Meadow Acres

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 inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people were not always safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 59 (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 had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Where incidents occurred, lessons learnt had been identified by the management team and lessons learnt. Staff confirmed they had regular discussions relating to lessons learnt. The provider had a dedicated newsletter which identified themes and learning from the organisation and wider partner agencies the relevant information and learning would then be disseminated more effectively to staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services and the transitions were meaningful and had people’s needs at the centre of the decisions being made.

Staff demonstrated a clear understanding of safeguarding procedures and acted promptly to address any concerns. People were supported in a way that promoted their safety in relation to safeguarding matters. A relative told us, ‘The staff have been nothing but respectful, caring and kind to [Relative]. I appreciate how they handle any situation.’ One person said, ‘They are kind. They are gentle.’ Another person said, ‘I am happy. The staff are kind."

People were not always supported to help understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive. Risk management systems were not sufficiently robust to ensure people’s safety. We found that staff supporting individuals with complex health needs, such as epilepsy or moving and handling, had not got the appropriate risk assessments in place. We found discrepancies between the care plan and risk assessment, where the documents did not triangulate. For example, we found people’s needs had changed in terms of their mobility, however the care plans did not reflect this, and risk assessments were lacking in evidence. The management team had identified the need for improvements in care planning and risk assessments. However, this lack of triangulation compromised effective risk management.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.People were supported to ensure they lived in an environment that met their needs. However, environmental standards required attention. Health and safety checks did not identify areas of risk such as fire door not shutting correctly and evacuation drills not being carried out at night. Personal evacuation plans (PEEPs) were detailed, however the night PEEP’s identified an evacuation procedure which meant they relied on another staff member that lived locally that would be called on. A drill had not been completed to see if this was appropriate or would work in the instance that a fire would occur.

Since the inspection an independent review of the building and fire procedures was completed by the fire department. They confirmed that overall, they were happy with the provisions for evacuating the premises. They shared some works had been completed which meant all doors were fully closing into their stops.

People were supported by staff who had the right skills. Staff received regular training and supervision to ensure they had the skills and knowledge to support people effectively. This included face to face training which considered the individual health and wellbeing needs of the people they supported to ensure staff were best skilled to support them. This included areas such as autism, learning disabilities, manual handling and safeguarding. Staff felt they had the right skills to do their role. A staff member said, “I feel I have the right training and skills to carry out my role safely and effectively as Iam confident in supporting individuals with their daily needs and following care plans.”

The provider operated a recruitment process; appropriate checks were undertaken to help ensure staff were suitable to work at the service. A disclosure and barring service (DBS) check and satisfactory references had been obtained for all staff before they worked with people. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff generally felt there were enough team members to support people.

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. This was evidenced through audits completed by the management team. The home was clean. Where appropriate staff wore personal protective equipment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.The medicines administration records showed people received their regular medicines in line with the prescribers’ instructions. However, there was a lack of assurance that one individual received their medication as intended. For example, medicine used to alter a person’s mood was administered on 2 occasions, yet there was no documented rationale in the daily records to explain why it was given, nor any evidence of steps taken prior to administration. PRN protocols (PRN stands for as needed or “as the situations demands”) were not consistently in place at the time of inspection, although the management team confirmed these have now been implemented. Nonetheless, further assurance was needed to ensure staff were following protocols and documenting decisions appropriately.