Mardon Neuro-rehabilitation Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our previous assessment, we rated the service as good. At this assessment, we rated the service as good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff understood how to recognise, raise and report incidents. Staff were encouraged to speak up about concerns and were able to do so through both formal and informal channels. We reviewed five incidents and found these had been reported promptly and investigated. Staff received feedback following incidents, and learning was routinely shared through daily safety huddles. We also saw incidents and complaints were discussed at the monthly community rehabilitations governance meetings, providing opportunities to identify themes, embed learning and share good practice across the wider service.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care. Staff told us about examples where they had carried out duty of candour.

There were clear systems for raising concerns, both formally and informally. We reviewed 5 complaints and found the service had undertaken thorough formal investigations, demonstrating openness and honesty when identifying areas for improvement. Patients told us they would feel comfortable raising any concerns with the service manager and were confident these would be listened to and addressed. The trust had a website which had information on how to make a complaint.

We scored the service as a 3. The evidence showed a good standard. The service worked with people to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured all essential information about the patient was received to determine if the patient’s needs could safely be met. Admissions to the service were assessed at a multi disciplinary meeting to ensure they were appropriate and met the centre's eligibility criteria. The service had clear admission criteria, which included patients being medically stable and suitable for rehabilitation. An assessment tool was used to determine eligibility for admission.

Patients could be admitted from a range of community settings, including both the Eastern and Northern sites of the trust, as well as from specialist rehabilitation services operated by other trusts. Where possible, staff from the centre visited patients prior to admission to undertake assessments and explain the services available. This helped to support continuity of care and ensure patients received safe care and support from the outset of their rehabilitation journey.

Patients' care, progress and rehabilitation goals were reviewed and discussed at weekly multidisciplinary team meetings. Staff worked closely with patients and their families to develop personalised rehabilitation goals, gain an understanding of each person's lifestyle, preferences and what mattered most to them, and support realistic expectations regarding rehabilitation outcomes and discharge planning.

People underwent comprehensive assessments on admission, throughout their rehabilitation journey and prior to discharge. The service used recognised outcome measures, including the functional independence measure and functional assessment measure to assess levels of independence and monitor progress. This enabled staff to evaluate rehabilitation outcomes, identify areas requiring additional support and evidence improvements in functional ability over time.

The service was working on improving their risk assessment documentation. The most recent audit, April 2026, identified overall documentation completion stood at 44%, with some areas, including pressure ulcer prevention, falls management and manual handling, achieving scores below 39%. Despite this, the service performed well in areas relating to patient observations and patient feedback. Following the audit an action plan had been implemented to improve documentation completion rates and address identified shortfalls. During the inspection, we reviewed 11 patient records and found all required documentation had been completed.

The service used an electronic patient record system to support the delivery of safe and effective care. The electronic system provided prompts and alerts to help staff identify when planned care interventions had not been completed. For example, it highlighted missed episodes of intentional rounding, enabling staff to take timely action.

Intentional rounding was undertaken at regular intervals by nursing staff and healthcare assistants to monitor patients' comfort, safety and wellbeing. These checks provided opportunities to assess and respond promptly to patients' needs, including pain management, positioning, toileting requirements and any other concerns, helping to promote safe and person-centred care. Patients had call bells if they required a member of staff. We saw call bells were responded to in a timely manner.

The service worked with other organisations to ensure patients had continuity of safe care, both within the service and post discharge. Patients were discharged when their care needs could be safely met in the community and when a package of care was available. There were issues with discharging patients and obtaining packages of care within the community (please see the responsive section of this report).

There was a medical emergency policy which included responsibilities and procedures. In the event of an emergency staff would commence first aid or resuscitation and call 999. Resuscitation trolleys were maintained and checked daily. Staff were trained in basic life support.

Staff identified sepsis using the national early warning score chart and scoring which alerted them when to raise concerns and seek medical help.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained to the required level of safeguarding. Staff told us they knew who to contact if they had safeguarding concerns. There was a trust safeguarding team who supported and advised on any concerns. Staff could explain the safeguarding process and knew how to document any discussions. Safeguarding concerns were flagged on the providers electronic patient record.

Staff told us they had received training in the Mental Capacity Act and felt confident in supporting patients and ensuring decisions were made in their best interests. They explained mental capacity assessments were undertaken jointly, with two staff members involved in the process.

At the time of the inspection, four patients were subject to Deprivation of Liberty Safeguards (DoLS), which form part of the Mental Capacity Act 2005. DoLS authorisations are used when individuals require continuous supervision and control and are not free to leave the care setting.

We saw evidence the service made reasonable adjustments to policies to ensure individual patient needs were met. For example, one patient subject to a DoLS authorisation was permitted to smoke in the grounds outside their room, rather than leave the site, which would ordinarily have been required under the provider's policy.

65% of staff had undertaken non mandatory breakaway training, which included conflict resolution and was focused on the prevention and de-escalation of challenging situations rather than the application of physical restraint. There was 1 incident of a patient requiring restraint in the past year. We reviewed this incident and saw actions were taken.

Staff we spoke with demonstrated understood the Mental Capacity Act (MCA) and explained capacity assessments were decision-specific, rather than applied as a blanket judgement across all aspects of a person's care and treatment. We saw, as well as mandatory training, the service had run an additional MCA and DoLS education session for 1.5 hours in September 2025.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked effectively with people to understand their individual needs and provide care in a safe, supportive, and person-centred manner. Risks were assessed, documented, and managed. Patients told us staff kept them informed about their care and treatment, enabling them to feel involved in decisions and confident in the support they received.

Relatives we spoke with said they were actively involved in goal-setting meetings and care planning. Staff also supported relatives to develop the skills and knowledge required to care for their loved ones. This formed an important part of the rehabilitation process and helped ensure patients could be discharged safely with the right support in place.

People benefited from the expertise of a multidisciplinary team that worked collaboratively to meet their needs. This included medical and nursing staff, occupational therapists, physiotherapists, speech and language therapists, psychologists, dietitians, and discharge coordinators, all of whom contributed to the planning and delivery of care.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They mostly made sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean, well maintained, and suitable for the delivery of rehabilitation services. Patients had access to their own private bedrooms as well as an additional room used for therapy activities, which included a small kitchenette to support the development of independent living skills. Although the accommodation was functional and met patients’ needs, several relatives told us they felt the décor could be refreshed to create a more homely environment.

Patient rooms for people who were on a Deprivation of Liberty safeguard were alarmed to ensure a detained patient could not leave the unit unsupervised.

The service had sufficient and correct equipment to support the safe delivery of care and treatment. Equipment and stock were subject to regular checks and monitoring. We completed random checks of consumable items stored in patient rooms and clinical areas and found all items inspected were within their expiry dates.

Most electrical equipment had undergone portable appliance testing within the required timescales. However, we identified a small number of items overdue for testing. We raised this with the service during the inspection, and an onsite engineer tested the equipment promptly to ensure compliance and minimise any risk.

Fire exits were unobstructed and clearly signed throughout the hospital. There were fire safety arrangements, including personal emergency evacuation plans for patients who would require assistance in the event of a fire or other emergency.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had calculated the number and grade of nurses and healthcare assistants required and the service mostly met this number. There was a 4.72 whole time equivalent vacancy rate which were out for recruitment. The service used bank and agency staff to cover any shortfalls and additional staffing needs required for patient acuity. The nurse manager worked as part of the shift when required. There had been delays in recruitment due to lengthy financial sign off processes for staff, however the senior management team had discussed a lighter touch process to speed things up. This was due to the trust being under financial scrutiny. The senior management team were confident the delays were not having a direct impact on patient care.

There had been a significant improvement in staffing levels since December 2025, when the service experienced workforce challenges. As a result of successful recruitment, new staff had joined the service, particularly healthcare assistants, many of whom were new to both their roles and the rehabilitation setting.

The service had implemented an induction programme to support new staff and ensure they developed the skills and knowledge required to provide safe and effective care. This was complemented by a structured staff manual, which provided clear guidance on key processes, expectations, and rehabilitation practices, supporting both induction and ongoing professional development. The service had a dedicated clinical nurse educator who played a key role in supporting staff learning, competency development, and ongoing training needs. The clinical nurse educator’s time had recently been protected, allowing them to focus on education, supervision, and workforce development. This helped ensure staff received the training and support necessary to deliver rehabilitation care and continue developing within their roles.

Medical staffing had improved since the 2019 inspection. The service had a dedicated specialty doctor who worked alongside and supported the rehabilitation-accredited consultant. The service had met the UK specialist neurorehabilitation standards requirements to have a consultant in rehabilitation that led and supported the service. While there remained some vulnerability within the medical staffing model due to reliance on a single consultant, there were arrangements to maintain continuity of care. The service worked closely with the trust’s neurology team, which provided medical cover during periods of annual leave or sickness, helping to ensure patients continued to receive timely medical oversight and support.

Staff had received and were up to date with mandatory training. In April 2026 mandatory training was at 92.7% completion which exceeded the trust target of 85%. Staff told us they planned mandatory training into their timetables to allow sufficient time to complete it. They received email reminders when training was due to expire.

Staff sickness rates were below the trust target. The current sickness rate for staff was 1.4% which was significantly below the trust target of 4.7%.

Staff received regular appraisals. In May 2026 81.8% of staff had received an appraisal.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with agencies promptly.

Staff adhered to infection control principles, including handwashing. We observed members of staff washing hands. Hand hygiene monthly audit data between December 2025 and May 2026 exceeded the provider target of 85%, with the exception of April 2026 which fell just below at 82%.

We saw staff had access to personal protective equipment and used this correctly. Hand sanitiser was available to staff and visitors. Staff were audited to see if they complied with being bare below the elbow which helps to prevent the spread of infection. For the last 3 months of data, March 2026 to May 2026, staff were 100% compliant with this requirement.

All room and communal areas were clean, had required furnishings and were well maintained. We reviewed the ward environment daily cleaning checklist. Cleaning records were up to date and demonstrated patients’ flats were consistently cleaned. However, not all communal areas of the service were regularly cleaned daily. We observed the communal area was visibly clean on the day of inspection.

The trust conducted legionella audits. We reviewed the most recent legionella audit for the 2 weeks prior to the inspection and they were regularly completed.

Deep cleans were completed when a patient was discharged for each patient discharge in the 6 months prior to the inspection.

During the inspection, we found boxes were stored on the ground in the food storage room and cleaning cupboard. We escalated these concerns to leadership who took steps to find alternative storage for these items.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service had effective systems to support the safe management and handling of medicines. Processes ensured people received their medicines as prescribed and when required. The unit used an electronic prescribing system, which supported accurate prescribing, administration and record-keeping. Staff also had timely access to doctors and consultants, ensuring clinical advice and support was available whenever medication related decisions or interventions were needed.

Fridge temperature checks, room temperature monitoring and controlled drug stock checks were routinely completed and documented. Medicines were stored safely and in line with best practice. For example, the controlled drugs cupboard was secured with its own lock, and access to the room was restricted by a separate key. We checked a variety of items and all were within their use by dates. However, we identified the controlled drugs key was stored together with other keys for the unit rather than being kept on a single key ring, which is considered best practice. This was fed back to the provider during the inspection, and we observed the issue was addressed immediately.

Patients were supported to manage and take their own medicines where this was appropriate and in line with their individual needs and abilities. During our inspection, we observed a member of staff explaining to a patient how to use a dosette box, a medication management aid designed to help people take their medicines at the correct time. The staff member provided clear and patient-centred guidance and supported the patient to set an alarm as a reminder to take their medicines when due. This approach promoted the patient's independence while helping ensure medicines were taken safely and as prescribed.