Meadow Walk

Updated 26 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was undertaken by 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

This service provides care to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is rented and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care service.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A manager had been in post since February 2023 and had submitted an application to register which CQC rejected due to incomplete information being provided and a failure to respond to communication.

Notice of inspection

This inspection was announced. We gave the service 48 hours' notice of the inspection visit. This was because we needed to be sure that the provider or manager would be in the office to support the inspection.

Inspection activity started on 24 July 2023 and ended on 8 August 2023. We visited the location office at Housing 21 Meadow Walk on 24 July 2023.

What we did before inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We spoke with 6 people and 5 relatives about the service they were receiving. We visited the provider's office on 8 August 2023 and spoke with the manager, regional manager, and team leaders. We had contact with 5 care staff. We reviewed records that included 4 people's care plans, risk assessments and medicine administration records. We also looked at records relating to the management of the service, including policies and procedures, quality assurance systems, staff recruitment and training records.

Updated 26 September 2023

About the service

Meadow Walk is an extra care housing scheme for older people, comprising of individual flats in one large building. The scheme has some communal areas, and an onsite restaurant. People who lived at the service had a separate care and tenancy agreement. At the time of our inspection, the service supported 25 people with personal care.

People’s experience of using this service and what we found

Risks had not been assessed consistently placing people at risk of harm. Whilst people were supported by kind and caring staff, we received feedback that people did not always feel safe with the staffing levels, particularly overnight.

The provider's governance arrangements did not provide assurance the service was consistently well led. The systems and processes to oversee the quality assurance of the service were not robust and effective, as they had not identified the shortfalls we found during our inspection and regulatory requirements were not always being met.

Risk was not consistently and safely managed. Some relatives felt communication was not always effective between themselves and the management team at Meadow Walk.

Safeguarding concerns were reported to the local authority; however, improvements were needed to ensure these were always reported to CQC. Effective systems were in place to prevent and control the spread of infection.

People and their relatives told us permanent staff knew them well and were caring, kind and respectful.

Staff understood the importance of gaining consent from people and ensured people's privacy and dignity was respected. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 13 May 2021 and this is the first inspection.

Why we inspected

This was a planned inspection to check whether the provider was meeting legal requirements and regulations, and to provide a rating for the service as directed by the Care Act 2014.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.