Meadway Court

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 requires improvement. At this assessment the rating has remained 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 continued breach of legal regulation in relation to the management of people’s safety and mitigation of risk and the safe management and administration of people’s medicines. The provider had not taken sufficient action in relation to our previous recommendation around staffing and was now in breach of this regulation.

This service scored 50 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had processes in place to enable learning from accidents, incidents and falls. Staff consistently supported people appropriately during incidents. However, the systems for oversight were not always effective and it was not clear that people always had their care plans reviewed following an incident. We found that records did not always demonstrate that additional referrals were being made, such as a referral to the falls team following more than one fall. Where people’s care plan made reference to specific exercises that needed to be done, records did not reflect that these were being regularly completed. The management team were responsive to feedback and took action to address areas of concern.

The provider did not always work effectively 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.

We found that the systems in place to monitor people’s safety was not always used effectively. For example, it was not always evident that the service was following their policy in relation to falls or clearly documenting where this advice had been sought and the guidance given. There was evidence that staff were working with other health care professionals including doctors and nurses.

The provider did not always work effectively with people and healthcare partners to understand what being safe meant to them and how to achieve that. Records did not demonstrate a focus on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People generally told us they felt safe with one person commenting, “I feel safe because there are people around.” A family member told us, “I can leave [after a visit] knowing that [family member] is in good hands.”

The provider had suitable policies in place and staff received training around safeguarding. However, we noted some shortfalls in the oversight and management of risk meaning that people were not always kept safe from avoidable harm. This including incidents between people living at the home.

The provider did not always work well with people to understand and manage risks. 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.

There was limited evidence in the records to demonstrate how people and families’ views were sought in relation to care planning and management of risk. Some family member told us they were involved in decisions around their relatives care with one commenting, “I am involved in all aspects of care and kept updated, and if anything changes, I am informed.” However, not everyone was able to confirm this was the case or were aware of information within their own or their relative’s care plans. People had a variety of risk assessments in place. However, not all of these had been completed accurately. For example, risk assessments in relation to skin integrity or falls risk had not always been accurately completed to reflect the person’s current needs. We found occasions where people had fallen, or had an incident, but not all relevant aspects of their care plan had been reviewed. We found one instance where a person did not have a falls risk assessment in place despite them having several falls. The management team were responsive to feedback and took action to address the feedback we gave.

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

The home was generally clean and tidy and malodours were mostly quickly addressed. There were regular checks of the environment and equipment was suitably serviced and maintained. However, whilst there were some adaptions to support people living with dementia, we found that further work to help people remain orientated and independent was needed in line with best practice guidance.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Recruitment processes were completed with relevant checks. However, it was not evident that gaps in people’s work history were sufficiently explored, or that all possibilities to gain assurances about a prospective employee’s character had been undertaken, when only dates of employment were provided within a formal reference. The provider had introduced an audit of recruitment records which was completed at the end of the process. However, this had not been completed for all the recruitment records we reviewed and did not demonstrate that any conflicting dates were noted and further explored with the employee.

Staff completed a variety of training and were generally kept up to date. However, we were not assured the provider was following best practice guidelines in how they trained their staff regarding how to interact appropriately with autistic people and people who have a learning disability at a level appropriate to their role.

We received mixed views about staffing levels. One relative told us, “The communal areas are always manned. [Family Member] is safe and well looked after.” However, one person told us, “There is not always enough staff and you can wait for a while for them to respond to the call bell.” Call bell logs reflected that there were occasions where staff had not been able to respond to people quickly. One staff member commented “I would like more staff so we can spend time with people, it can be difficult [on one unit].” Another staff member commented, “You don’t get protected time [to complete aspects of your job] you have to find it in your day.” We observed staff were very busy and not always visible across the home.

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.

The home was generally clean and we saw domestic staff worked hard throughout the day. However, we noted that staff were not always following good infection control practice. For example, on one day of inspection we found the laundry room was disorganised and a system of dirty to clean pathway was not being utilised, but this was improved by our second visit. We found one occasion where soiled clothing and continence products had been left on the floor of a person’s ensuite bathroom and were told this was not uncommon by staff. Infection prevention and control audits were completed and had identified shortfalls, but this had not yet led to the action needed to address all these concerns.

Records did not always show that people were receiving good levels of support with personal care in line with care plans and preferences. Several people’s records indicated they went long periods of time only receiving a wash, rather than bath or shower and the records did not demonstrate that this was the person’s preference. A number of family members commented that they would like to see their family member have more frequent personal care and their hair washed more often. We found examples where toothbrushes were not in place or had not been used although records indicated that support with oral care was needed and had been given.

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

We continued to find shortfalls in the oversight of medicines management. This included the oversight of the levels of medicines, including controlled drugs stored within the home, and appropriate arrangements for the disposal of medicines. We found several stock counts were incorrect and found 2 occasions where a medicine had not clearly been signed as given. We asked the provider to raise a safeguarding referral in one of these cases. There continued to be shortfalls in the management of variable dose medicines but we did note some improvements in the management of cold storage medicines. Protocols for medicines people had ‘as required’ were in place, but did not consistently follow good practice guidance or the provider’s policy. Following feedback, the management team introduced further systems for checks and oversight of medicines and reassessed all staff members competency to administer medicine.