Archived: The Meadows Nursing Home

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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

At our last assessment we found leaders did not ensure risks to people were managed or mitigated to protect them from the risk of harm. Leaders had not ensured the environment was safe for people to live in. Staff did not always have up to date information to follow to ensure they were aware of people's current risks. Staff had not always received the training required to keep people safe. Managers had not fully completed all pre-employment checks for staff. At this assessment we found the provider had not made enough improvement and remained in breach of legal regulations in relation to safeguarding, safe environments and recruitment. Whilst some improvements had been made to the environment, we found concerns had not been fully addressed from our last visit. We identified ongoing concerns with care records, pre-employment checks and training.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of learning. Leaders had not fully addressed or resolved concerns identified at our last assessment. Staff did not always record accidents and incidents, and managers did not analyse recorded incidents to identify patterns and trends to reduce further occurrences. However, staff told us they felt listened to and could raise concerns.

Staff and leaders did not always work well with health professionals to establish and maintain safe systems of care. Staff did not always follow advice and instructions from health professionals in a timely manner. The local authority had put actions plans in place following quality monitoring visits. Leaders had not completed all required actions as required.

People did not always receive safe care and treatment. Staff did not keep all care records up to date or accurate. People’s care records in relation to specific health conditions did not always contain sufficient detail. This increased the risk of avoidable harm. At our previous assessment we identified people who required special diets to reduce the risk of them choking were not always provided with food prepared to the correct consistency. Whilst we found processes around food preparation and delivery had improved, some staff who were involved with meal preparation or supporting people to eat, had not been provided with appropriate training. Relatives we spoke with gave mixed feedback on how safe they felt their family members were. “I know they [the service] have had some issues, but I feel [Person’s name] is generally safe” and “When [Person’s name] was there first, they weren’t as safe as I feel they are now”. Staff were not always provided with training to support people safely.

The service did not work well with people to understand and manage risks. People’s care records did not always contain clear instructions on how to reduce risks and there was an inconsistent approach to involving people and their relatives in assessing and managing risks. One person’s care record contained 3 different instructions regarding the frequency staff were required to provide them with pressure relief to prevent their wound from deteriorating. Equipment required to reduce risks to people, for example, people at risk of falls, was not always available. Most relatives we spoke with told us they had not been involved in reviewing their family members care records. This increased the risk of staff providing incorrect care and placed people at further risk of harm. One relative told us “They have never discussed it with me” and another said, “They do talk about it but not recently”. However, 1 relative told us, “They do phone me and they involve me in any changes”.

Leaders did not always detect and control potential risks in the care environment and arrangements to monitor the safety and upkeep of the premises were not effective. At our last assessment, we identified hot pipes had not been covered to prevent people from burning themselves, and large items of furniture had not been secured to walls to prevent them accidently tipping over. Following our previous visit the provider assured us these concerns had been addressed; however, we found on this assessment there were still areas of hot pipes exposed, and 1 wardrobe had not been secured to the wall. During this visit, we also found the door lock to the cupboard where cleaning trolleys and cleaning products were kept was faulty. A member of staff was heard saying, “it’s been like it for some time”. The provider’s audits and checks had not identified the safety concerns we found.

Leaders continued to fail to ensure safe recruitment processes were followed. We reviewed 4 staff recruitment records and found 3 of these contained unexplained gaps in employment history and 1 staff member did not have evidence that a Disclosure and Barring Service (DBS) check had been undertaken prior to them commencing employment in the service. Staff did not always receive the necessary training and induction to enable them to deliver safe care. The staff training matrix highlighted gaps in mandatory and specialist training. Staff were not always given an opportunity to undertake shadow shifts as part of their induction.

Leaders did not assess or manage the risk of infection. Systems to manage Legionella bacteria risks were not effective. Staff did not undertake required checks to flush infrequently used water and records where checks were recorded contained gaps. At the time of our assessment people were not living on the 1st floor of the building, the manager did not understand the importance that this part of the service still required water outlets to be regularly flushed. Cleaning schedules were in place for housekeeping staff to follow, however, we found gaps in these records. Flooring in 1 person’s bedroom was damaged which meant cleaning may not be effective.

Staff and leaders did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medication administration records (MAR) contained inaccurate information; staff had not updated people’s room numbers on the MAR to reflect room changes. At our previous assessment we found staff had not stored medicinal creams safely. During this visit, we found lockable cabinets had been fitted in people’s rooms so medicinal creams could be locked away. However, we found some cupboards were unlocked and some rooms had creams left out on the side. Staff did not consistently record blood sugar levels for people with diabetes in line with their care plan. Managers had completed medicines audits; however, they had not identified the issues we found during our assessment.