Meadows Edge Care Home

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

People did not always have all the information in their care plans to guide safe practice. Risk assessment did not always contain information on how outcomes had been decided. Additionally, it was not always clear in some risk assessments what the outcome was and how staff were to support that person to keep them safe. Incidents were not always recorded because staff had not reported them in a timely manner. This also meant opportunities to learn from incidents had been missed. Some areas of concern that had been previously identified in the environment had not been addressed appropriately. The provider had locked rooms including bedrooms, bathrooms and toilets which meant there was a limited amount of bathing facilities in use. The environment did not support the care and support needs of people who used the service and put some people at increased risk of neglect.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most relatives we spoke with told us they were not involved with their family member’s care and support reviews and had not received much feedback from the service. An unexplained injury that had been noticed on a person had not been thoroughly investigated and relatives told us they were unsure of what actions the service had taken to keep their family member safe.

Incidents were reviewed and discussed with staff at monthly meetings. However, there was no evidence staff received post incident debriefs soon after incidents which would increase their effectiveness to identify and minimise risk to people and staff. Following the assessment the provider shared that incidents are discussed at staff handovers. However there remained missed oppurtunities for staff to learn and for service improvements following incidents.

The provider had systems for investigating complaints and other adverse events, however concerns had not always been fully resolved or responded to. We saw the records of some incidents and how issues had been resolved. There was some evidence of discussions during staff meetings and meetings called Flash meetings to share learning.

We looked at a recent event where a person had been supported when moving between different services. Staff had worked with other professionals to support the continuity of care. A relative had been happy with the care and support their family member had received. They told us there had been conversations in the home about their family member’s care and support needs when they first arrived.

Staff worked with external professionals to ensure safe transitions. This support enabled people to make transitions between other services when required. A nurse told us they would speak with people in regards to their care planning and if they were unable to contribute they would speak with relatives to ascertain information.

People’s care and support needs were reviewed; however, it was not always clear if they reflected people’s current needs. A professional told us they had been working with the home to help them understand that care plans should be open documents as things could change. Staff ensured they attended meetings in relation to a person’s care and support needs. A professional told us staff were involved in discussions to support a person to safely return to the home.

Systems were in place to ensure the continuity of safe care, however it was not always clear if these were always effective. Staff completed an assessment of people's needs before they started to provide care and support, however we noted that important details relating to people’s diagnoses were not always known. For example, staff did not know what type of epilepsy people had, with 1 staff member telling us they were not aware a person had epilepsy.

Most relatives told us they thought their family members were safe but there had been times some relatives had raised concerns. We looked at a particular concern raised and could see this had not been fully investigated or resolved to ensure a person’s safety.

Staff told us they had undertaken training in safeguarding and were generally able to explain how to recognise and report abuse. However, some staff told us they were not confident in raising concerns if they felt they needed to.

A board was displayed in the home with information on how to raise concerns although there was no accessible information available for people who required information in a simpler format or if English was not their first language.

The provider’s safeguarding log was not up to date with incidents they had identified as needing to be referred to the local safeguarding team. People were not empowered to raise concerns about their care and treatment. For example, it stated in 1 person’s care plan they could say things which were not true. It did not state that allegations should be taken seriously and what procedures staff needed to follow if the person raised concerns. This made the person more vulnerable to abuse. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, this is through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA. When people were assessed as lacking mental capacity for certain decisions, staff recorded assessments and any best interest decisions made. However, we were not assured staff had reviewed people’s capacity to ensure they were still able to safely make decisions about their care and treatment. DoLS applications were applied for and people were lawfully deprived of their liberty following an application and authorisation to relevant authorities to restrict their freedom. However, we found that a person had been waiting a long time to be assessed which had not been followed up by the provider. This meant the person was in a vulnerable circumstance without legal protection for an extended period.

Care plans did not always contain specific information for the person including when people were living with diabetes or epilepsy. Following feedback, the provider created specific care plans, however these did not contain all the relevant personalised information to ensure staff knew how to support those people safely. Most relatives told us they were not part of the care planning process or their medicine reviews. Relative meetings had also not gone ahead as planned.

Care staff told us staffing levels were good and they were able to meet people’s care and support needs. Some of the clinical staff said that they were frequently expected to work more than their contracted hours to ensure all shift were covered, this was to cover staff holiday and sickness.

We observed staff supporting people to eat their lunch when they needed support, however we saw a staff member continually overloading a spoon when supporting someone to eat which meant mealtimes were seen more of a task than an experience to be enjoyed. Staff supported people safely in line with their care and support needs when mobilising, for example, we saw a staff member supporting someone with their walking frame to ensure they were safe.

Some risk assessments stated that people had been consulted, however there was no evidence around what had been discussed, whether they agreed with the outcome of the assessment or if they had been involved in any decisions relating to their care and treatment. Risk assessments were sometimes vague with no clear conclusions around how to mitigate any identified risk. Furthermore, there was no signposting to relevant parts of people’s care plans for staff to find that information.

Most relatives told us the home was clean, however relatives also said it required updating. A relative told us it had been painted in areas which had helped to brighten the place up.

The managers told us there were plans to continue renovations, although these were on hold. We requested a copy of the ongoing improvement plan to see what renovations had been identified including in the locked rooms, however this was not provided. Following the assessment the provider share with us Plan of renovation. However there were no time scales attached. A manager told us that most people including the people on the first floor requested a shower and there had been no issues with people accessing the shower when they wanted one. However, we found that at least 1person were resistant to personal care with it not being considered that the environment may have been contributing to this. During the assessment people were moved from the first floor to the ground floor, closer to the shower. The provider shared after assessment that there remained some resistance to care.

The home appeared clean with no malodours in the areas we observed. There had been past concerns relating to the condition of the building which had resulted in the provider locking many bedrooms, bathrooms and toilets in the building. This meant there was only 1 shower in the building and 1 bath that was accessible for people with mobility needs on the ground floor. On the first floor, there was 1 toilet and 1 bathroom which included a bath and toilet that was not accessible for people with mobility needs. The environment did not suit the needs of the people who were living on the first floor which had put them at risk of neglect. Following feedback, the provider told us they had moved the people onto the ground floor, however it was unclear whether people had been consulted in that decision or if they had consented. Most people’s rooms did not have ensuite facilities with people having commodes in their room. Some bedrooms were very small, and we observed a commode tightly left next to a person’s bed which was undignified and unhygienic. The environment had not been made safe from additional risks. We observed a packet of razors in the back of a wheelchair and another pack of razors left on a linen trolley. These were brought to the attention of the manager who told us they had now created a signing in and out sheet for razors to minimise the risk of this happening again. The building had been adapted into a care home but remained quite clinical with long corridors that could be confusing to navigate. There was no signage to help orientate people to support them to maintain their independence. It was not always clear what was behind doors, for example there were no signs on the shower room and on the laundry doors. Most people living at Meadows Edge Care Home were unable to ensure their own safety which put them at increased risk of harm.

A maintenance log was used to report any ongoing maintenance issues that staff had identified. These showed when issues had been rectified and who completed the work. We saw in some records that nurses and housekeepers had completed some maintenance, however it was not evident whether there had been arrangements to ensure any repairs completed by non-maintenance staff were checked over to ensure they were safe. For example, a nurse had fixed a broken bed rail but there was no record of whether this had been inspected to ensure it was now safe to use. We saw from records that health and safety checks had been completed monthly for window restrictors and tall furniture to ensure these were fixed to the wall to prevent accidents.

People we spoke with told us staff were kind and helped them when they needed it. Relatives told us there had been improvements and the ambience of the place had changed which was positive. Most relatives told us they thought there were enough staff to meet people’s needs however, some relatives said this was just basic or adequate care and believed staff could be doing more to support people’s social needs as there were no activities on offer.

There was mixed feedback with regards to staffing. Some staff told us there were times they were unable to fulfil their role because of additional work. Other staff told us they were currently working more hours to cover shortfalls which they did not want to do. Some staff were positive about the staffing numbers and felt they were able to carry out their roles and deliver timely care. Staff told us they worked together when it was busy or if people required the support of 2 staff members.

We saw that whilst staff were present in communal areas at other times, they were not always well deployed. For example, there were long periods of time when no one was engaging with people using the service because the staff were attending to other tasks. Additionally, it was not clear how much staff engagement people got when they were in their bedrooms, especially when bedrooms were located in quieter areas of the home.

The provider has a condition on their registration to ensure a clinical lead is physically present for 30 hours a week. We could see from staff rotas the clinical lead had minimal hours where they were able to solely complete their role without extra responsibilities including training new nurses and working in a registered nurse role. This meant there had not been appropriate clinical oversight to ensure duties were achieved accurately, efficiently, and timely alongside records being completed and accurate. Additionally, the clinical lead had not received supervisions as there was not an appropriately qualified staff member appointed in the home to oversee and support them in their clinical lead role. From records we could see some staff had received supervisions in line with the providers policy which was 2 supervisions a year. However, 1 supervision was individual, and another conducted as a group supervision which meant there was less time devoted to the staff members individual development needs. Staff had been recruited safely. There were effective systems in place to complete checks before staff started work at the service to make sure they were of suitable character to work with people. The provider carried out Disclosure and Barring Service (DBS) as part of their recruitment process. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The record of staff training indicated there were effective systems to ensure staff had completed training relevant to their roles.

Most relatives told us they thought the home was clean and well-maintained but that it required updating. One relative told us, “It is clean and well-maintained but needs a lot doing to it.” Some relatives told us they had seen some improvements.

A housekeeper told us cleaning schedules were in place and followed by staff. They explained that deep cleans took place daily which meant they would concentrate on 1 person’s room to ensure they were well cleaned.

The building was not always well maintained. Some carpets showed wear and damage. There was an unpainted area in a toilet under a soap dispenser and crumbling plasterwork under a radiator. This meant these areas could not be sufficiently cleaned and there was a risk of harbouring bacteria. Several rooms had been locked where we had raised concerns in past inspections regarding infection, prevention control and the condition of the building. These included bedrooms, bathrooms and toilets. We observed the environment we could access to appear clean with no malodours.

We discussed some of the building issues with the management team and requested their improvement plan to show what renovations had been identified to improve the condition of the building and the locked rooms. However, this was not shared so we were unable to establish if there were plans in place to make these improvements with timescales for how long that work would take. The head housekeeper completed regular audits of the environment where areas of improvements had been identified. However, these audits had not highlighted the areas of concern we had found. The head housekeeper also completed mattress audits to identify mattress covers and mattresses that were in poor condition as these can be a source of cross-infection. We could see actions had been taken when mattresses had been found not to be in good condition.

We received mixed feedback in relation to people’s medicines and treatments. Some relatives told us they were not involved in medicine reviews and were unaware of changes that had been made to their family member’s medicines. Other relatives explained they had been involved in medicine reviews or had been invited to start being a part of the reviews. Medicines were given to people in a person-centred and caring way. Staff had access to people's allergy status and preferences on how they liked to take their medicines.

Staff were trained in medicines administration and were regularly assessed for their competency to ensure that they could safely administer medicines. Changes in treatment plans were documented in people’s care plans.

Care plans did not always contain sufficient information for staff to support people with complex conditions such as diabetes and epilepsy. This meant that there was a risk that adverse events would not be managed appropriately. We discussed this with the manager during our assessment and amendment were made to included information on diabetes and epilepsy. When people were prescribed as and when required medicines (PRN), guidance did not always contain person-centred information to support staff on when to administer these medicines. For example, we looked at the PRN protocols for 2 people prescribed pain relief who were unable to communicate verbally. Staff were referred to use a ‘facial grimace scale’, however staff were unaware of this tool. This meant there was a risk that people would be left without adequate pain relief. We looked at records for 1 person who was administered their medicines through a feeding tube placed through the skin directly into the stomach. There was no information available from a healthcare professional on how these medicines should be administered safely. Medicines including controlled drugs which are medicines requiring additional control due to the potential for misuse, were stored safely and securely.