Mardon Neuro-rehabilitation Centre

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

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 previous assessment, we rated the service as good. At this assessment, the service remained rated as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was good team working and culture within the service. Staff told us they enjoyed their roles and valued working within the service. Staff consistently described the team as supportive and collaborative, and said they worked well together to deliver patient care. The senior leadership team were visible, approachable, and fostered a positive working environment. Staff described an open-door culture and said they felt comfortable raising concerns, seeking advice, or discussing issues with managers.

We reviewed feedback from a speech and language therapist who had previously worked at the service. Their comments reflected a positive experience of working within the team. They stated: “I will forever be grateful for your time, your energy, all of the opportunities, for the patients allowing me to be part of their time and therapy, and for the welcoming, kind and simply wonderful team.” This feedback aligned with what staff told us during the inspection and demonstrated a culture of teamwork, support, and professional development.

The service had a clear vision and set of objectives focused on delivering high-quality, person-centred specialist neurorehabilitation to individuals with complex neurological disabilities. Staff understood and worked in line with this vision, providing goal-orientated multidisciplinary rehabilitation designed to maximise patients’ functional independence and participation in daily life. The service aimed to reduce long-term care needs and prevent avoidable hospital readmissions through effective rehabilitation and ongoing support. It also provided education, guidance and emotional support to patients, their families and carers to promote understanding, involvement in care and improved outcomes.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. The movement of the location from the acute trust leadership team to the community trust leadership supported the aims of the NHS 10 year plan to move care into the community.

Leaders had the appropriate skills, knowledge and experience to carry out their roles effectively and provide clear oversight of the service. They demonstrated a good understanding of the challenges facing the service and were able to identify key risks and implement measures to mitigate them. We observed proactive and responsive leadership that was focused on meeting the needs of both patients and staff. For example, leaders recognised the ongoing difficulties in discharging patients due to limited availability of community care packages. They had already identified this as a significant risk and, prior to our inspection, had taken steps to address the issue and minimise its impact on patient flow and continuity of care.

Development opportunities were available to staff. There was a clear progression pathway for healthcare assistants.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff said they were confident speaking to management about any concerns. The trust had freedom to speak up guardians and staff were aware of how to contact them.

Managers and staff had access to the feedback from patients, carers and staff. This was used to make improvements to the service as well as an opportunity to learn.

Staff were aware of discussions about the future of the service. Senior managers confirmed staff would be engaged and consulted in relation to future service delivery arrangements.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff demonstrated compassion and inclusivity in their approach to care and working relationships. This was consistently reflected across all staff groups, who described positive team working and mutual respect across disciplines, from consultants and nursing staff to healthcare assistants and domestic staff. Staff reported a strong sense of teamwork and collaboration throughout the unit.

Staff surveys were undertaken to gather feedback; however, due to the small size of the unit, anonymised results could not be reported at unit level. The community care group staff survey conducted in 2025 for the question ‘We are compassionate and inclusive’ achieved a score of 7.6, which was above the trustwide acute services score of 7.4, indicating a positive staff experience overall.

Staff were able to apply to work flexibly, there were flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers supported reasonable adjustments for staff members to help them carry out their role.

The provider undertook equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group, although this is carried out at trust level.

Staff reported initiatives such as the “Taste of…” events, where food from different countries was brought in for everyone to try, were very well received. In addition, both staff and patient BBQs had been organised. Feedback from staff about these events was highly positive, with many stating they helped bring the team together and created a welcoming, enjoyable atmosphere.

We scored the service as 2. The evidence showed some shortfalls. 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 some areas where governance processes could be strengthened. We found several items of equipment that had not undergone portable appliance testing within the required timescales. As a result, we were not assured there were effective oversight mechanisms to ensure all equipment received testing in a timely manner.

The service lacked clear arrangements for monitoring and allocating responsibilities when key staff were absent. For example, the ward housekeeper’s duties had not been formally covered during a period of sick leave. Staff told us, and we observed, that completed paper cleaning audits were stored in a stack on the individual's desk rather than being subject to routine oversight. A third-party audit undertaken on 21 May 2026 identified actions for follow-up by housekeeping staff. However, when we inspected the service on 11 June 2026, these actions had not been addressed, as the responsible staff member had been on leave and there were no effective systems to ensure continuity and oversight.

The electronic patient record system did not accurately reflect the position regarding delayed discharges. Service leaders were aware of this issue and had implemented a manual audit process to review patients who had been discharged. The service told us changes to the electronic reporting system were planned to improve the accuracy of discharge reporting, with implementation expected from September 2026. While leaders had recognised the issue and taken interim steps to mitigate the risk, the lack of reliable electronic data limited the service’s ability to maintain effective oversight of discharge delays.

The service had a clear governance structure. Rehabilitation units reported into the community governance group, which in turn fed into the performance assurance framework meeting. Information from the performance assurance framework was then escalated jointly to the patient safety committee and risk committee, with oversight ultimately provided by the trust board.

The service also operated a monthly speciality performance assurance group. This group was responsible for reviewing and understanding the overall position of the service across people, finance and performance domains. Areas reviewed included workforce metrics such as vacancy rates, staff turnover and learning arising from exit interviews. The group also monitored appraisal compliance, statutory and mandatory training compliance, sickness absence rates and any emerging themes.

The group reviewed operational performance, including waiting list management, the impact of waiting list validation activities and the number of patients meeting the ‘no criteria to reside’ position. These meetings took place monthly and provided assurance regarding service performance and areas requiring improvement or escalation. The service had a risk register, and staff were aware of the main risks to the service and how these were being mitigated.

The trust managed sickness absence fully in line with the Supporting Health and Wellbeing (Attendance) at Work Policy. This set out a clear approach to support colleagues when they were unwell. There were clear processes for reporting sickness, maintaining regular contact, undertaking ‘welcome back to work’ check‑ins, making timely occupational health referrals, and considering reasonable adjustments to help staff remain in or return to work.

We scored the service as 3. The evidence showed a good standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

The service worked with the wider healthcare system. The service used an electronic referral platform that had been implemented across Devon and Cornwall for all adult referrals to inpatient neurorehabilitation services. The system supported effective communication and sharing of clinical information between referring organisations and neurorehabilitation providers, helping to streamline referral pathways, reduce duplication and improve coordination between acute hospitals, neurorehabilitation units and community hospitals. There was a clear standard operating procedure to support the consistent use of the referral platform.

Service leaders worked collaboratively with a range of external stakeholders to promote equitable access to services. This included engagement with staff from other NHS trusts, integrated care boards, patients and carers. The service also benefited from well-established arrangements with partner organisations to provide specialist support. Psychological services were delivered by a neighbouring trust and were available 5 days a week. Staff had access to both acute and community dietetic services and told us these were responsive and readily available when required. Staff spoke positively about the support provided by external partners and described effective multidisciplinary working across organisational boundaries.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Learning was supported by an effective audit programme. The service used a trust wide accreditation programme to assess ward and departmental performance against a set of agreed quality standards and clinically sensitive indicators. The accreditation process was designed to provide an objective measure of performance while recognising frontline staff are often best placed to identify opportunities for improving patient care and service delivery.

The service had demonstrated sustained improvement over time, with accreditation scores showing a positive upward trend. The programme incorporated both staff and patient feedback, ensuring the views and experiences of those delivering and receiving care were used to inform quality improvement initiatives and drive service development.

Staff were encouraged to contribute ideas for change and innovation through a dedicated email mailbox and an improvement page on the trust’s intranet. These mechanisms supported an open culture in which staff were actively involved in identifying and implementing improvements to enhance patient care and the overall quality of the service.

Staff were actively encouraged to participate in learning and development opportunities to enhance their clinical knowledge and support continuous improvement within the service. Staff attended external conferences, seminars and specialist events and were expected to share learning with colleagues through feedback sessions and team discussions, helping to disseminate best practice across the multidisciplinary team.

We saw learning from the UK Acquired Brain Injury ‘Time for a Change Summit’ was shared with staff during a 1 hour session. The session was open to all healthcare professionals and provided an opportunity to discuss key themes, reflect on current practice and consider how learning could be applied to improve patient care within the service. This demonstrated the service’s commitment to promoting professional development and fostering a culture of shared learning.

Staff were supported through a comprehensive induction programme and ongoing clinical skills development. The service had a dedicated practice educator who provided support to all new starters during their induction and also delivered education. Staff could access individual support to address specific training needs or concerns, as well as participate in group learning sessions covering a wide range of topics. In addition, staff had access to multidisciplinary team education sessions, clinical skills training, and regular drop-in sessions to support their continued professional development.