Meade Close

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.

The service was in breach of legal regulations in relation to safe management and administration of medicines, staff training, development and support, individual and environmental risk and the standard of accommodation provided.

This service scored 44 (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 had systems in place to report and investigate any safety events. However, lessons were not learnt which would help to reduce repeated incidents and embed good practice.

Records showed any accidents and incidents were monitored and reviewed, helping to identify any themes or patterns. Management meetings explored themes within care and support and where additional learning could be provided in line with best practice. Action was taken to address practice issues with staff through meetings and discussion. We saw counselling forms were completed detailing discussions with staff along with any corrective action required such as reflective piece and observations to help improve practice. There was little evidence of discussions across the team to reinforce learning or check understanding. We found repeated issues, such as medication practice, which indicated required learning had not been embedded. We were informed following our visits plans were to be put in place around staff knowledge checks and reflection within future meetings.

The provider did not always work well with healthcare partners to establish and maintain safe systems of care.

We received a mixed response from health care professionals involved with the service. One healthcare professional told us, “Staff are proactive in seeking advice or support when they have any queries or concerns.” Whilst others reported challenges in communication with Meade Close. We were told they had experienced difficulties in contacting the home by phone or email due to the lack of a voicemail facility and delays in email responses. One healthcare professional also told us, “I occasionally arrange to visit and they don't add it to the diary etc, therefore I attend and they aren't expecting me, which leads to wasted time.” Following our visits we were told further telephone handsets had been introduced and management of email communication, to help improve accessibility and reduce delays in responding to calls and messages.

A review of one person’s records included a comprehensive hospital passport. This information included the person’s personal details as well as relevant information about their health care needs, how they communicate and any reasonable adjustments that might be needed.

Systems were in place for the recording and report of any safeguarding concerns. Any accident, incidents or concerns identified by the provider or brought to their attention, managers were proactive in reporting issues and working with the local authority to address action required, where necessary, and improve practice.

A high number of concerns had been raised with the local authority safeguarding team. Following review, the local authority found a number of the concerns were substantiated, identifying areas for improvement. Managers were seeking further clarification from the safeguarding team about some decisions made. Where necessary, disciplinary action and further staff training had been undertaken. Healthcare professionals told us they had worked with the team to help make improvements in areas of concern they had raised. One incident was subject to further investigation by CQC due to an unexplained injury.

Policies and procedures were in place to guide staff in safeguarding people from abuse. Records showed and staff confirmed they had completed training in safeguarding adults from abuse, Mental Capacity Act, and deprivation of liberty safeguards. Staff told us they generally felt able to raise concerns with managers. During one of our visits a staff member raised concerns with us, about one person living at the home. This was shared with senior managers and local authority.

All the people living at Meade Close were being deprived of their liberty. Appropriate legal authorisations were in place, as required. Safeguarding concerns were notified to CQC in line with legal requirements.

The provider did not always work closely with people to fully understand and manage risks. In some cases, records lacked accurate or complete information, which could make it harder for staff to support people’s needs safely.

Due to the complex needs of people, levels of risk were high. People required support with all aspects of their health and physical care needs. A review of records showed risk management plans were in place, however these were not always effective. For example, one person was nil by mouth due to the risk of choking however the critical information in the care plan stated they were to have an oral pureed diet. Another person’s care plan stated they were able to have certain food items which were not at the assessed level for their diet. Another person’s care plan showed there were also inconsistencies regarding the volume of water to be used as a flush through their feeding tube. This did not demonstrate safe and effective systems were in place to help keep people safe.

Records also evidenced gaps in training in areas of risk. This included Epilepsy and Buccal, emergency first aid, fire warden and safer people. Further, more serious concerns were identified in relation to the training and assessment of staff in the support offered with Percutaneous Endoscopic Gastrostomy feeding tubes (PEGs). This training is essential due to the complex health and physical care needs of people, so staff have the knowledge and skills to respond in a timely way, minimising the risks to people.

Environmental risks were also reviewed. A fire risk assessment had been carried out in October 2024 and a food hygiene inspection in March 2025 and not all work required had been completed. In addition, the providers schedule for fire drills states these are to be held on a quarterly basis for both day and night staff. A review of records did not evidence these had been done.

We saw ‘grab bags’ were available in each of the bungalows and were easily accessible in the event of an emergency arising. Bags included personal emergency evacuation plans and the procedure to follow. A copy of the service contingency plan should be included so staff have access to essential information in the event of an emergency including a current list of emergency contact numbers for all utilities (gas, water, electricity) and key staff members.

The provider did not always detect and control potential risks in the care environment.

Meade Close comprises of 3 adapted bungalows. Aids and adaptations were provided throughout. Bedrooms were single occupancy with shared bathing and toilet facilities. The relatives of 2 people had refurbished their family members bedrooms, providing a good standard of furnishing and decoration. Other bedrooms and communal areas required redecoration and old furnishings replaced. We also saw posters in the shower rooms advising staff ‘all toiletries to be returned to rooms’, however this was not being done. Curtains in some bedrooms needed rehanging.

We found the kitchens in both bungalow 1 and 2 also required attention, work tops and tiles needed replacing and cupboards needed cleaning and tidying. This had also been identified by the Food Safety Agency during their inspection in March 2025, however remained outstanding.

We were told the provider was in discussion with the landlord in relation to works required. A refurbishment plan had been drawn up, this explored improvements to bedrooms and kitchens to be completed by June 2026.

A fire risk assessment (FRA) was carried out on the 2 October 2024. A suggested review date of 2 October 2025 was noted; however, this had not been done. Work required to ensure compliance with fire regulations were not fully complete. We also saw in one of the bungalows, fire doors separating communal rooms were propped open with chairs, due to a delay in fitting magnetic holding devices. It was confirmed following our visits this had been resolved.

The FRA also identified additional training and drills required for staff. The provider health and safety monitoring checklist also stated quarterly drills should be completed involving both day and night staff. A review of records showed not all staff had taken part in evacuations. Considering the turnover in staff further drills were required to ensure staff understood the procedure to follow in the event of an emergency.

Systems were in place to check the home environment was safe. Safety certificates were in place for mains gas and electric, small appliances and the fire alarm and equipment. During our visits to the home, we found old fire alarm sensors had not been removed, with 3 continually sounding and old door sensors hanging from a door.

Internal checks were also completed in relation to fire safety, health and safety checks and water and food temperatures. Internal audits had identified these had not been consistently kept up to date. A senior member of staff had been identified to take responsibility for completing necessary checks.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received essential training and development.

We reviewed the staffing arrangements across the service. Each of the people living at Meade Close are funded for different levels of support. Several people had individual 1-2-1 hours funded to support them in accessing community activities. We were told the minimum number of staff required throughout the day was 7 and 5 at night. A review of staff rotas for a 5 week period showed commissioned hours had been achieved on all but 8 occasions. Separate records were held to show how staff were deployed each day by the shift leader.

We also found support was task focused and provided little flexibility for people. For instance, due to the high level of personal care and support required, particularly in bungalows 1 and 2, people were moved between the 2 properties so sufficient numbers of staff were available to carry out care tasks. Staff spoken with said current levels were not always enough and this did impact on what people could or could not do, as minimum numbers of staff needed to be available at Meade Close if other people were being supported with community activities. We were told the provider had been in discussions with the local authority over the last year about the funding for individuals, due to their changing needs. As arrangements had yet to be finalised, the provider had agreed to fund an additional staff member therefore increasing the core staffing number to 8.

We looked at the training, development and support for staff. A comprehensive induction was in place along with a programme of face to face and e-learning training. During the assessment we were told additional face-to-face training sessions had been planned and the new management team were planning to hold individual supervision meetings with staff.

Whilst staff had completed specialist training with the speech and language therapists and dietician, we found little evidence to show specialist training in the complex and sensory needs of people had been provided. Following our visits we were advised additional training was being sourced. The provider should also consider the Oliver McGowan Code of Practice and the requirements for learning disability and autism training. This training helps staff develop the skills to effectively engage with people with sensory impairment and no-verbal communication.

Staff recruitment processes were safe. Additional information had also been sought for overseas staff confirming their right to work in the UK. Staff spoken with felt most staff had a good working relationship and teamwork was good.

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.

Personal protective equipment was available along with soluble laundry and clinical waste bags. However we found in one bathroom, the clinical waste bin had been used with no bag lining the bin. This was addressed immediately following our visit. During our 3rd visit to the service staff told us there were on-going issues with laundry equipment being out of order, in both bungalows 1 and 2. We were told laundry was being sent across to bungalow 3 or taken to a laundry. We also found laundry areas were cluttered with items being stored.

In March 2025, the service was awarded ‘5 good’ by the food standard authority. However as identified above under ‘safe environments’, work was required to improve kitchen areas, including the cleaning of cupboards and replacement tiles. This had yet to be concluded, along with the cleaning of cooker hoods.

Policies were in place along with training to support and guide staff in maintaining hygiene standards as well as food safety. Audits and checks were completed in relation to hygiene standards within the home. Information provided showed a that hygiene standards within the home needed improving.

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

People did not always have their medicines administered safely or at the right times either because there was a delay in obtaining medicines or the prescribers’ and manufacturers’ directions were not followed. One person missed doses of vital medicines which placed their health at risk of harm and two people were not given antibiotics safely which meant the antibiotic may not have been fully effective.

The records about stocks of medicines were inaccurate and there were discrepancies between the stocks of medicines on the computer and the actual physical stock in the home. The provider told us after the inspection that due to the number of discrepancies found that a new system had been put in place to ensure, in the future, that medicines could be accounted for and had been administered as prescribed.

When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, the protocols to support their administration were not detailed enough to ensure they were administered safely and consistently.

Some people were fed through a tube in their stomach and also were given their medicines through the tube, however some staff who were administering feeds and medicines had not been trained and had not been assessed as safe to do so. Further assurances were sought following our visits. The provider was working with the GP and relevant healthcare professionals to ensure appropriate arrangements were in place.

There was contradictory information in some peoples care plans, one person care plan stated they could have food orally and in another part of the plan stated they had all their food through a feeding tube in their stomach. One person’s care plan listed food they could have which posed a choke risk and another person’s care plan recorded the water they were to be given via their feeding tube in three different places, but the entries did not match each other. It is important that staff have clear and accurate information to follow when supporting people.

The storage of medicines and equipment for the administration of medicines was not always safe or hygienic; there was a medicated toothpaste tube that was dirty as was the bottom shelf of the medicine trolley.

We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.