Meadow Court Residential 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 people were not always safe and protected from avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 56 (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 had a proactive and positive culture of safety based on openness and honesty. Staff were communicated with verbally about any lessons learnt from safeguarding concerns, incidents or accidents. The service listened to concerns about safety from their staff, however, did not always investigate or report safety events.

Lessons were not always learnt to continually identify and embed good practice. The service did not audit or document events of concern accordingly. For example, not all accidents and incidents were appropriately documented. The most recent incident, accidents and safeguarding audits identified no analysis to evidence lessons learnt. Staff told us they were advised of any changes or lessons learnt verbally by leaders.

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

The service completed pre-admission assessments before people moved into the service to ensure they could meet their needs. The service worked closely with all stakeholders to ensure safe transition and continuity of care. The service had a close period of monitoring and observation during the first days of admission to ensure they could appropriately update people’s care plans.

However, the service did not have effective systems in place to maintain, monitor or provide assurance. For example, daily notes were not recorded on the electronic recording system, and the service was not clear where appropriate information relating to daily interventions would be recorded by staff. Leaders were unable to demonstrate the ability to monitor and have oversight of people’s needs.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff did not always concentrate 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 did not always shared concerns quickly or appropriately.

We received positive feedback from people and their relatives, who said they felt the service was safe. One person told us, “Yes, I’m safe because everyone’s so nice and friendly and know what they are doing.” One relative told us, “I know they are safe; they were falling at home and [they are] very safe here.” People appeared well cared for and were treated with respect by staff.

However, unexplained injuries or falls were not always recorded on accident and incident reports. The service did not always report safeguarding concerns to the local authority safeguarding team or notify the Commission. For example, accidents and incident forms highlighted several safeguarding incidents that had not been reported to the relevant agencies by the provider. This placed people at risk of harm.

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

We reviewed care plan’s and identified the quality of these were mixed. Some care plans demonstrated good links with the external professionals. External professionals advised us the service were quick and responsive to the people’s health needs and made appropriate contact with services for additional support where required. However, the service did not always involve appropriate services or make referrals for those with more specific needs. For example, service did not make appropriate referrals for support for individuals who had communication and sensory needs. The service has put measures in place to improve their ability to involve people to manage risks.

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

We observed some windows on the first floor did not have restrictors in place. Some bed-rails were broken, damaged or did not have appropriate safety bumpers in place. Some areas of the service were not fully safe or secure. For example, people had access to rooms and cupboards which presented a hazard; this was immediately addressed by the service.

We identified concerns in relation to fire safety. Staff said they had not taken part in regular fire drills. This was in contradiction to the service’s fire risk assessment that stated fire drills should be carried out twice per year.

The service did not ensure safe systems within the service to support the safe delivery of care. For example, there were inconsistencies in the provider’s Do Not Attempt Resuscitation (DNAR) and fire risk policies. People’s bedroom doors had different coloured dots on them. The service was not clear what each dot meant, either DNAR or fire risk, which exposed people to risk in the event of an emergency.

A small garden area was unsafe for people to access due to falls risks and hazards in the area. During our first site visit, this area was freely accessible. The home immediately rectified this following feedback, and ensured the area was appropriately locked. The service has ensured mitigating measures are in place to better ensure a safer environment.

The service ensured there were enough qualified, skilled and experienced staff. They worked together to provide safe care that met people’s individual needs.

The service used a staffing tool to calculate staffing levels, and this showed there was above average staffing levels within the service consistently.

We received mixed feedback from people and staff regarding staffing levels. Staff told us there were not always enough staff to safely support people, especially overnight. One person told us, “I don’t think there’s enough staff sometimes; you can be waiting ages.” Another person told us, “I get help if I ask for it. When I press [my buzzer], they [staff] usually come.” One person provided us with positive feedback regarding staffing saying, “I pulled the alarm, and they came within 5 minutes.”

There were robust recruitment and training processes in place. However, we received mixed feedback from staff, some said the training they had received supported them to fulfil their role, others felt they required more in-depth training. We reviewed the service’s training records which showed staff had received appropriate training to fulfil their role. We observed an effective deployment of staff throughout the building.

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.

We found the environment was kept clean and domestic staff were deployed appropriately. One person told us: “Yes, it’s clean; my room is nice.” There was plenty of Personal Protective Equipment (PPE), available throughout the service. Staff were responsive to any areas that required cleaning in the service. We reviewed cleaning logs that supported evidence the provider assessed and managed the risk of infection throughout the service.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were involved in planning in relation to their medicines.

During our last inspection, the service was given a recommendation around the management of medicines, storage of medicines as some were opened and not documented. During our site visits, we found there to be several topical creams stored in people’s bedrooms in unlocked cupboards. This was not consistent with safe storage and administration practices. Creams were still being applied using paper charts that lacked detail for staff to apply consistently, and to the correct areas of the body. This detail needed was due to be input into the online system in due course. Medication Administration Records (MARS), charts were not always appropriately completed by staff. We also observed a lack of oversight from staff when giving medicines to people. The service therefore did not ensure the safe administering of medicines to meet people’s needs.

Medicine stock levels counted on the day of assessment were correct and well organised. Staff told us they had a good relationship with the community pharmacy who supplied medicines, and they did not have problems getting ad-hoc supplies when needed. Appropriate levels of stock were evident.

People that were prescribed ‘as and when required’ (PRN) medicines had protocols in place for staff to know how to give these appropriately, but some had incorrect details documented, and lacked person-centred information. This increased the potential for inconsistent administration by staff.

Controlled drugs were being stored in a locked trolley which did not conform to British Standards regulations. However, during the assessment, senior staff were responsive to any improvements needed and a new cabinet was ordered to ensure medicines were being kept in an appropriate place.

The service received positive feedback from people and relatives regarding medication management. People told us, “There’s no problem with tablets” and there are “no problems with medication.”

Staff told us they did not have enough training to feel competent in completing medicines within the home. Staff who were medication trained, were unclear of medication protocols. The service has put in place mitigating measures to ensure safe medicines optimisation within the home.