through various forums people were encouraged to attend. Managers told us they explained the complaints process before people moved into the home.

The provider valued and listened to the views of staff. The provider had a ‘Speak up’ policy that was available to all staff. Staff felt able to brings things to the attention of the managers and senior nursing staff.

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

Staff told us they were part of a diverse team, treated equally and fairly, and they felt able to speak up. Staff told us their managers were supportive and reported feeling cared for, respected, valued and listened to by them.

Managers understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided with support through relevant training to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The service 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.

At our last inspection we found the providers established quality and safety monitoring systems were not always operated effectively and this represented a breach of regulations. At this inspection we found not enough improvement had been made by the provider in relation to the effectiveness of how they operated their governance systems. This was because they had failed again to take appropriate and timely action to address the issues, they and the CQC had identified at this and their previous inspection. This included issues we found in relation to the way they monitored and managed their fire safety arrangements, formal staff supervision and work performance appraisal meetings and record keeping in general.

This repeated failure notwithstanding, the outcomes of the providers routine checks and audits were still being used to identify performance shortfalls, which feed into an action plan to improve the quality and safety of the service people living at the care home received. For example, an internal audit conducted by managed had identified a lack of staff supervision and appraisal meetings in the past 12 months, contrary to the providers own staff support policies and procedures.

Managers understood their responsibilities in relation to regulatory requirements around notifiable incidents. Managers continued to notify the CQC in a timely manner about any incidents and events they were legally required to. An external care professional told us, “The care homes reporting has improved.”

We saw the service's previous CQC inspection report, which was conspicuouslydisplayed in the care home and easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

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.

The provider shared information and learning with partners and collaborated for improvement. Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. Managers and staff confirmed they worked closely with GPs from a local surgery, community tissue viability nurses and the local authorities’ care home therapy in-reach team who all regularly visited the care home. An external care professional told us, “We were happy with the engagement we’ve recently had with the provider and have seen a significant reduction in the number of incidents involving people living in the care home since May 2025.”

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The service did not always have a proactive culture of continuous learning and improvement. This was because the service was inconsistently managed by a constantly changing management team who had failed to always focus on continuous learning and improvement.

We found opportunities to continuously learn lessons and improve the service were still being missed. For example, the providers repeated failures to always identify and/or take appropriate and/or timely action to address issues relating to fire safety, staff supervision and work performance appraisal, and record keeping. This was mainly because the service continued to experience higher than expected rates of management turnover and remained without a registered manager in day-to-day charge of the care home who would be best placed to focus on continuous learning and improvement.