Meadow View Residential 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 Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, assessing the risk of, and preventing, detecting and controlling the spread of, infections, and staffing.

This service scored 25 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

When incidents occurred, investigations to ensure that lessons were learnt and appropriate action was taken did not always happen. Incident records were not always documented accurately by staff, which had not always been addressed by leaders. For example, one person had an incident where they became unable to stand. Staff documented that they tried to ‘lift the person from the ground,’ but failed to document how they did this safely. There was a concern that staff used a technique that puts a dangerous strain on the shoulders of people, inevitably causing discomfort and often injury. This had not been thoroughly investigated by the provider to understand what happened and how staff did this. This placed people at risk of being harmed through poor manual handling techniques.

Incidents of concern including unexplained bruising and skin tears were often attributed to people’s health conditions, without sufficient investigation. Consideration as to if there was a pattern with the staff supporting people with personal care, if staff needed re-training , and if the person had a care plan in place for supporting them with delicate skin had not been implemented.

Other incidents of concern, staff had not always documented the events accurately. Although this was identified by the provider following an incident, the learning and training shared with staff following this and other incidents was not always shared or clearly recorded.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

When people had been discharged from hospital, their discharge information was not always followed. For example, one person was discharged from hospital after being admitted following a fall. The advice from the health professional was to offer pain relief, but stated there was no further medical intervention needed. Their relative told us that they asked staff to review the pain relief the person was prescribed, as they were showing signs of pain. However, a week later the person was still not being given regular pain relief or referred to be seen by the visiting GP despite the relative telling us their loved one was in pain. We reviewed care plans and MAR for this person and found that the pain relief had not been given as suggested, and the person’s care plan had not been updated. We discussed this with the registered manager, and they organised for the visiting GP to see the person the following day.

A relative told us that information is not always communicated within the staff teams, and therefore important information was missed. For example, when someone returned from hospital, it was advised they use a wheelchair until their strength returned. However, their relative told us that they had mobilised to the dining room without their wheelchair.

Systems to protect people from abuse were not always effective. Not all incidents of abuse were identified and acted on by the provider. A relative told us they shared concerns with staff regarding a blister their loved one sustained, without explanation. This was not raised as a safeguarding by the provider, so the family shared their concerns with the local authority safeguarding team. Incident records showed that concerns of unexplained bruising were not reported to the local authority safeguarding team.

Other safeguarding incidents had been recorded and reported to the local authority safeguarding team and reported to the CQC as required. The registered manager had a safeguarding log, which detailed the concern. However it did not detail the outcome, or how learning was shared with the staff team.

Staff told us they understood their responsibilities in relation to safeguarding people. They told us, “If I see anything unusual, like a bruise, I take a picture and show the team leader” and “Safeguarding is about minimising harm and risks to people.” However, we found that incidents of abuse were not always escalated as concerns, including unexplained bruising.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People lived with complex and unstable health conditions including epilepsy. Systems to support people with epilepsy were inadequate and not safe. Guidance for staff to follow to inform them how to support people during a seizure were poor. Staff we spoke with showed a lack of understanding of what to do if a person experienced a seizure. One incident where a person was suspected of having a seizure demonstrated poor responses from staff, including understanding of how a seizure could affect the person, and how they may present following the seizure including feeling tired. Staff were not trained and were also unaware how to administer rescue medicines (in the event of a seizure), and staff did not understand the importance of timing seizures.

Other health risks were not well managed. For example, when people were at risk of constipation there was no guidance for staff to follow. One person was only documented as having opened their bowels on one occasion in 3 months. There was no evidence that medical intervention had been sought for the person. Staff told us this person would tell them if they were constipated, however if the person was unwell, there was no care plan or risk assessment to inform staff of signs to look for or actions to take if the person was unable to tell staff. Another person had a period of not opening their bowels for up to 6 days. Staff told us that this was shared with staff on the daily handover but could not evidence any actions taken to ensure the person was not constipated or had been supported to seek medical attention. Staff failed to understand the serious risks of people being constipated.

Other risks to people were not well managed. Some people could become distressed, however guidance to inform staff how to reduce their distress was not sufficiently detailed. This included when people were prescribed medication to reduce their distress. There was a risk that staff would not be able to support people in a safe way during incidents of distress.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment supported the delivery of safe care.

We found that equipment was not always provided to people in a timely way. For example, one person was too tall for their wheelchair. We observed this was not safe for the person; they slipped down the wheelchair, and their feet dragged on the floor when they were being supported to move around the service. Although this had been identified by staff, there was a delay in purchasing a wheelchair which was fit for purpose for the person. We raised this with the registered manager, and the wheelchair was ordered on the day of our assessment.

During lunch we observed people that struggled to eat, that could have benefitted from adapted cutlery. This was not noticed by staff or provided.

During a quality assurance audit review in February 2025, it was noted that wires were ‘not always appropriately stored and posed a trip hazard.’ At our assessment, within one person’s room we noted that wires from their sensor mat also posed a trip hazard. This had not been identified by staff.

Other checks on the safety of the building had been completed. There were regular fire drills to ensure that staff understood how to respond in the event of a fire.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs.

During our assessment, there was not enough staff to meet people’s needs. We observed people needing support from staff and not receiving it, for example during lunch time one person asked to use the toilet and had to wait for 10 minutes before receiving support. We observed people who needed encouragement to eat were not supported by staff and ate very little.

Staff and relatives told us they did not always feel there was enough staff. Staff told us, “Not really. In general, on both floors we are stretched, and it gets hectic. One extra person would make all the difference in being able to respond to people more quickly. It’s been mentioned to the deputy manager” and “Upstairs especially, there isn’t enough staff’ and “Staffing shouldn’t be based on the number of people living here but on people’s needs.” Staff also told us, “We can’t always do the role to the standard we want to.” A relative told us, “They need more staff here, these poor (staff) need help.”

Although the staffing met the assessed number of staff the providers dependency tool suggested, this was not calculated on people’s individual needs. We spoke with the registered manager about how they assessed the number of staff on duty, and they implemented another dependency tool, which assessed people’s needs in order to assess the number of staff needed. However, when we shared our concerns about staffing numbers with a senior manager, they told us they had sufficient staff and had no plans to increase the numbers of staff. This response did not support people in being safe, and meant they were at ongoing risks to their needs not being met due to insufficient staffing.

Staff did not always have the skills and experience to support people safely. When people were prescribed medicines to support them in the event of an emergency, staff had not been trained how to administer them safely. Three staff we spoke with who supported people with epilepsy did not have the training, skills and knowledge how to support people safely during a seizure. Despite supporting people with epilepsy, most of the staff had not received any training in epilepsy. This placed people with epilepsy at risk that staff would not be able to support them safely during a seizure.

Staff had also not received training in supporting people with other complex health conditions. For example only 20% of staff had completed training in supporting people with diabetes, and 37% of staff had completed training in supporting people with Parkinson’s disease. Despite some staff having completed training, we identified poor practices around moving and handling, safeguarding, epilepsy and medicines administration.

Safe processes to recruit new staff were followed. For example, before working with people, reference checks and employment checks were completed on all staff.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There was one cleaning member of staff for each floor, which staff told us was not always sufficient. One staff member told us, “We are pushing fluids to keep people hydrated. Then people have to wait to go to the toilet, it’s their basic need they shouldn’t have to wait.” Whilst we found that rooms were generally clean, there was a strong smell of urine in several parts of the home. A relative told us, “Sometimes it smells of wee when you come in, sometimes it doesn’t.” We discussed this with the registered manager, who was aware, and had ordered a machine to deep clean the carpets. However, on the second and third day of the inspection we found no improvement in the odour of the service, and the registered manager had not informed us of plans to replace the malodourous carpets. We observed one person had black dirt under their fingernails, which had not been identified by staff, and posed a risk of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Some people had medicines prescribed on an ‘as and when’ basis, such as paracetamol. When these medicines were administered by staff, they did not always document the reason for the administration, or if the medicine had been effective. When people were prescribed ‘as and when’ medicines there was not always adequate guidance to inform staff how to administer the medicine.

In addition, there was not detailed guidance for staff to follow to inform them when to administer these medicines for pain relief. Some people were not able to express pain due to advancing dementia and may not be able to articulate when they were in pain. There was a risk these people could not be administered pain relief when needed.

Some people were prescribed medicines with special requirements including medicines that needed extra administration records to be completed. We completed a re-conciliation of medicines and found that for one medication, medicine numbers did not match the documented numbers. Staff had not checked the medication between 11 July 2025 and 14 July 2025 as they should have, and did not identify the missing medication. When we raised this, an investigation was completed and staff identified that the medicine had been wrongly documented on 11 July 2025.

Medicated creams did not always have body maps to inform staff where to apply the cream. We also found medicated creams within people’s rooms outside of the medicines cupboard which could be locked. This posed a risk to people who could become disorientated. Medicated creams were not always dated when they were opened, and when people’s rooms were hot measures were not taken to ensure that creams did not exceed the maximum temperature indicated by the manufacturer.