Melton Care Services Limited

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 Requires Improvement. This meant the 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 was in breach of legal regulation in relation to good governance.

This service scored 62 (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 provider had a clear vision and values statement that was well understood by the staff. A staff member said, “I’m very happy in my role, we work well as a team and provide the best care we can, maintaining the person’s independence and control over the care they receive as fully as possible. I would be happy for one of my family members to receive care from the company.”

Another staff member emphasised the importance of “honesty” and “transparency.” During the inspection, we found the management team to be open and honest in their approach. A director spoke candidly about the challenges the service had faced earlier in the year, and the actions taken to stabilise and improve the service, including work to develop a more positive staff culture.

Staff confirmed these improvements. One staff member told us, “[Name] is the best person for the manager’s job, and since they took over, I have seen many improvements: training is up to date, there are more meetings, communication is excellent, and I feel well respected by them — and I respect them too.”

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.

The senior management team consisted of 3 directors who were all actively involved in service oversight and development. A new manager was in post who became the registered manager during our inspection of the service. The registered manager was supported by experienced and competent senior care workers.

The management team demonstrated a commitment to continually developing the service. The directors met regularly, with one maintaining daily contact with the registered manager, who carried out routine audits and checks. The registered manager was positive about the support they received.

Staff meeting records demonstrated an inclusive approach to care delivery and service development. Staff confirmed they felt valued, respected and listened to under the leadership of the new manager.

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

The provider had created systems and processes, including policies and procedures such as Freedom to Speak Up, Whistleblowing and Safeguarding to support staff to raise any concerns.

Staff informed us that they had access to the provider’s policies and procedures and felt confident speaking up when required. A staff member said, “I feel 100% confident in reporting issues and concerns, and I feel secure in the knowledge I would be believed, listened to, and it would be dealt with correctly.”

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 systems and processes to support and develop an inclusive workforce that respected equality and diversity. Staff received regular and ongoing support through supervision meetings, annual appraisals, ongoing training, spot checks, and staff meetings.

The management team informed us of the improvements they had made within the last year to develop a more supportive culture. This included the introduction of the Employee Assistive Programme, which was reported to have been beneficial. The provider reported they felt this had helped them to retain staff, reduce conflict, and improve the quality of care delivered.

Staff received equality and diversity training, which equipped them with the knowledge and awareness needed to recognise and respect people’s individual characteristics, cultural backgrounds, and personal identities.

The provider did not have sufficiently robust, clear responsibilities, roles, systems of accountability and good governance. They did not consistently act on the best information about risk, performance and outcomes.

The provider’s governance systems, processes and procedures that assessed risks, and monitored quality and safety were not fully effective. They had failed to identify the shortfalls we found during this inspection, and this put people at increased risk of harm.

Assessment and monitoring procedures for individuals' care and support needs and known risks had failed to identify shortfalls in risk management and mitigation, as reported in the Safe key question of this report.

Systems and processes for monitoring care records were not fully effective. Care records showed that the care assessed and planned was not consistently recorded by staff during the care call. For example, a person was at risk of their skin breaking down and required staff to check and record the condition of their skin at every care call. The care records of this person showed that staff were not routinely recording what was asked of them. Whilst the person’s skin was intact, the provider’s monitoring procedures to ensure risks were effectively managed had not identified this.

The oversight and monitoring of staff training had failed to identify that staff had not been provided with training in areas of known needs and risks, as described in the Safe key question of this report.

Furthermore, internal systems had not identified the lack of guidance for staff about people’s known health conditions and how this impacted them. People’s communication needs had not been sufficiently assessed and planned for. This put people at increased risk of their individual needs not being understood and or safely met.

Monitoring systems had failed to identify the gaps in staff recruitment. Whilst the provider took actions to make improvements, it showed a lack of oversight and effective monitoring.

The provider’s systems and processes for opportunities to continually learn and develop needed strengthening. The provider had an ongoing action plan developed from audits and checks; however, the oversight and review of this plan were not robust. This meant there was a risk that required improvements would be delayed. A senior director we spoke with following our site visit acknowledged that some improvements were required and assured us that improvements would be made.

There were regular director and staff meetings, and records showed these were used to oversee service delivery and discuss plans for improvement. However, these records also showed a lack of robust planning and review. For example, timescales, actions, and responsible persons were unclear, and actions were not consistently reviewed or followed up at subsequent meetings. This meant there was a risk that required improvements might not be completed in a timely manner, and the lack of accountability increased the risk that some actions would not be completed at all.

We recognised at the time of the inspection that the provider had experienced a challenging year with changes to the management team in the early part of 2025, which had negatively impacted the service. Staff reported that the new manager had made some improvements and was well-liked and respected. The management team was open and honest during the inspection about the fact that further improvements were still required.

Additionally, at the time of the inspection, the provider was using two different electronic care systems, with the new system set to replace the previous one imminently.

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, and records confirmed, the provider had a positive approach to partnership and collaborative ways of working. They made timely referrals and sought guidance and support when required from external health and social care partners. They acted upon the recommendations made. For example, a person had been identified as having swallowing difficulties, following an assessment by a speech and language therapist who recommended a specific diet to reduce the risk of choking. The person’s eating and drinking care plan reflected this guidance.

The provider’s systems and processes, designed to support learning, improvement and innovation, required further development. Existing arrangements did not consistently ensure that lessons were identified, shared or embedded across the service, which limited the provider’s ability to drive sustained improvement.

The registered manager informed us that they attended local authority forums and meetings, receiving updates from the local authority and the CQC to enhance their awareness and knowledge of changes in adult social care legislation and best practice.