Melbreck

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 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.

This service scored 71 (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 clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an understanding of the challenges and the needs of people and their communities.

The registered manager told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. Staff told us there was a good and positive culture within the home where people and staff had a good rapport, and the atmosphere was one of respect and care.

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions. They told us, “We follow ETHOS (Empowering Outstanding Honest and Supportive). This is for the residents and staff. To work together and aim to become outstanding in everything we do. We also want to fulfil everyone’s life.”

The management team were passionate and committed to developing the service for the benefit of people who used it.

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.

People and relatives knew who the registered manager was and told us they had a good relationship with them and the rest of the staff. One person said, “[They are] a nice manager.” A relative agreed and said, “The manager is relatively new. [They are] absolutely approachable.”

All the staff we spoke with were positive about the registered manager and provider. They told us the service was good and the managers respected and valued them. They added the managers put people at the centre of everything they did and led the staff team by example. A member of staff told us, “[Registered manager] always does [their] best to help out. Since [they’ve] been here, the whole atmosphere has changed” and “A couple of months back, I wasn’t quite sure how to run a report, I went to [Registered manager] and [they] explained step by step.”

The registered manager had worked their way up from care worker and had developed a good knowledge of the client group they supported. They told us they enjoyed working at the service and had a good relationship with staff and people alike. They felt supported by their line manager.

The registered manager undertook all the training available to help ensure they kept their skills up to date. They were currently undertaking a management qualification which they said should be complete by May 2026. They told us, “I have done all the training including leadership training. I also get involved with the care of people too, especially if we are short staffed.”

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

People and relatives were given information when they moved to the home about how to raise a concern and said they knew how to make a complaint.

Staff told us they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home. The registered manager told us, “I truly believe the staff are good at reporting things. For example, previously a staff member had reported another for misconduct.” They added, “The whistleblowing policy is online and displayed for staff to access. This is also discussed during meetings so staff know what to do.”

The provider had some processes in place to support staff to speak up. This included supervision meetings, handover meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up.

In addition to regular staff meetings, there were daily handover meetings to discuss important information, and any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities.

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.

The provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. Staff were supported to develop their skills within the company.

Staff’s cultural and religious needs were supported. The registered manager told us, “We do have a lot of cultures here and we try to bring this into the home. I organise different events where we can cook meals. We look at all different events and celebrations, so everyone is involved. We invite everybody. And food wins all day long.”

People and staff’s sexuality and identification was respected. This included how they wanted to identify and their choice of pronouns. The registered manager said, “We do diversity training, and we also openly talk about this. We celebrated Pride.”

Although the provider had clear responsibilities, roles, systems of accountability and good governance. Overall, systems in place for monitoring the quality of the service were effective. However, medicines audits had failed to identify and address the shortfalls we identified during our inspection.

The registered manager took immediate action and all shortfalls had been addressed by the end of our inspection. Furthermore, they strengthened their monitoring systems to prevent this from happening again. They told us, “The clinical lead will now increase the frequency of audits. We have also liaised with the GP surgery and the pharmacy to make sure all documentation is correct.” They also informed us they were working closely with the nursing staff to ensure they followed the medicines policy and procedure going forward.

Staff at all levels understood their roles and their level of accountability. Managers and support staff worked well together and understood how their duties impacted and supported the other.

Staff, people, relatives and external professionals had confidence in the leadership of the service. A staff member told us, “All colleagues are nice. I can speak with the manager and colleagues on any issues” and another said, “The manager is supportive.”

There was a continuity plan in place. Short term and long-term plans were reviewed and updated 3 monthly. This was detailed with photographs and information. The registered manager told us they carried out scenarios for example, a gas leak, so they could practice how to deal with this should it happen.

The provider 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.

Staff told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals. For example, the GP and the local authority. They told us, “We go to the GP for advice, such as with the MAR charts at the moment. We aim to have good working relationships, such as with the local authority clinicians. Like the SALT team and learning disability team. I think it is so important to build good working relationships. We need them and they need you.”

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The registered manager told us they ensured the staff learned from healthcare professionals involved in people’s care to help understand people’s needs better. Our conversations with various support staff showed they understood people’s needs and were keen to learn from professional input.

The provider 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.

People and relatives told us they were consulted individually during a review or regular conversation, to find out if they had any concerns or requests. We saw people’s opinions and requests were taken seriously.

Staff told us the registered manager was always aiming to make improvements to the service in order to benefit people, and they enjoyed being part of this. For example, they had successfully recruited 6 bank nurses in addition to the permanent ones. The registered manager told us, “This means we never use agency nurses. They come from the hospital so bring a wealth of knowledge.”

The registered manager was committed to developing the service to benefit people and the staff team. They told us when they started working at the service, there were some concerns about some of the staff’s practices. As a result, they had placed them on performance management. They said, “I now monitor their performances and how to help them develop and improve. It is easy to become stagnant in your work. We are not there yet. it is work in progress.”