Archived: The Meadows Care Home

The Meadows Care Home is registered to provide nursing or personal care for up to 69 people, some of whom may live with dementia. At the time of our inspection there were 46 people living at the home, 19 of whom required nursing care.

A registered manager was in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (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 of the home in March 2016, we asked the provider to take action to make improvements. This was because we found the provider had breached a number of regulations. We found the quality of the service had not been monitored effectively to ensure issues relating to people's care and welfare were identified and investigated in a timely manner. Staffing levels were not sufficient to safely meet the care needs of the people who used the service. Staff did not always have the time for meaningful one to one contact with people. There was a lack of continuity of qualified nursing staff. The registered provider was not following the requirements of the Mental Capacity Act (MCA) 2005 to support people to make decisions about their care. Some decisions had not been made in line with the MCA, such as for the administration of medicines covertly and the use of bedrails to keep people safe. People had been placed at increased risk due to staff not following the advice of health care professionals. Systems and processes to maintain complete and accurate care records were ineffective. Safe recruitment practices had not been followed. People were not supported to ensure their nutrition and hydration needs were met in a dignified manner. The meal time experience lacked co-ordination and was disorganised. People's food and fluid charts were not always completed or accurate.

During this inspection we found the provider had made improvements in some areas. The overall rating for this service is now ‘requires improvement’ so the service is no longer in special measures. We have made recommendations about the management of some medicines, dining arrangements, the specialist needs of people with dementia, activities and quality monitoring.

People said there was enough staff on duty, but relatives and some staff we spoke with felt more staff were needed. Since the last inspection the provider had recruited more nursing staff so there was now continuity of nursing staff.

Staff did not always have time to spend on a one to one basis with people. During this inspection we found this had not improved. We observed some occasions when staff spent some time on a one to one basis with people, but this happened infrequently as staff were mainly busy elsewhere.

Improvements had been made to the arrangements for people who required specialist diets. People with nutritional needs such as swallowing difficulties had a specific care plan about how they should be supported, which was shared with care and kitchen staff. People who required pureed foods were served these in a more attractive way than previously.

Improvements had been made to the safeguards that were in place for people who did not have capacity to make some significant decisions. People were encouraged to make their own day to day choices. The registered provider was following the requirements of the Mental Capacity Act 2005 (MCA).

People were supported to access health services when they needed these, but not everyone had a health action plan in case of emergency treatment.

People told us they felt safe at The Meadows. One person told us, “I feel as if I’m at home.” People spoke positively about the caring nature of staff. One person said they were “very happy” with the care they got and that “The girls couldn’t be nicer. They are very helpful and very kind.”

A relative told us, “We’re really happy with [family member’s] care. They’re very happy here. The staff treat [family member] like one of their own.”

Staff received training, supervisions and appraisals to support them in their job role.

Care records we viewed had been rewritten since the last inspection and showed people’s current individual needs. These were reviewed and updated regularly or when people’s needs changed.

People, relatives and staff had regular opportunities to provide feedback although it was not always clear what action had been taken as a result.

The provider’s quality monitoring processes had led to some improvements since the last inspection, but there were still areas for improvement.

The Meadows Care Home is registered to provide nursing or personal care for up to 69 people. At the time of our inspection there were 66 people living at the home, some of whom were living with dementia.

The home did not have a registered manager. The manager at the time of our inspection had applied to register to become the registered manager with the Care Quality Commission. The application was granted shortly after the completion of our inspection. 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.

During this inspection we found the registered provider had breached regulations 9, 11, 12, 14, 17, 18 and 19. Due to a lack of management oversight the quality of the service had not been monitored effectively to ensure issues relating to people’s care and welfare were identified and investigated in a timely manner. Staff had not followed some policies and procedures and important aspects of the service were overdue, such as the deployment of a consistent staff team. Care staff and family members described a “divided home” following the admission of a number people from a different home. The dependency tool used to determine staffing levels was based on inaccurate information. The registered provider had not acted on the findings from quality checks carried out by the local authority commissioners. Systems and processes to maintain complete and accurate care records were ineffective.

There were shortfalls in the numbers of staff deployed to keep people safe and meet their needs in a timely manner. Some family members and care workers gave us negative feedback about staffing levels in the home. One family member commented there was a “shortage of staff, they don’t have a full quota of staff”. One care worker commented, “There is a lot of time when we are seriously under-staffed. We see some people [staff] are really down, on the point of leaving. If staff are on edge, residents are on edge. They can get quite aggressive.” We observed throughout the four days of our inspection people were regularly left alone and unsupervised in communal areas. There was a lack of continuity of qualified nursing staff with seven different agency nurses working at the home during the four days of our inspection.

Records showed that people had been placed at increased risk due to staff not following the advice of health care professionals. Care documentation lacked sufficient information to provide staff with guidance on meeting people's individual needs. Safe recruitment practices had not been followed particularly in relation to carrying out risk assessments to confirm staff were suitable to work with vulnerable people.

People were not supported to ensure their nutrition and hydration needs were met in a dignified manner. Some people had to wait a long time, often in wheel chairs, before receiving something to eat. One person did not receive the consistent one to one support they needed. Staff were not always proactive in offering help and support to people. The meal time experience lacked coordination and was disorganised. People's food and fluid charts were not always completed or accurate.

The registered provider was not following the requirements of the Mental Capacity Act (MCA) 2005 to support people to make decisions about their care. Some decisions had not been made in line with the MCA, such as for the administration of medicines covertly and the use of bedrails to keep people safe.

The registered provider did not have effective infection control procedures. We saw pull cords in bathrooms were not plastic coated so they could not be wiped clean to reduce the risk of infection. During our inspection we detected unpleasant odours in areas of the home. We found these were present throughout the four days of our inspection.

Information was not always provided in appropriate formats to help people make choices. We asked one care worker whether information was appropriate. They said, “It probably isn’t.” They acknowledged “pictures could also be useful” to help people with making their own choices about what they would like to eat. Staff did not always have the time to have meaningful one to one time with people. One care worker said, “Staff feel quite stressed. It is quite a rush, we have no time for one to one conversation.”

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

People told us they received good care from kind considerate and caring staff. One person told us, “It is very, very nice. If I looked around I wouldn’t find a nicer home.” One family member commented, “Yes, definitely well cared for. Brilliant, fantastic like home from home.”

Staff knew how to report safeguarding and whistle blowing concerns. They said they would report concerns straightaway. One staff member told us, “Hand on heart I have never seen anything bad. They would be quite quick to deal with anything like that. They deal with things quickly.”

The registered provider carried out health and safety checks which were up to date at the time of our inspection. One care worker commented, “[Staff] conform to the health and safety rules, we are not allowed to get away with not following the rules.” Incidents and accidents were logged with details recorded of any action taken to help keep people safe.

Most care workers told us they felt supported working at the home. One staff member commented, “The manager is excellent, he is a lovely bloke.” Training was up to date and recent supervisions had been carried out. Appraisals were overdue for all staff.

There were opportunities for people, visitors and family members to give feedback about the home through attending relative’s meetings or using the online feedback system located in the home. One family member said, “We go to relative’s meetings to find out what is going on with the home. We can put our concerns across. If we have anything to say we just say it.” Most anonymous feedback provided had been positive.

The registered provider had a complaints procedure which people and family members knew about. One family member said, “I know about the complaints procedure. I haven’t got one complaint.” There had been no formal complaints received.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We carried out the visit at 5.45am to see if people were up. We found none of the people who lived at the home got up until they were ready for breakfast. Some people got up independently at their own choice. Other people were supported to get up and dressed when they awoke around 8am. Some people were still in bed at 9am because they had chosen to have a lie-in and their choice was respected by staff.

We found there were enough staff on duty during the night to support people with their individual needs. Night staff carried out between two and four shifts each week. There was no occasion in the past month when night staff had worked for more than four nights without a break. Equipment was available in the home to meet people's individual mobility and continence needs and staff were using these in the correct way.

We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found. If you want to see the evidence that supports our summary please read the full report.

Is the service caring?

People were supported by calm and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. Visiting relatives described staff as 'caring' and 'lovely with people'.

In discussions staff were knowledgeable about people's individual needs and preferences and were respectful of their diverse needs. A visiting relative told us, 'The staff are very patient with people, even those who can become aggressive.'

Our observations of the care provided and discussions with people showed us that individual wishes for care and support were taken into account.

Is the service responsive?

There was a visible staff presence throughout the home so that staff could support and supervise people when needed. The call alarms were responded to promptly so people got support in a timely way.

The home had an activities staff who arranged games and social events which helped to keep people active and involved. A visitor told us, 'The activity staff is very good and always encouraging them to get involved in something.'

People and visitors told us they could approach the manager at any time if they wanted to discuss anything and felt they were listened to. One person told us, 'I could tell her anything and have confidence that she would put it right.'

Is the service safe?

People told us they felt 'safe' at the home. One person commented, 'It's very safe and I can rest easy that my relative is well looked after.'

People were treated with respect and dignity by the staff. The premises were well maintained and clean. Equipment was regularly serviced and the health and safety records were up to date. These checks meant that people were not placed at unnecessary risk.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The manager understood the home's responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The manager was aware of the recent court ruling regarding DoLS in care settings, and training from the local authority was planned for the near future.

Is the service effective?

People all had an individual care plan which set out their care needs. People felt the service met their needs. One person told us, 'The staff stability and consistency has improved so they get to know each person's needs.'

Relatives felt the service met people's individual needs. One person told us, 'They are really skilled at dealing with challenges and complex situations.'

We found that people of varying needs and conditions were well cared for and that their care and treatment was being delivered in line with their needs and planned care. We saw that relevant research and guidance was being successfully applied and that changes in people's needs were dealt with swiftly and efficiently.

Is the service well-led?

The home had had several managers over the past two years. The current manager had applied for registration. People and their visitors told us they had confidence in the current manager and felt she had made 'huge improvements' over the past three months to the service provided at this home. People, visitors and staff told us the manager was 'very open' and 'very approachable'.

The provider had a system to assure the quality service they provided. The way the service was run had been regularly reviewed. A range of checks were carried out including care records, medication and the dining experience for people who lived there. A regional manager carried out monthly visits to audit the systems and procedures at the home.

We observed care and found that staff could respond to people's individual needs and cared for people in a kind and respectful way.

We spoke with two relatives of people who used the service. One person told us they had 'No issues', they said their relative was 'settled' and the 'Carer's are lovely'. The other relative we spoke with said they were 'Happy' with their relative's care.

We found that people needs were being assessed, planned and delivered in line with their individual care needs. People were protected from the risk of inadequate nutrition and dehydration.

There was an accurate record of people's needs in relation to their care and treatment.

We spoke with a relative who told us that things were improving at the care home. They said the new manager was turning things round. They told us sometimes the tables were not set for meals and there were no aprons for people to wear when they ate their meals. We brought his to the attention of the manager who explained that 200 new aprons had just been ordered. The relative said that staff were generally good but sometimes there were issues, for example, putting food down in front of people and not asking them if they needed some help, such as cutting up their food.

We found that there were sufficient numbers of staff on duty at the care home.

We found that care was still not planned and delivered to meet the people's needs. Sufficient steps were not taken to ensure the risk of poor nutrition and hydration was addressed.

The provider did not support staff in relation to their responsibilities by holding yearly appraisals. Care records were not accurate and there was a lack of proper information about people.

Relatives we spoke with raised concerns raised over staffing levels. One person said, 'There have been a lot of different managers, I cannot speak highly enough of the care given by staff however I have seen staff upset when they have been unable to give good care due to staffing levels. Sometimes there are only two care staff downstairs. They do not seem to have a plan b if staff phone in sick'. Another relative said, 'Very quiet, there are no activities, not like the home where he/she was'.

Another relative told us they had raised concerns regarding staffing levels with the management of the care home. One visitor said they thought their relative was 'looked after alright. There are no problems with staff and my relative has put weight on since living here.'

We found that care was not planned and delivered to meet the people's needs. We found there were not sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of people who use the service at all times.

Staff were seen to interact well with people and knew them by their first name. The privacy and dignity of residents was respected as we observed care interventions being carried out. Staff spoke to people in a very pleasant and dignified manner.

People had been individually assessed to see if they could make their own decisions. Care records had sufficient information so staff would be able to know how to support each person in the right way.

We saw on the day of our visit, there were enough qualified, skilled and experienced staff to meet people’s needs. The provider had a system for checking the quality and safety of the service and records were maintained and held securely.

In this report reference is made to a registered manager who was not in post and not managing the regulatory activities at this location at the time of the inspection. This is because they were still a registered manager on our register at the time.

One person we spoke with told us that they liked their bedroom and confirmed that they had been able to decorate it with their personal belongings to make it more "homely".