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Archived: Meadow Green Requires improvement

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 September 2016

This inspection took place on 29 June and 12 July 2016. The visit on 29 June 2016 was unannounced and the visit on 12 July 2016 was announced.

We previously inspected the service on 08 and 10 January 2016 and at that time we found the registered provider was not meeting a number of Health and social Care Act regulations relating to person centred care; consent; managing risk; managing medicines; good governance and sufficient staffing, as well as failing to notify the Care Quality Commission (CQC) of safeguarding incidents or allegations.

After the last inspection we issued a warning notice for Regulation 17, good governance and told the registered provider to make improvements. The registered provider sent us an action plan telling us what they were going to do to make sure they were meeting the regulations. On this inspection we checked to see if improvements had been made.

Meadow Green is an extra care housing scheme registered to provide personal care, consisting of 53 one or two bedroom flats. People who live at Meadow Green have their own tenancies. The service also includes Meadow Green Lodge, a separate building of 10 flats which delivers specialist support to people living with Dementia. The extra care scheme has on-site care staff 24 hours a day. The building has an alarm service, lift, lounge, restaurant, garden, an activities room and hairdressing salon. The building is owned by Kirklees Council and managed by Pinnacle Housing, who were responsible for the alarm call system, cleaning, maintaining and security of the building and grounds. At the time of our inspection 29 people were receiving support with personal care.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The current manager had commenced employment with the service in April 2016 and had applied to register with CQC. At the time of this inspection the application had not been finalised.

People who lived at Meadow Green told us they felt safe and said the service had improved greatly in recent months.

The registered provider showed us they had safe recruitment and selection procedures in place and vetted staff before they commenced employment with the service. However, the registered provider had not referred two staff members who were dismissed in November 2015 to the Disclosure and Barring Service (DBS) until May 2016. The DBS helps employers make safer recruitment decisions and reduces the risk of unsuitable people working with vulnerable groups. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, fit and proper persons employed.

Staff had a good understanding about how to safeguard adults from abuse and who to contact if they suspected any abuse.

Individual incidents and accidents were analysed and measures put in place to reduce future risks to people. Risk assessments minimised risk whilst promoting people’s independence.

There were enough suitably trained staff to meet the assessed needs of people who used the service.

Medicines were managed in a safe way for people, although some gaps in recording had not been addressed through the audit system of the service.

Staff had received an induction, supervision, appraisal and specialist training to enable them to provide support to the people who used the service. This ensured they had the knowledge and skills to support the people who lived there.

People’s consent was sought when decisions needed to be made. The registered provider was seeking clarification regarding responsibilities for Mental Capacity Act (2005) assessments and showed us evidence capacity was being considered when decisio

Inspection areas

Safe

Requires improvement

Updated 20 September 2016

The service was not always safe

The registered provider had not always followed safe recruitment practices.

Staff had a good understanding of safeguarding adults from abuse

Identified risks to people were managed well.

Medicines were managed in a safe way for people, although there were gaps in recording.

There were enough suitably trained staff to meet the assessed needs of people who used the service.

Effective

Requires improvement

Updated 20 September 2016

The service was effective.

People�s capacity to consent was considered when decisions needed to be made, but records did not always show this in line with legislation.

Staff had received specialist training to enable them to provide support to people who used the service.

People were supported to eat and drink enough and maintain a balanced diet.

People had access to external health professionals as the need arose.

Caring

Good

Updated 20 September 2016

The service was caring.

Staff interactions with people were supportive, caring and enabling.

People were supported in a way that protected their privacy and dignity.

People were supported to be as independent as possible in their daily lives.

Responsive

Good

Updated 20 September 2016

The service was responsive

Care was planned to meet people�s individual needs and preferences.

People and their representatives were involved in the development and the review of their support plans.

People told us they knew how to complain and told us staff were always approachable.

Well-led

Requires improvement

Updated 20 September 2016

The service was not always well led.

The registered provider had not notified CQC of all safeguarding incidents.

The registered provider had a system in place to assess and monitor the quality of service provided, however this had not addressed the problems we found with accurate and up to date records.

The manager was visible in the service and knew the needs of the people who used the service.

Incidents and accidents were analysed across the service for lessons learned.

The registered provider sought feedback from people who used the service, relatives and staff to improve the quality of the service provided.