The Meadows

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 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 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 provider did not have a clear shared vision, strategy and culture which was 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 provider did not have quality assurance oversight of the service; there was not a service development plan in place to support the service to develop learning and improvements. Meeting minutes we saw did not refer to the services values or strategic goals.The nominated individual recognised that there were areas requiring improvement and was proactive in actioning concerns we raised throughout our assessment.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge and experience to lead effectively. We identified breaches in regulations and concerns in governance. The leadership team had not independently identified and acted on these concerns prior to our inspection. This meant development was needed in skills and knowledge to lead effectively.However, relatives told us the manager was accessible. One relative told us, “The manager is very approachable.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.There was a whistleblowing policy in place and staff felt confident to talk to the leadership team at the service.

All staff completed equality and diversity training and understood the importance of treating colleagues and people with respect.There were no reports of bullying or discrimination, staff said they felt valued and supported.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on information about risk, performance and outcomes.The provider did not have an audit and quality assurance process of the service provision. This meant the service did not identify the concerns we found during our assessment. We found medicines expiry dates were not checked and Controlled Medicines were not recorded in line with national protocols; the service did not have general risk assessments completed for the service. Staff were rotated to complete prolonged shifts putting people at risk due to staff sleeping on duty. The service did not respect people’s dignity, we found kitchen cupboards padlocked with no risk assessments in place, times for people to be able to smoke or vape were on a poster on the communal activities board, we observed people going to a shelf by the office door when their medicine was due, staff then dispensed the medicines and placed it on the shelf for people to take from. People had baby monitors in place to be used at night, we found these monitors were on in the staff office during the day. People were not always supported safely in line with their individual needs which included night checks not being documented, people’s mental capacity assessments had not been completed in line with information we found in people’s care plans.Although we found no evidence that people had experienced harm, these issues presented a potential risk to people. The leadership team responded when we raised concerns and provided evidence of improvement and actions being worked on to improve.

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 service worked with external professionals and agencies to support people’s care and wellbeing. Relatives told us they were involved in people’s care planning and reviews.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider did not have systems which consistently identified issues before the inspection. This meant opportunities to learn, improve and prevent recurrence had not always been fully realised.

However, during our inspection the leadership has implemented quality assurance oversight which will help support in developing learning, innovation and improvement within the service.