Meadowside and St. Francis

We found the following examples of good practice:

Some people and staff had previously tested positive for Covid 19. The service followed national guidance and self-isolated people and staff for the required amount of time. The registered manager had reflected on the outbreak. People and staff were supported emotionally during and after the outbreak.

Polices and procedures were in place to keep people, visitors and staff safe. These were reviewed and updated as guidance changed. Staff training had also taken place and refreshed often to ensure practices remained safe.

The service was clean and there was a team of staff dedicated to ensuring this was maintained. Infection control was audited often, and action taken to replace equipment, amend practice and ensure people were safe.

Staff, people and visiting family were tested for Covid-19 in line with guidance. The service had ensured people and staff had the opportunity to receive the vaccination. Staff understood how to use PPE effectively and had refresher training and guidance when needed.

People and staff were encouraged and supported to socially distance from each other when possible. Communal areas had been rearranged so people could sit apart. People could choose to safely to use these areas of remain in their rooms.

Visiting rooms had been specially built to ensure families and people could have contact with each other. Systems were in place to ensure family could visit their loved ones at their end of life.

People’s experience of using this service:

People were at the heart of the service. They were truly respected, valued as individuals, and were empowered in their care. People were cared and supported in a service which had a strong and visible person-centred culture.

People and staff were complimentary of the management and leadership of the service which continued to help to improve the quality of the service and motivate and inspire staff.

There were positive working relationships with external professionals and a passion for continuous learning and improvement. Staff were well trained to be able to meet people’s needs, and there was an effective system in place to ensure the ongoing review and competency of staff.

People were kept safe and protected from avoidable harm and abuse, and people now had their medicines safely managed. New processes had been put into place to ensure a more robust oversight. People lived in an environment which was fully assessed for cleanliness and safety.

People received personalised care and support, and now had their human rights fully protected. Quality monitoring systems had been further developed. However, we have recommended the provider takes action to continue to strengthen their overall governance systems, because the system had not identified that some records were not always in place, or up to date.

More information is in Detailed Findings below.

Rating at last inspection: Requires Improvement (published 07 April 2018).

Why we inspected: This was a planned inspection. At this inspection we rated the service Good.

Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our re-inspection schedule for those services rated Good.

Meadowside and St Francis is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home is registered to provide care for up to 69 older people. On the days of the inspection, 40 people lived in the home. The provider also operates another nursing home in the same locality.

In June and July 2017, the service was rated Inadequate and was placed into special measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

We told the provider to make improvements to ensure people were kept safe from abuse, that people’s medicines were managed safely and risks associated with their care were known by staff and risks mitigated. We also asked the provider to ensure they followed infection control practices to help reduce the risk of the unnecessary spread of infection, and to make sure there were enough suitably trained staff to meet people’s needs, and that staff were recruited safely. In addition, people’s nutritional needs were not always known and met safely by staff, people’s human rights were also not being protected, and people’s privacy, dignity and independence was not always respected. Action was also required to ensure people’s changing healthcare needs were monitored so responsive action could be taken, that people’s care records were created in line with people’s wishes and preferences, and that they were an accurate reflection of how their care and support needs should be carried out. Improvements were also required to the leadership and culture of the service. People’s confidential information was not always held securely, the provider did not use valuable feedback to help improve the service, staff did not always feel management were approachable, and there were ineffective quality monitoring systems in place to help identify when improvements were required.

Immediately after our inspection, the provider told us they would voluntarily stop new admissions to the service, in order for them to put things right. They also employed a health and social care consultant to help advise them about how they could make improvements, and a robust action plan was submitted to the Commission. We also contacted the local authority safeguarding team who took prompt action to ensure people's health, safety and wellbeing.

During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. However, whilst action had been taken, some improvements were still needed and ongoing, and where improvements had been made, more time was required to demonstrate they had been embedded in practice and could be sustained.

Since our last inspection the manager had now registered with the Commission and was now the registered manager of the service. 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.

A new management structure had been put into place to help drive improvement and to support staff. This included a new clinical lead, a clinical manager, and a quality manager. The provider spoke proudly of the staff he had employed into these roles, and it was obvious from their interactions with us, that they were a cohesive team, who were passionate and fully committed to improving the service. The service unlike before, no longer felt like two different care homes, but was now more joined up, with staff engaging and leaning from each other across both the residential care home and nursing home.

The registered manager and provider had devised some new systems and processes to help monitor the ongoing safety and quality of the service, for example care plan, medicine and environmental checks. However, these had not always been effective in identifying where improvements were required, such as with the risk management of peoples care, accuracy of people’s care records, making sure people’s human rights were promoted, and that people’s privacy and dignity was respected. The provider had continued to trust the registered manager and staff team, without having effective systems and processes in place to check what was actually occurring within the service. By the end of our inspection, a new provider monthly audit had been created by the registered manager and provider, and would be used.

Changes to clinical management and governance, was in its infancy, and were still being developed. The introduction of a new clinical lead and clinical manger would help ensure clinical practices were monitored.

People had chosen what they wanted the ethos and culture of the service to be, placing them at the heart of the service. People and staff’s views were obtained to help with the ongoing development of the service. People and families told us that staff, were kind and caring, and since our last inspection, they had visibly seen the change in the atmosphere and culture of the service. Telling us, “I am staggered at the turnaround in the culture and atmosphere since your last inspection, and importantly I am confident it’s not just for effect”.

The provider had introduced the voices forum which was a new meeting that took place each week, with people and their relatives. The ethos of the forum was to ensure people’s voices were heard. People spoke positively of this new approach.

Staff told us they now enjoyed coming to work, and expressed how well they felt supported. Staff recognised the service was undergoing continued development and ongoing improvement, but were committed to be part of the process, with one member of staff telling us, “Everyone has signed up to improve the service”.

People lived in a service whereby the registered manager, provider and management team were continually learning, which helped to adapt and improve the service. Partnership working with other providers was important to the registered manager to help keep on top of ongoing developments and changes in the sector.

Following our last inspection, the provider and registered manager had met with people, relatives and staff to share the findings of the inspection and rating given. Relatives had told us, how they had appreciated this, and the honesty shown at a difficult and challenging time. This open and transparent approach demonstrated the providers understanding and recognition of the Duty of Candour. The Duty of Candour means that a service must act in an open and transparent way in relation to care and treatment provided when things go wrong.

Whilst there had been improvements relating to the management of risks associated with people’s care, by implementing risk assessments to help guide staff about how to mitigate risks and by holding more detailed staff handovers. Risk assessments continued to not always be in place when a person had a specific healthcare.

Overall, the arrangements for managing medicines had improved, with one relative telling us, “The medication regime has improved immensely”. However, people’s medicine administration record (MARs) charts were not always accurate or legible. This meant it was not possible to be sure whether people received their medicines in the way prescribed for them.

People and their relatives told us they felt safe commenting, “I feel that I am safe living here”, and I am happy that my relative is safe and well cared for here”. People were now protected from abuse and improper treatment, and staff acted to keep people safe. Safeguarding had become a topic which was now being openly discussed with people and their families, helping to empower them to share with staff if they felt vulnerable, so immediate action could be taken to protect people.

People lived in a service whereby staff, were now recruited safely to ensure they were suitable to work with vulnerable people. To help improve recruitment practices there had been a change in the management of this area.

People were now supported by suitable numbers of staff to help ensure their needs were met. The registered manager had taken into consideration the Commission’s recommendation made at the last inspection, and would be implementing a staffing tool to help assure that staffing levels met with the needs of people. The provider had also installed a new call bell system, which meant the response time to staff answering call bells was now being monitored, helping to identify trends so necessary action could be taken, such as increasing staffing levels at particular times of the day.

People lived in a clean and odour free environment. Staff had been trained in infection control and put their knowledge into practice. People lived in an environment which was now being assessed for safely. People’s accidents and incidents were now being monitored to help establish if themes were emerging so practice could be changed. The provider was responsive when things went wrong and used their learning to help improve the service.

Overall, people’s healthcare was now being monitored and action was being taken to promptly contact the relevant health as social care professionals. However, people’s care plans were not always updated to help ensure the effective management of a healthcare condition. People’s health and social care needs were now being assessed in an organised way, however ongoing proactive approaches to peop

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.

The inspection took place on 29 June 2017, 30 June 2017, 04 July 2017, 05 July 2017 and 14 July 2017 and was unannounced. Meadowside and St Francis is divided into two units; St Francis provides complex nursing care for up to 44 people. Meadowside provides personal care for up to 25 people. The home is registered to provide care for up to 69 older people. On the day of the inspection, 58 people lived in the home. The provider also operates another nursing home in the same locality.

There was a management structure in place. The service had a registered manager. 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. There was also a separate manager for each unit; with a clinical lead and a matron in post, to oversee the nursing care being provided. A new manager had recently been recruited to share the responsibility of the day to day management of the home. They were in the process of registering with CQC. Following the inspection, the registered manager told us they would be recruiting a new manager to replace them, so they could focus on their role as a director of the two nursing homes owned by the provider.

Prior to our inspection we had received concerns from the local authority safeguarding team. These included concerns about poor standards of care, lack of dignity, respect and compassion shown to people, unsafe recruitment practices, lack of training for staff and staff not meeting people’s complex care, skin care or end of life care needs safely. They also included concerns regarding incomplete monitoring and recording of people’s healthcare needs, staff not following recommendations made by external professionals, unsafe medicine’s management and ineffective monitoring or equipment and stock.

At our last inspection on 14, 15, 19 April and 03 May 2016, we found breaches of regulation. We found care and treatment was not always appropriate to meet people’s needs or reflective of their preferences. Care and treatment was not always provided in a safe way. People’s risks were not always assessed and guidance regarding people’s care was not always followed. Medicines were not always managed in a safe way. The legislative framework of the Mental Capacity Act (MCA) 2005 and associated Deprivation of Liberty Safeguards (DoLS) were not always being followed. Records of people’s care were not always accurate, complete and contemporaneous. At this inspection we found that action had not been taken to make improvements to the service and to the care people received.

St Francis (Nursing Care)

People did not receive safe care and treatment. Nursing practice was not always safe and put people at risk of potential harm. We witnessed nursing staff provide unsafe care and treatment and they did not always have a comprehensive understanding of people’s health needs or how to meet them. The registered manager had not ensured requirements set by the Nursing and Midwifery Council in relation to staff had been complied with. This meant nursing staff were not receiving the correct support to help ensure they provided safe care and remained competent in their role. We have referred our concerns to the nursing and midwifery council. The nursing and midwifery council is the regulator for nursing and midwifery professions in the UK

People’s healthcare needs were not always dealt with promptly and recommendations from external healthcare professionals had not always been followed. This meant people were at risk of their health deteriorating. Where people required staff to monitor their health this had not always been done effectively or acted upon which meant any further action required, to maintain the person’s health was not taken.

People’s care plans and risk assessments did not reflect their up to date, complex care or health needs. People’s dietary needs were not always known or met by staff. People who needed a soft, pureed, diabetic or high calorie diet did not always receive appropriate food to keep them safe and healthy. Staff were often unaware of people’s needs, how to meet them and how to recognise they were unwell; and we found examples of staff providing incorrect care to people.

Staff had not all received up to date training or training to meet people’s individual needs such as diabetes or epilepsy. Nursing staff had not all completed or updated the training required to help ensure they provided safe, effective care. Records showed they had not received assessments of their competency to carry out procedures related to people’s complex needs such as tracheostomy care.

Where people lacked the capacity to make decisions, their rights had not always been protected. There was no evidence to show how decisions about people’s mental capacity had been made or who had been consulted. Staff showed a lack of understanding about people’s mental capacity.

Staff did not always have access to information about how people could, or preferred to, express their views. People’s care plans for care at the end of their life did not always contain information about their preferences or details about how to meet people’s needs.

Medicines were not always managed safely and infection control practices were not always being followed to reduce the risk of cross infection.

The provider did not seek and act on feedback from external professionals in order to improve the service.

Meadowside and St Francis

Staff members had not always been recruited safely to help ensure they were suitable to work with vulnerable people. Some new staff members had started working at the service before a satisfactory Disclosure and Barring Service (DBS) check had been returned. Other staff members had begun to work at the service, even though their career history or references did not give a clear picture of their skills and previous experience. Nursing staff had been employed without references being sought regarding their nursing expertise and with no information about where they had worked previously.

The provider had not developed a culture of continuous improvement. They had not used the outcomes of previous inspections, complaints, incidents or safeguarding investigations to ensure the quality of the service improved. They had not acted to make improvements when external professionals had raised concerns with them. During the inspection we found similar concerns to those that had been found at previous inspections or raised during recent safeguarding investigations.

The provider and registered manager had not maintained a clear overview of the quality of the service and had failed to act when gaps in quality had been brought to their attention. Audits that had been completed to assess the quality of the service were not always fit for purpose and where improvements had been identified through audits; these had not always been acted upon. Feedback had not been sought on a regular basis from people or their family members in order to improve the service.

People and staff had not always felt confident raising concerns with the registered manager. Staff members told us they did not have the opportunity to share their ideas and when they had questioned practice, this had not been received positively by senior staff. The provider had a whistle blowing policy but no-one working at the service had whistle blown about the quality or safety of the care being provided. Some people and relatives told us they knew how to raise a complaint but did not always feel comfortable doing so.

The provider had not ensured staff understood their responsibilities for reporting incidents accurately. There was no formal system in place to monitor any themes or trends arising from accidents or incidents occurring in the home.

Staff did not always act to keep people safe from risks relating to the environment. Doors to several rooms or cupboards containing potentially hazardous material or equipment were left unlocked. Medicines were not always stored securely. When people had accidents, incidents or near misses these had not been monitored to look for developing trends. This meant learning to reduce the risks of these happening again had not been identified.

Some staff members had not attended training on how to move people sa

The service provides care for older people and people with a physical disability and can provide care for up to 69 people. Meadowside and St Francis is registered to provide nursing and residential care. When we inspected, 66 people lived at the service.

A registered manager was employed to manage the service locally. 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.

We found aspects of medicine management were not always safe. We found it was not always clear whether people had been given all their medicines at the right time.

People’s risk assessments and care plans did not always accurately reflect their needs or the care they required. Some care plans were detailed, but staff did not always follow the guidance in the care plans, for example regarding diabetes management. This placed people at risk. We found care records were not always updated promptly as people’s needs changed. This meant there was the risk of people not receiving care according to their care plan. In addition, people’s end of life care was not consistently planned and delivered to reflect their needs and preferences. People did not always have personalised end of life care plans.

The legal requirements of the Mental Capacity Act (2005) were not always followed. Assessments had not been requested by the service to ensure people were not being deprived of their liberty unlawfully. Staff were due to receive training on the Mental Capacity Act (2005) and associated Deprivation of Liberty Safeguards (DoLS) to improve their understanding of these laws which protect people’s human rights. Staff however asked people for their consent as they provided care and treatment.

Audits were undertaken but these had not identified the areas we found required improvement during this inspection. People’s views on the service were sought by the provider.

We found people who had more complex needs would benefit from a more individualised approach to keeping them stimulated. Group activities were enjoyed by many and included visiting animals, garden fetes, seasonal events such as horse racing and musical entertainment.

Staff were recruited safely.

People and relatives knew how to raise complaints and the service had a process for managing complaints. We found complaints were investigated and responded to.

People told us they enjoyed the food and people had their dietary needs met. Meals were a social event and people enjoyed the company of others whilst eating in the conservatory and dining room.

Staffing levels were flexible and based upon people’s needs and occupancy at the home. People and staff told us there were enough staff on duty and if there was sickness every effort was made to replace staff.

The service was clean and we saw staff followed infection control guidance.

People told us they felt safe. The service was well maintained and decorated. The staff team worked hard to create a home from home environment.

The leadership within the home was keen to provide a quality service. The registered manager was approachable and visible within the home.

We found a number of breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

As part of this inspection we spoke with the Head of Care, the Matron, ten members of staff, 19 people who used the service, two relatives and two visiting healthcare professionals. We reviewed records relating to the management of the home. These included seven care plans, the home's training matrix, several audits and the service's complaints file.

Below is a summary of what we found. The summary describes what people, staff, relatives and visitors told us, what we observed and the records we looked at.

Concerns had been identified during our previous inspection in November 2013. These related to staff not being supported with appropriate training, there being a lack of staff supervision and records not being kept up to date.

During this inspection, in June and July 2014, we found that processes had been put in place to ensure the concerns identified had been addressed and rectified.

Is the service safe?

People's needs had been assessed and regularly reviewed. There were plans in place to ensure people's care was delivered in a way that ensured their safety and welfare. Care needs and risks were identified and appropriate steps were taken to respond to these.

Is the service effective?

People told us they were satisfied with the care they received. We saw from care records that people's care needs had been appropriately assessed and care plans reflected these needs. Where people's needs had changed, care plans had been updated to reflect these changes.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed understanding and gave encouragement when supporting people. Staff communicated clearly and at an appropriate pace with the people they were supporting. People's preferences had been obtained by the home and were included in people's care plans. During our inspection we overheard a person saying to a member of staff 'I feel secure, I feel at peace here, I feel happy here.'

Is the service responsive?

The home responded to people's changing needs and sought advice and guidance from relevant healthcare professionals. Appropriate actions had been taken to respond to accidents and incidents. The service took steps to obtain views from people who used the service and staff and responded to these.

Is the service well-led?

Quality assurance processes were in place in the home. We saw evidence of people being asked for feedback and this being responded to and acted on. We saw that several audits and internal inspections had been carried out and that issues identified had been acted upon. Staff told us they were asked for their feedback and felt their opinions had been listened to and used to improve the home.

People told us 'I'm very well looked after'; "It's very good here, how they put up with us all I don't know"; "Yes, they respect my privacy and dignity and respond quickly"; "I have nothing to complain about" and "The staff are kind, we are happy with the service."

We found that people were happy with the care they received and the staff were knowledgeable about people. Assessments had occurred relating to people's needs and care plans reflected the care and treatment required.

We found that Meadowside and St. Francis had recently recruited to two new trained staff. There were sufficient staff on duty which was based on dependency and skill mix.

We found that information was not always recorded about the care and treatment people received. Staff told us that they followed the care plans but there was not the written, documented evidence to substantiate this.

People told us that they felt respected and involved in the running of the service and that staff respected their privacy and dignity. We found the staff were knowledgable about the people they cared for and people's care plans and healthcare assessments were accurate and regularly reviewed.

We found people's nutritional needs were assessed, reviewed and met with sufficient, nutritious food. We found the environment and equipment was clean and there were processes in place to manage the risk of infection.

We found that although staff attended training in relevant courses, there were significant gaps in some essential training areas. Additionally we found there was not a regular system in place to ensure all staff were regularly supervised and received appraisals. Staff however told us they felt supported.

We found there were adequate mechanisms in place to ensure the quality of the service. People's views through resident meetings and questionnaires. Staff felt they were able to talk about issues in staff meetings. There was a process to regularly review people's care and monitor complaints.

We visited Meadowside and St. Francis on the 13 December 2012. Due to outbreak of the winter sickness and diarrhoea illness we were only able to speak with one person using the service. We also spoke with six members of staff, the acting head of care, two Registered Nurses and the provider.

All the staff we spoke with confirmed the provider had increased the staffing levels and now had sufficient staff on duty.

The one person we spoke with said, 'It's much better now as they have floaters (two staff that move from floor to floor where needed) over the three floors and it helps'.

We observed staff working as a team to provide comfort and reassurance to people who were unwell.

We saw staff spoke with people in an attentive, respectful, and caring way. We saw people's privacy and dignity being respected at all times.

All people we spoke with stated that the home was short of staff and people living in the home had to wait for long periods for assistance.

We saw that staff and people using the service knew each other well and chatted in a relaxed way. People using the service told us, 'Well looked after but sometimes have to wait', 'All staff are lovely, helpful but not enough of them'.

All of the people we spoke with were happy with the care they were receiving. We saw that people were spoken to by staff in an attentive, respectful, and caring way. We saw people's privacy and dignity being respected at all times. We saw and heard staff speak to people in a way that demonstrated a good understanding by staff of people's choices and preferences.

We pathway tracked four people who use the service. Pathway tracking means we looked in detail at the care four people received. We spoke to staff about the care given, looked at records related to them, met with them and observed staff working with them.

People said that they would feel able to complain if they needed to.