Meadow Court Residential 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-centered 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 means there were shortfalls in leadership. Leaders and the culture the provider created did not ensure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service’s care objectives for the service were stated in the Statement of Purpose. However, it was not clear how these were shared amongst staff or adopted in practice. Neither leaders or care staff were able to tell us about the service’s care objectives or the vision and values.

The service lacked a shared vision and values in relation to inclusion. For example, people with learning disabilities within the service were not provided with the appropriate referrals or external support.

The service had inclusive leaders at all levels and displayed integrity, openness and honesty. However, they did not always understand the context in which they delivered care, treatment and support, or embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to effectively lead, and they did so with integrity, openness and honesty.

There was a consistent management presence. Staff and people spoke positively of leaders within the home. One person told us if they had any concerns they would speak to a manager. Another person said, “[If I had any issues] I would tell any of the girls [staff] and they would go straight to the top.”

We observed a good level of management visibility within the home. Our observations found leaders within the service modelled compassion and inclusivity towards people and staff. However, leaders did not always display understanding of the context in which they delivered care, treatment and support. For example, leaders lacked an understanding of support or interventions which would be required for people with additional needs. Leader’s also lacked oversight of the service’s systems and processes. The service has put measures in place to improve leadership within the service following feedback.

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

Staff consistently told us that they felt able to raise any concerns openly with leaders within the service and were assured that their voices and concerns would be heard and dealt with appropriately. We also observed this during our site visits.

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

There was evidence of staff meetings and surveys to show staff were included in decision making. The service was a family run business and as such, various family members were employed throughout the service.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We identified widespread concerns relating to governance and quality assurance. Effective systems were not in place to assess, monitor, improve and sustain the safety and quality of the service. For example, the service did not always document or record appropriately, accidents, incidents and safeguarding concerns. The service did not have sufficient oversight of any emerging patterns or trends that could be identified to drive improvements within the service. Provider insight of the service was not robust. We found breaches relating to monitoring and mitigating risks to people’s safety, medicines, lack of contemporaneous records and documentation relating to staff supervision and appraisal. Robust systems were not in place for leaders within the service to have an appropriate overview, analysis and wider understanding of any concerning patterns, trends or learning in the service. The service did not have appropriate oversight to drive overall improvement of the quality and safety of the service. The service has now put measures in place to improve their governance, management and sustainability.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

There was a lack of oversight and monitoring at the service that impacted the effectiveness of collaborative working and sharing of information. As such, evidence of learning and quality improvement was not in place. For example, safeguarding referrals were not made to the local authority, and notifications were not submitted to the commission. People’s care plans and supporting documents were not always up to date. We reviewed documents and found supplementary information identified as a requirement in people’s care plans, was missing for example, regular weights or repositioning. We, therefore, could not be assured that partnership fully supported effective care. The service put measures in place to improve partnership and communities in their service following feedback.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service lacked robust and effective systems to ensure continuous learning and improvement. There was no evidence that learning from incidents, accidents and safeguarding concerns had been discussed with staff. Staff told us this was discussed with them verbally. Accidents, incidents and safeguarding events were not always appropriately recorded. Quality management systems did not provide sufficient or robust oversight to identify patterns or trends in regards of areas of the service that required improvement. Safety issues we identified were addressed swiftly by the service. Measures have been put in place to improve learning, improvement and innovation within the service.