Mardon Neuro-rehabilitation Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs. At our last assessment this key question was rated good. At this assessment the service remained as rated good. This meant people’s needs were met through good organisation and delivery.

The service was in breach of regulation related to discharge planning, there were significant delays in discharging patients.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff demonstrated a strong commitment to person‑centred care, ensuring patients and their families were meaningfully involved in planning and making decisions about their rehabilitation. We observed staff engaging with patients tailoring their approach to meet individual needs. One family member commented, “It was lovely to meet all the professionals supporting ‘x’ on their journey and how all the different elements of their care knit together’.

Teams worked collaboratively across disciplines to create care plans that addressed physical, emotional, and social needs. Patients received care aligned with their personal preferences, circumstances, and priorities. Patients were supported to participate in activities promoting wellbeing and rehabilitation.

Staff encouraged patients to make their own choices about their care and treatment. Staff were aware of patient’s wishes when it came to resuscitation. They knew which patients were for resuscitation and those which were not. This was part of their person-centred approach towards patient care.

Staff worked with patients to plan home visits and supported them to spend weekends at home. They ensured all necessary equipment was available and stayed with them until they were safe to stay alone with family. They were able to call a member of staff at any time if they needed support.

We scored the service as 2. The evidence showed some shortfalls. The service understood the diverse health and care needs of people and their local communities, however care, in particular discharge planning, was not always joined-up to allow for timely discharge and improve access to the service.

People who were clinically ready for discharge were experiencing significant delays due to a lack of available care provision within the community. Staff told us discharge processes had become more challenging following the transfer of service leadership from the acute trust to the community trust, which they felt had negatively impacted the effectiveness of discharge planning.

People stayed in the rehabilitation unit longer than they needed, and this meant other patients could not be admitted in a timely way. A review of the discharge process presented at the directorate business meeting on 3 June 2026 highlighted the extent of these delays. Of the 12 inpatients on the unit, 7 were experiencing delayed discharges, with a median delay of 25 days and delays ranging from 18 to 139 days. There was an example of a patient who remained in the unit for3 months awaiting allocation of a social worker. There were 3 people waiting to be admitted at the time of the inspection, who would benefit from timely access to specialist rehabilitation care.

Length of stay for patients remained consistently higher than data for comparable rehabilitation units. The service had previously reviewed this and identified a range of factors contributing to extended lengths of stay, most of which related to delays in discharge.

Leaders were aware of the impact discharge delays had on patient flow and length of stay and had identified this as a priority area for improvement. The service was working with the senior leadership team and system partners to develop and implement measures to improve the discharge process and reduce avoidable delays. We saw evidence the service had flagged discharge issues to the senior leadership team in April 2026. However, leaders acknowledged some challenges, particularly those relating to the availability of community care packages and placements, reflected wider system pressures being experienced nationally.

Although the service told us actions had recently been implemented to address delayed discharges, these measures were in their early stages and there was not yet evidence of sustained improvement. The lack of care packages available in the community is also a national problem.

Despite the challenge of discharge, the service performed better than other services of the same type for its mean referral to admission times. The UK Rehabilitation Outcomes Collaborative was established in September 2008 to develop a national database for collating case episodes for inpatient specialist rehabilitation. Data from this source stated the service mean time of referral to admission in 2025/2026 was 10 days compared to 15 days for other services of the same type.

The service was commissioned as a 12-bed unit; however, an additional room (Room 13) had the potential to increase capacity. Historically, this room had been occupied by a permanent resident. Following the resident's death more than a year ago, the room had remained unused. Staff told us the room required refurbishment to bring it up to the required clinical standards before it could be used for patient care.

The service was accessible to the population of Devon and neighbouring areas. Staff worked in partnership with other providers to ensure patients could benefit from specialist neurorehabilitation services. Regular Peninsula meetings, involving providers across Devon and Cornwall, facilitated effective collaboration and referral arrangements, enabling patients from across the region to access the service. The service also accepted referrals from acute rehabilitation trusts as a step-down facility and had established referral pathways for patients from Salisbury and the wider Wiltshire area.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

On admission, patients and their families were provided with information about the centre, including details of staffing roles, mealtimes, therapy schedules, and educational groups. Feedback from families was consistently positive regarding the quality of communication from staff and the information shared about care and treatment. The service held regular meetings with patients and family members to ensure they were kept informed about care plans, rehabilitation goals, and progress, promoting effective communication and involvement in decision-making. However, some of the feedback received from patients stated communication around the discharge process required greater clarity. They were unsure when the discharge was happening as it kept changing and they weren’t assured their relative would receive the amount of care required in order for them to be discharged home safely.

Translation services were available for patients and families whose first language was not English, helping to ensure information was accessible and communication needs were met. Patient information leaflets covering a range of neurological conditions were available in communal areas, providing patients and visitors with additional information and support about specific diagnoses and treatments. We were told this information could be made available in other languages and formats.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service provided a range of opportunities for patients and carers to share feedback about their experiences. Patients could provide feedback through patient feedback cards, and the service also collected and reviewed thank-you cards received from patients and their families. In addition, patients were able to submit comments through an electronic feedback system.

We saw evidence the provider actively responded to comments received through the electronic system, offering to investigate concerns where appropriate and providing information on how to raise a formal complaint. Patient feedback was regularly reviewed through governance processes to identify and monitor themes, trends, and areas for improvement. For example, patient feedback was discussed at the community care group governance patient experience meeting in May 2026, demonstrating how the service used patient experiences to inform quality improvement and service development.

The service was implementing new electronic systems to improve the collection and collation of patient feedback. A dedicated team provided individual locations with feedback reports to enable local ownership and oversight. This approach was undertaken at a community service level.

Community rehabilitation services received a limited number of complaints during the reporting period. The majority of these related to access to services, including issues associated with referral pathways, waiting times, and service availability. The service had 4 complaints in the last year all of which had been investigated and closed. Once an investigation was finished an action plan was created to ensure improvements were made. Learning from the complaints was shared with staff.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

During 2025/26, 30 patients were admitted to the service, compared with 48 admissions in 2024/25. Delays in discharging patients remained a significant challenge for the service and had contributed to the reduction in admissions. However, the complexity and acuity of patients' needs also influenced the length of stay and overall bed availability. Reflecting this, the average length of stay increased from 77 days in 2024/25 to 103 days in 2025/26, suggesting patients required a longer period of rehabilitation and support before discharge.

There was adequate medical cover available within the service, with additional support accessible from acute trust medical teams when required. The service accepted patients who were assessed as medically stable; there were clear processes to respond to any deterioration in a patient's condition.

Discharge coordinators were involved in the discharge process for patients as well as mental health teams and local integrated care boards.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The service had processes and policies which ensured patients were treated in line with requirements under the NHS constitution and legal and human rights.

Staff received appropriate training in equality, diversity, inclusion and human rights. Information received from the provider evidenced staff were above the trust target for compliance with completing the learning disabilities training. Patients’ heritage and values were reviewed during admission assessment, and the service determined any support people needed to meet their needs.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes so they had enough time to make informed decisions about their future, including at the end of their life.

Staff told us goal setting and care planning commenced within the first week of a patient's admission. Staff took time to get to know patients, understand their individual circumstances, and identify what they wished to achieve through their rehabilitation. Examples of goals included returning home to be with family or regaining the ability to walk independently.

Patients were actively involved in decisions about their care and treatment and were encouraged to express what they wanted to achieve during their stay. Staff worked collaboratively with patients to develop personalised rehabilitation plans and provided support through occupational therapy and physiotherapy interventions to help them progress towards their goals.

Staff told us goals were designed to be realistic and achievable, enabling patients to monitor their progress over time and recognise improvements in their independence and wellbeing. This approach supported patient-centred care and encouraged patients to remain engaged in their rehabilitation programme.

Staff were aware of which patients held Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). This information was held on the patient electronic record system.