Meadow View Residential 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 Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the lack of robust governance at the service.

This service scored 25 (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 did not have a shared vision, strategy and culture based on transparency, inclusion, and engagement. We identified a closed culture at Meadow View Residential Care Home. A closed culture is a poor culture in a health or care service that increases the risk of harm.

Some of the terminology used by staff and leaders at the service was poor and not reflective of kind, informed dignified care. For example, when explaining people to us leaders used terms such as, ‘vile.’ Staff used language which was inappropriate for example telling us that one person wasn’t ‘allowed’ to use a communal bathroom due to a falls risk. Daily care records for one person stated that they had ‘sent the person to their room’ and ‘put them to bed.’ This is not inclusive language or a dignified way to describe people.

During one of our visits, at 5am a staff member’s phone sounded with an alarm. We asked what the alarm was for, and they told us, “To get people up.” This is not a person-centred approach and does not put the needs of people first. Staff were not focused on people’s needs but were task focused, not considering the detrimental effect waking people, including people living with dementia could have. Care notes we reviewed were task focused and not person centred.

Relatives gave us mixed feedback about the culture of the service. The registered manager told us they had an ‘open door policy.’ However, we observed the registered manager’s office had a sign on the door saying, ‘meeting in progress, do not disturb.’ Relatives told us this was often in place and therefore they did not always feel they could approach the registered manager.

We found that there was a lack of high-quality leadership at the service. Staff and relatives told us there had been a lack of consistent leadership at the service over a long period of time. Changes with leaders meant that any improvements were short lived, and did not significantly impact of benefit people or staff at the service.

Leaders were not always alert to examples of poor culture within the service, which had a detrimental impact on staff and people. Leaders had failed to identify and act on the widespread risks highlighted within this inspection. Leaders did not always lead by example; leaders had used poor language when describing people living with dementia, and how they could present when they were distressed.

Staff and relatives raised concerns about the leadership team, and the lack of modelling of inclusive behaviours. A relative told us, “I don’t feel like staff can be themselves.” Some staff raised concerns about how some changes are being implemented and communicated with staff. They said, “The registered manager is a force to be reckoned with. They have done well they have improved the home. They’re abrupt, not here to make friends but they have turned the home around.”

We also received some positive feedback about the leadership including from a healthcare professional, “I believe their leadership has improved a lot after seeing a long period of frequent changes. Most of the senior carers have the acumen to pick up the problems and deal with them in a timely fashion.”

Staff and relatives did not always feel they could speak up and that their voice would be heard. Staff told us that there was a ‘blame’ culture at the service, and when things went wrong they were not always supported by leaders. Staff told us, “I don’t feel the management team are supporting the staff to the best they could. Morale is low.” Another staff member told us, “It feels like we are scape goats.”

Some staff shared with us that if they did have concerns, they did not have the confidence to raise them within the organisation, due to perceived friendships within the leadership and head office staff. Staff told us, “I would not be confident to go to anyone else in the company.” Another staff member told us they were not confident to raise things higher than the team leaders. They said, “I would go to my senior rather than the registered manager or deputy manager.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed feedback from staff regarding equitable treatment of staff. Some staff told us that leaders had ‘favourites’ and that these staff were treated differently and received preferential treatment. Staff told us that when investigations took place leaders did not consider staff well-being or mental health or anxieties, which led to further distress. We found where staff supported people who could show high levels of distress appropriate risk assessments were not always in place, for example for pregnant women.

However, one staff member we spoke with told us they had received support, with leaders making reasonable adjustments for them at work. Staff told us, “[Leaders] have been really supportive and given me the time I’ve needed to come back.”

The provider 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.

The provider failed to ensure that documentation was accurate. For example, on one person’s MAR, it stated that they had been administered co-codamol, however they were not prescribed co-codamol. This had not been spotted or addressed by staff. MAR audits reviewed for May and June 2025 found no issues, despite the widespread and significant issues identified within this inspection.

Other audits completed by leaders failed to identify issues highlighted during our inspection relating to care plans and risk assessments. Care plan audits had not been effective in driving improvements with guidance for staff. Staff had worked on improving care plans to be more person centred but had not considered this element in relation to risk, or prioritised ensuring high risk care plans were completed first.

The providers internal compliance report did identify some issues highlighted within this assessment, however action to address these areas had not been timely. High risk areas such as epilepsy risks, and issues with medicines and constipation had not been identified and mitigated which left people at risk of harm.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Staff did not always follow guidance provided by professionals.

Relatives told us there could be improvements with partnership working. One relative told us the GP was good, but if their loved one needed a prescription it was delayed due to the pharmacy not being local. The provider was in the process of changing pharmacies to a local one.

We found leaders had not always worked closely with specialist clinicians to support people with their healthcare conditions. For example, people living with epilepsy had no involvement with a specialist epilepsy nurse, to support their care and inform staff how best to support people.

Staff told us they worked well and closely with the visiting district nurse. Staff said, “The district nurse will update the team leader of their actions, but I attend with the district nurse when she does wound dressing and update the care plan straight after. It really helps to see and understand what is happening.” A healthcare professional told us, “I think the care home has gotten better in the past year."

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Staff and relative told us they escalated concerns but these were not always acted on or learnt from. For example, one relative told us that other people frequently went into their loved one’s room. When they raised this with leaders, querying the stimulation people received, they were told it wasn’t a service that provided “1:1 care.” Leaders missed the opportunity to learn and act on this concern and review activities and stimulation available for people.

Staff told us that they raised with leaders that there was not enough staff, but this was not acted on. The registered manager and deputy manager told us that people’s needs had been assessed, and a decision was made to move some people, with higher needs to the first floor. They told us that staff were “More trained in behaviour and monitoring” on the first floor.. However, staff told us they raised concerns with leaders about this, as there was less staff on the first floor to the ground floor. Staff breaks were not covered, and therefore when staff had breaks there was less support for people within the home. Staff told us that they raised these concerns with leaders, but staffing had not increased. The registered manager told us that staffing would only increase, when more residents moved in, however had not considered each individual person’s needs. One relative told us they had to step in when incidents of distress between people occurred due to staff not being present.

Incidents of concern re-occured. For example, in May 2025 there were 19 medicines errors recorded, which included documentation not being signed, and people not receiving their prescribed medicines. In June 2025 not only did these incidents continue, but they increased to 23 incidents. Nearly half of all reported incidents in June were medicines errors. Despite this, medicines audits for May and June 2025 showed 100% compliance.