Meadows Court Care Home

Updated 8 November 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Meadows Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Meadows Court Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 2 October 2023 and ended on 16 October 2023. We visited the location’s service on 2 and 4 October 2023. The inspection ended when we gave feedback to the provider and registered manager on 16 October 2023.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, Healthwatch England and professionals who work with the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 6 people and 12 of their relatives about their experience of the care. We spoke with 7 members of staff including the registered manager, catering and care staff and we spoke briefly with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with two professionals who work with the service and reviewed 10 people’s care records and 9 people’s medicine records. This included 2 people who were at the end of their life.

We reviewed 2 staff files and 3 agency staff files as well as looking at various quality assurance audits, documents and policies.

Updated 8 November 2023

About the service

Meadows Court Care Home is a residential care home providing accommodation and personal care to up to 22 people. The service provides support to older and younger people and people living with dementia. At the time of our inspection there were 18 people using the service.

Meadows Court Care Home are registered to provide care to people in their own homes, living in the community. However, the service was not providing this type of care at the time of the inspection or in the past 18 months. The provider told us they were applying to have this aspect of their registration removed.

Meadows Court Care Home is designed across two floors with bedrooms on both the ground and first floors. The service has 12 ensuite bedrooms and shared bathroom and toilet facilities. There are shared communal spaces such as lounges, dining room, conservatory and garden. The service also has a kitchen, laundry room and office on site.

People’s experience of using this service and what we found

Risk management was poor. People were not supported to have risks to their health and well-being assessed. Staff did not have sufficient guidance to understand how to identify when people’s health might be deteriorating and what to do. Where guidance was in place staff did not always follow this in practice which could lead to harm or improper treatment.

People were not supported to manage their medicines safely. Medicine records showed a significant number of discrepancies suggesting medicines were being administered incorrectly.

Recording of incidents and accidents was not consistent. Information was not accurately analysed to identify any increases of risk or deterioration of people’s health and well-being. There was a failure to learn lessons with a view to improving care following incidents occurring. This meant concerns about people’s health could go unnoticed.

Agency staff were living in the service. Not all recruitment checks had taken place to ensure the staff were of good character and suitable for their role. Risks to people in relation to staff living in the service had not been explored or assessed. This placed people at risk of harm or abuse.

People lived in a service where maintenance plans were not in place. This resulted in repairs not being addressed. Some of these such as damage to the flooring in the laundry and shower room could result in increases of bacteria and the spread of infection. Some areas where people lived also had a strong smell of urine.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice, however, the registered manager did not well understand best practice in this area. Records did not promote person centred care and identical information had been duplicated across a number of people’s records.

Quality assurance systems such as audits and surveys were ineffective in identifying areas for development and making improvements. We found significant failures in relation to registered manager and provider oversight of quality. This resulted in a failure by the provider to improve the service despite these concerns being identified at 4 previous inspections. This posed a risk to people’s safety, health and well-being.

Despite these findings, overall, people and relatives told us they were happy with the care they received.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (27 April 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We received concerns in relation to the management of medicines, management of risk, and people’s care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Meadows Court Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risks to people, staffing, medicines management and quality assurance at this inspection. Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.