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Inspection Summary

Overall summary & rating


Updated 16 September 2017

This inspection took place on 1 and 2 August 2017 and was unannounced. This meant the registered provider and staff did not know we would be visiting the service. At the time of our inspection 29 people were living in the home.

Meadowbrook Manor is registered to provide accommodation for a maximum of 31 people who require personal care to adults aged 65 and over. It is located in a residential area close to Garforth town centre, near Leeds and is near to local amenities.

The home is an adapted three story building and there is a passenger lift to access all the floors. Externally there is parking for a limited number of cars. There was a large lounge and an open plan dining area on the ground floor. The home also had another lounge on the first floor which included a hair dressing salon and sofa’s to relax. This was a functional room for people to have their hair done or for when family’s had parties.

There was a registered manager at the home and a deputy manager. A registered manager is a person who has registered with the CQC 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.

At the last inspection in August 2016 Meadowbrook Manor were rated as requires improvement due to concerns over medicines management and issues in relation to the operation of the quality assurance systems as accidents and incidents were not being effectively monitored. At this inspection we found that these concerns had been addressed.

Medicines were managed effectively and all medicines stored correctly in line with the providers policy.

Accidents and incidents were managed well with actions taken when required and there was a policy with guidance for staff to follow should an incident occur.

People using the service felt safe and staff had a clear understanding of how to protect people from any harm. Staff were provided with annual safeguarding and whistleblowing training.

The provider completed appropriate checks to ensure the safety of the premises.

Staffing levels were adequate to meet people’s needs and recruitment checks were carried out to ensure people were not placed at risk.

People using the service were met by staff who clearly communicated with them on all aspects of their care.

Mental capacity assessments were completed for people however, we saw on one occasion documents had not been recorded in line with the MCA principles.

We found that one of the DoLS applications had expired on 7 April 2017 but had not been renewed until 21 June 2017. This meant that the person may have been unlawfully restricted as there had been no DoLS in place for a period of 10 weeks and the application process had not been completed.

Maintenance logs were used to identify issues regarding the upkeep of the environment or premises, although dates were not always recorded for completion.

Staff were provided with adequate training to do their job. Supervisions and appraisals were also completed to ensure staff could develop their skills and be managed effectively.

People told us they enjoyed the food, were encouraged to make choices about what they ate and drank. Fridge temperatures were not always completed.

Monthly weight monitoring records were in place. Staff informed us nutritionists and dieticians were contacted should a person require further support. Other health care professional’s visited the home when there was a need.

People using the service and their relatives felt staff were caring and friendly. Staff had built positive relationships with people and involved them in all aspects of their care.

Staff respected people’s privacy and dignity. We saw people’s diverse needs were catered for and care planned for these. People using the service were encouraged to be independent and risk assessments completed to make sure people were safe.

People were included in the care planning process and initial assessments were completed with reviews of people’s care carried out. Activities were provided to promote peoples wellbeing.

Complaints were managed well and actions taken when needed. Staff and people using the service felt confident to complain if required.

People using the service and staff spoke positively about the management arrangements in place at Meadowbrook.

Policies and procedures were in place and updated to ensure staff followed relevant and up to date practice. The provider carried out a variety of audits to ensure people using the service were safe.

The provider used questionnaires, surveys and meetings to receive feedback about the service and to monitor the quality of the service provided to help learn and develop the service.

Inspection areas



Updated 16 September 2017

The service was safe.

Medicines were managed safely.

People were protected from the risk of avoidable harm or abuse. The provider had effective systems in place to manage any safeguarding concerns.

Risk assessments had been completed and regularly updated when needs changed.

Pre-employment checks on employees were completed that helped to minimise the risk of unsuitable people working with vulnerable adults.



Updated 16 September 2017

The service was effective.

Staff received an induction and on-going refresher training to enable people to be up to date with their practice.

People were supported to access health care services and received appropriate support with their nutritional needs.

For the majority of people, the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were met.



Updated 16 September 2017

The service was caring.

People were treated with care, compassion, dignity and respect. Interactions demonstrated positive relationships had been developed with people by staff.

People’s care records detailed their wishes and preferences around the care and treatment provided.

People were encouraged to be as independent as possible.



Updated 16 September 2017

The service was responsive.

People's needs were assessed and appropriate care plans were in place. These contained information about people's individual needs and were regularly reviewed.

People had access to a range of activities that they told us they enjoyed which help to promote their general well-being.

The registered provider had a system in place to manage and respond to complaints.


Requires improvement

Updated 16 September 2017

The service was not always well led.

We found minor recording issues which included capacity assessments, one care record, fridge temperature records and maintenance logs.

People were satisfied with the service they received and their views were sought.

The service was monitored, when shortfalls were found action was taken to maintain or improve the service.

The registered manager reported accidents and other notifiable incidents that occurred to the Care Quality Commission.