Malvern 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.

This is the first assessment for this newly registered service. This key question has been rated 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 68 (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 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.

The service promoted a positive culture that was open, inclusive, and empowering. Leaders, managers, and staff encouraged people to express their views and concerns and acted on feedback to help shape the service and its culture. Relatives told us they felt listened to and involved in decisions about their loved one’s care. Staff were positive about their roles and demonstrated pride in the care they provided. They told us they felt supported by managers, who were described as fair, approachable, and responsive to concerns. Staff said they could raise issues openly and were confident these would be addressed.

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.

There was an inclusive culture at the service. Staff were aware of the roles and responsibilities of the registered manager and the lines of accountability. Staff said they were part of a good team and could contribute and felt listened to. The registered manager was experienced and had the skills, knowledge, and credibility to lead effectively and demonstrated understanding of regulatory requirements.

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

The service encouraged a culture of openness and transparency to prevent closed cultures from developing. Leaders set clear values and behaviours that supported honesty and accountability. A relative told us, “They had put the CQC signs so didn’t hide anything”, which reflected the provider’s commitment to transparency. Staff had multiple ways to raise concerns, including regular team meetings and open-door policy with managers. Staff told us they felt confident to speak up and managers were described as approachable and responsive.

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 service demonstrated a strong commitment to equality, diversity and inclusion within the workforce. All staff completed an equality and diversity form, and information was collated to monitor representation and promote a multicultural team. Leaders encouraged diversity whilst remaining vigilant about team dynamics, addressing any concerns about cliques through supervision and open dialogues. Reasonable adjustments were made to support staff with disabilities and health conditions. For example, adjustments were in place for women experiencing menopause, including extra breaks and access to fans to manage their symptoms.

The provider had clear responsibilities, roles, systems of accountability or good governance. However, some improvement was needed.

The service had a governance structure in place; however, audits to monitor the quality of the service and identify areas for improvement were not consistently completed. As a result, the provider had not always identified or acted on concerns relating to risk management for people’s health needs and medication safety. This lack of robust auditing and analysis limited the provider’s ability to maintain effective oversight.

During the assessment, the service was responsive to the issues identified and began taking action to strengthen governance arrangements. An action plan was initiated to improve oversight and ensure audits were completed regularly, enabling timely identification of risks.

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.

The provider worked closely with relatives, health professionals and community organisations to support inclusion. Discussions with staff and review of records showed representatives from a variety of health and social care professionals were actively involved in supporting people. The service utilised a wide range of community groups to enhance people’s wellbeing and social inclusion. These partnerships enabled access to local resources, activities and support networks, promoting independence and improving quality of life

The provider did not always actively contribute to safe, effective practice.

Leaders demonstrated an understanding of how to make improvements; however, there was no consistent approach to measuring outcomes or monitoring the impact of changes. The service had an improvement plan, which was being embedded and regularly updated. However, this needed strengthening to reduce risks. Audits were undertaken and informed service improvements; however, they required strengthening to effectively identify patterns and trends. Staff in all roles expressed a pride in working for the service and in the care and support they provided. Comments included, “Training needs were discussed during supervision, and a training plan was agreed to support development.”