The Mead

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to providing safe care and treatment effective management of risks and the way people’s medicines were managed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not consistently exhibit a proactive and constructive safety culture defined by transparency and integrity. Incident records showed that while events were reported, the documentation regarding follow-up actions and lessons learned at times lacked clarity. Details recorded at the time of incidents were occasionally inaccurate, and risk assessments demonstrated inconsistency, which potentially increased risks for people. The management team had not previously identified these inconsistencies; for example, one report indicated a person was found in one area, but this changed later in the report. During our feedback session, we brought these concerns to the attention of the management team, who told us they would review this process.

The provider did not consistently work with people to ensure safe care systems or monitor safety effectively, and some care plans contained conflicting information. The manager was aware care plans needed to be reviewed and updated. Staff worked with relatives and other health professionals to make sure people moved safely between services. They also worked closely with GPs and district nurses to help keep people safe. People and their relatives said they got healthcare support when they needed it.

People were protected from the risk of abuse, neglect and discrimination. Safeguarding policies were in place and staff had completed safeguarding training. The provider had safeguarding systems and processes in place to ensure compliance with statutory requirements and to protect people from abuse and neglect. We saw evidence that safeguarding concerns were logged and actioned in a timely manner, and referrals were made to the relevant professionals.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that appropriate processes and procedures had been followed to ensure people were not unlawfully deprived of their liberty.

Risks to people were not always considered, assessed, or planned for to ensure they received care safely. Although risk assessments were in place, they did not always contain accurate or up-to-date information. Risk assessment was at times inconsistent and did not provide staff with the correct information to care for people. For example, one person’s risk assessment stated their catheter bag needed to be changed on a Saturday, whilst another stated it was on a Tuesday. In one person’s falls risk assessment, we read that they always required supervision, but later it stated they “mobilised independently without a walking aid”.

If people had specific health conditions, there was not always enough information to guide staff in caring for the person.

People had a personal emergency evacuation plan (PEEP) in place, which took into account the person's comprehension and ability to take appropriate action in the event of a fire.

The provider detected and controlled potential risks in the care environment. They ensured that equipment, facilities, and technology supported the delivery of safe care. People told us the care home was a comfortable place to live.

The care home was “tired” in places and would benefit from some upgrading, as paintwork was marked and carpets were stained. At times, we identified some malodour, but staff were proactive in addressing this.

The kitchen areas were unclean in places and some dishwashers needed to be cleaned. We identified large areas where limescale was an issue particularly in bathrooms, however, senior staff were aware and were trying to identify a product that they could use safely.

The provider had a health and safety policy in place, and there were processes and checks in place to help ensure a safe environment for people, staff, and visitors. These included gas, water, and fire safety checks.

The provider did not always ensure there were enough qualified, skilled, and experienced staff. Staff deployment was not always effective to meet people’s needs safely. During the site visit, staff were at times rushed including a breakfast and there were periods in communal areas when people did not receive prompt support. We raised this with the home manager who agreed staff to deployment needed to be reviewed. The provider used dependency assessments to monitor staffing levels.

Staff received training and supervision relevant to their roles. Some staff had not completed some of their mandatory training, this was brought to the attention of the home manager.

Recruitment processes were safe and included background checks to confirm staff were suitable to their role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading, and shared concerns with appropriate agencies promptly. Policies, procedures, and areas of training were in place to guide staff in infection prevention and control, as well as food hygiene. Designated staff were responsible for cleaning the home each day. Staff wore personal protective clothing when assisting people with aspects of their care. Items were cleaned away and disposed of properly. A food hygiene inspection was undertaken in October 2025; the service was awarded a hygiene rating of 5 – very good.

The provider did not consistently ensure the safe management of medicines. Protocols for administering as-required (PRN) medicines were sometimes inaccurate, and records showing the reasons and times for PRN administration were not always complete.

Procedures for handling medicines that require refrigeration were also inconsistent, especially when fridge temperatures fluctuated outside recommended limits. Although staff routinely recorded refrigerator temperatures, they failed to follow policies by reporting problems when temperature excursions occurred. From reviewing the records on site, we identified that the minimum refrigerator temperature dropped below 2 degrees Celsius, creating a risk of freezing medicines such as insulin and potentially reducing their effectiveness and increasing harm. Despite these risks, medication was still given to one person. This issue was reported to management, who took prompt action.

Medicine training was not up to date, as only 73% of staff were current with mandatory medicines training.

Staff interviewed demonstrated an understanding of safe prescribing, supplying, administering, and storing of medicines. They stated they had received training in medicine administration, although not all staff were current with their training. The manager was actively working with staff to ensure training requirements were met.