The Meadowcroft Care 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 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.

This was because the service was in breach of legal regulations in relation to people’s safe care and specifically how they monitored and managed their fire safety systems to ensure they remained fit for purpose.

This service scored 62 (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 made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

At our last inspection we found medicines were not always safely managed. This represented a breach of regulations. At this inspection we found the provider had made enough improvements to the way they now managed medicines to ensure they were well-organised and safe. This meant they were no longer in breach of regulations in relation to medicines.

At the services last inspection, the providers own internal audit had identified a higher-than-expected number of medicines recording errors. At this inspection we found no gaps on any of the electronic medicines records we looked at. Managers and staff confirmed the provider had introduced an electronic medicines system which automatically flagged up whenever a medicines administration, recording or auditing error had occurred.

People’s medicines records had also been improved to include guidance that was routinely reviewed and updated when changes occurred, so staff had easy access to all the information they needed to know about how people needed and preferred their prescribed medicines to be administered. Staff were clear about their roles and responsibilities in relation to the safe management of medicines. For example, staff knew who needed to have their medicines administered covertly which was clearly stated in the relevant people’s medicines records. Relatives and external care professionals told us staff supported people to take their prescribed medicines as and when they should.

Staff received relevant training and their competency to manage peoples prescribed medicines safely was routinely assessed. The provider conducted regular audits of the care homes medicines handling practices to ensure they remained effective and safe.

The service 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.

Information was obtained from people, and others involved in their care, about individual’s needs and potential risks they might face. This was used to develop individualised care and risk management plans to ensure people received safe and appropriate care and support from the moment they moved into the care home.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Managers and staff understood how to safeguard people. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. People told us they felt safe and protected living in the care home. A relative told us, “They [staff] provide my [family member] with a safe place to live.”

Managers worked proactively with the relevant external health and social care professionals and bodies when a concern was raised and took appropriate action to safeguard people from further risk, when this was required. An external care professional told us, “There has certainly been a reduction in safeguarding activity and there have been no service concerns raised since May [2025].”

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had recently introduced a new electronic management system which helped staff identify potential risks people might face more easily and decide the best course of action to take to mitigate or safely manage them. This meant people remained safe when taking part in activities and events of their choice.

People’s care records contained sufficiently detailed and accurate information, which ensured staff had access to all the guidance they needed to prevent or appropriately manage identified risks. Staff were aware of these risks and the steps they needed to take to prevent or safely manage them. People confirmed staff knew how to keep them safe. People moved freely around the care home and spent their time as they wished.

Systems were in place to ensure risks people might face were continually assessed, monitored and reviewed. Staff told us they regularly discussed risk during daily staff catch up and shift handover meetings. Typical feedback we received from staff included, “We discuss people who are at risk during shift handovers,” “We always make sure agency staff know who is at risk on the unit” and “We operate a ‘resident of the day’ system here, so peoples care plans are regularly updated.”

The service did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service had established systems in place to monitor fire safety and upkeep of the premises and had developed time specific action plans to address any health and safety issues they identified. However, these health and safety checks and audits were not always carried out at regular intervals and action plans developed because of issues found were not always implemented in a timely manner. This meant we were not assured the provider had done all that was reasonably practicable to mitigate potential risks associated with the care homes environment which had placed people at unnecessary risk of harm.

For example, an external risk assessment conducted prior to our inspection had identified several fire safety issues. An improvement plan had been developed to address all these outstanding fire safety issues, but managers confirmed the plan had yet to be fully actioned and records of some of the actions that had already been taken were incomplete.

We discussed this issue with the managers at the time of this inspection who assured us all the outstanding fire safety concerns would be completed by the end of September [2025].

In addition, we found other fire and health and safety issues during this inspection. These included a failure to routinely check the care homes fire extinguishers, windows restrictors and shower heads, contrary to recognised best health and safety practices and the providers own related policies and procedures. This meant we could not be assured all the aforementioned equipment remained fit for purpose and in good working order. We were also unable to establish what action the provider had taken in response to all the issues they had recently identified during a routine fire drill evacuation of the premises.

Notwithstanding the issues described above, we observed the care home was free of trip hazards, which enabled people to move safely around their home. Emergency evacuation plans were in place for everyone who lived at the care home to help staff evacuate individuals safely in the event of an emergency. Staff confirmed they had clear guidelines available to help them safely deal with emergencies.

The service did not always ensure staff received effective supervision and had their overall work performance appraised regularly. There were enough qualified, skilled and experienced staff who worked well-together to meet people’s individual needs.

At our last inspection we discussed with the registered manager at the time the issue of staff not receiving regular supervision or annual work performance appraisals meetings with their line managers. At this assessment we found limited progress had been made by the provider to resolve this ongoing staff support issue. For the second consecutive inspection we found staff still did not attend quarterly individual and/or group supervision meetings with their line manager or have their overall work performance formally appraised annually, contrary to the providers own related policies and procedures and recognised good practice. This meant staff still did not have enough formal opportunities to reflect on their working practices and professional development.

Staffing levels matched the staff duty rota on the day of our onsite inspection. Staff were visibly present on all 4 wings of the care home and were quick to respond to people’s questions and requests for support. An external care professional told us, “There does seem to be enough staff working in the care home. For example, at mealtimes I see there’s always enough staff to support people who need assistance eating and drinking.”

However, the service continues to be heavily reliant on agency care staff who were not so familiar with the needs, preferences and daily routines of the people living in the care home. A relative told us, “The service remains too reliant on agency staff which has only got worse over the past 18 months.” An external care professional added, “Our community team has noticed the service uses agency care staff a lot. These agency staff can’t know the residents as well as the permanent staff, which might adversely impact on the standard of care people receive.”

Managers confirmed the service was still short staffed when it came to care workers and this continued workforce pressure meant anywhere between a quarter and half of the care staff on duty in the home at any given time were agency staff.

We discussed this staffing issue with the services latest interim manager who told us the provider was in the process of reviewing staffing levels at Meadowcroft and their heavy reliance on agency care staff. They also confirmed the service was actively recruiting new staff to increase their pool of bank care workers so these could be used more effectively in the future to cover staff shortfalls.

Staff were well-trained to meet people’s individual needs and encouraged to continually improve in their role. Staff received a mixture of e-learning and in-person practical and theoretical training, which was routinely refreshed as frequently as staff required it, which included regular competency-based assessments. An external health care professional told us, “The staff are experienced and appear to have an appropriate level of training.”

However, staff had received any specialist positive behavioural support (PBS) training. This training would help staff prevent and safely manage incidents involving people who had become distressed and presented behaviours considered challenging. We discussed this matter with the managers at the time of the inspection who agreed to arrange for all staff to receive additional PBS training by the end of [2025].

Newly employed staff were subject to a probationary review and received a thorough induction to ensure they could safely meet the needs of people living in the care home. Managers confirmed agency staff also received an induction and would not be permitted to work unsupervised in the care home until this had been successfully completed. The provider continued to operate safe recruitment practices and only fit and suitable staff were employed to work at the care home.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had an in-house domestic team who were visibly present during this inspection and continued to maintain good standards of cleanliness and hygiene throughout the care home. An external care professional told us, “The environment in general is always kept clean.”

Staff received up to date infection control and food hygiene training and had access to appropriate resources and equipment, such as personal protective equipment [PPE] and hand sanitiser and soap for effective hand washing. This helped them minimise the risk of infections spreading in the care home. Staff told us they had adequate supplies of Personal Protective Equipment (PPE) and were aware how to control the risk of infection spreading in the care home. The provider’s infection prevention and control policies and procedures were current and reflected national guidance and recognised good practice.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

At our last inspection we found medicines were not always safely managed. This represented a breach of regulations. At this inspection we found the provider had made enough improvements to the way they now managed medicines to ensure they were well-organised and safe. This meant they were no longer in breach of regulations in relation to medicines.

At the services last inspection, the providers own internal audit had identified a higher-than-expected number of medicines recording errors. At this inspection we found no gaps on any of the electronic medicines records we looked at. Managers and staff confirmed the provider had introduced an electronic medicines system which automatically flagged up whenever a medicines administration, recording or auditing error had occurred.

People’s medicines records had also been improved to include guidance that was routinely reviewed and updated when changes occurred, so staff had easy access to all the information they needed to know about how people needed and preferred their prescribed medicines to be administered. Staff were clear about their roles and responsibilities in relation to the safe management of medicines. For example, staff knew who needed to have their medicines administered covertly which was clearly stated in the relevant people’s medicines records. Relatives and external care professionals told us staff supported people to take their prescribed medicines as and when they should.

Staff received relevant training and their competency to manage peoples prescribed medicines safely was routinely assessed. The provider conducted regular audits of the care homes medicines handling practices to ensure they remained effective and safe.