The Meadows Nursing 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

We looked at 7 quality statements under the Safe key question: Learning culture, safeguarding, involving people to manage risks, safe environments, safe and effective staffing, infection control and prevention, and medicines optimisation. We found risks to people were not managed or mitigated to protect them from the risk of harm. Staff did not always have up to date information to follow to ensure they were aware of people's current risks. Staff had not always received the training required to keep people safe. The provider had failed to ensure the environment was safe for people to live in. This resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Safe recruitment processes were not always followed. The provider had failed to ensure all relevant checks were undertaken before staff started to work at the service. This meant they could not be assured staff were suitable to work with vulnerable people. This resulted in a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some people we spoke with were aware of how to raise a concern or complaint. Two people told us they had not needed to make a complaint. We received mixed feedback from relatives, some felt communication was good, however, one relative felt they did not receive open communication during and following safety incidents which involved their family member, they told us they had raised a complaint but did not receive any response from this.

Staff had limited opportunities to discuss and reflect on safety incidents. Staff told us they had not had any one-to-one meetings. Some staff attended staff meetings. The manager told us they had started to have regular structured meetings where incidents from the previous day were discussed.

Systems in place to learn lessons when things went wrong were not effective. We found incident forms were not always completed. Analysis was not routinely undertaken to identify patterns and trends to prevent further incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Not all people felt safe. One person told us, “Sometimes I don’t feel safe as they [staff] talk to one another and not to me”. Another person said, “I don’t feel safe here, particularly at night”.

Not all staff had received safeguarding training. One staff member told us they had only been given safeguarding training following our visit.

During our visit we observed staff supporting people. On one occasion we witnessed poor moving and handling practice from a member of staff. The Inspector reported this to the manager who took the member of staff off the floor to be retrained in the correct moving and handling techniques. We saw 2 people had bruises which had not been documented or investigated by the provider as to how these had been acquired. These had not been raised as a concern by staff to the manager.

Whilst the manager responded appropriately to the safeguarding concerns we found during our visit, we found that the safeguarding policy was not always followed. We found the provider did not always notify the CQC and the Local Authority of all reportable incidents. Where mental capacity assessments had taken place records of assessments and best interest meetings had not been uploaded onto the providers electronic care records and could not be produced for us to review.

People told us they had not been involved in managing their risks. One person said, “I know I am losing weight; they don’t discuss my weight with me”.

The management team told us there were 3 people living at the service that required diets that were prepared to soft and bite sized consistency. However, there was no corresponding documentation to confirm this in the form of care plans or risk assessments. We discussed this with the manager, and they assured us they would make referrals to the speech and language therapy team and complete the relevant risk assessments. The manager told us they had systems in place such as daily handovers, flash meetings and weekly clinical meetings to enable staff to be kept up to date with any changes in people's needs. We reviewed these records, however, we found some of the meetings had not started or were not held consistently.

We observed unsafe practices during our visit. There was insufficient written guidance for staff about how identified risks were to be mitigated. For example, staff did not always support people who required their meals prepared to a specific consistency to reduce their risk of choking. We observed 2 out of the 3 people were not provided with food prepared to the required consistency during our visit. We observed some people had restrictions placed on their movement, however, this was not recorded on their care records and was not the least restrictive measures which could have been used. We found mattress settings were not always correct for people who were at risk of skin damage and support with repositioning was not always given as required. Where people had experienced skin damage records were not fully completed.

We were not assured risks to people were accurately assessed and mitigated including risk of choking, skin damage, weight loss and entrapment. The provider operated a ‘resident of the day’ where care records were reviewed to ensure they were accurate and up to date, however, we found that care records were not always regularly reviewed or accurate. Where people had lost weight, measures had not always been put in place to monitor this. Some records showed significant drops in weight, the manager told us the weighing scales had not been calibrated which meant people’s weight may not be accurate. The provider had not followed their own policies around restrictive practices.

One person told us there was an occasion where staff had left their call bell out of reach, they spoke with the staff, and it had not happened since. We saw 2 other people did not have their call bell within reach. Feedback from other people did not highlight any concerns they had about the safety of the environment.

One staff member told us they had not undertaken a fire drill and would not feel confident of what actions to take in the event of a fire.

The environment was not always safe for people. The provider had failed to ensure the environment was safe for people to live in. People were at risk of accessing items such as prescribed creams, drink thickening powder and razors, without staff supervision. This was of particular risk for those people living with dementia who were reliant on staff to maintain their safety. Chemicals were not always locked away when not in use and prescribed creams were not stored safely, this increased the risk of people accidently ingesting them and causing themselves harm. People who required bedrails did not have bumpers fitted to reduce the risk of entrapment. We found large items of furniture had not been secured to walls to prevent them accidently tipping over and hot surfaces had not been covered to protect people. Corridors were used for storing equipment and we found one fire door was blocked. We saw fluid on the floor in one of the corridors and no sign over it to prevent people from slipping. The provider could not be assured people would not be harmed from these risks.

The concerns we found had not been identified by the provider. Following our visit, we wrote to the provider to seek assurances that the high risk concerns we had identified would be addressed as a matter of urgency to ensure risks to people reduced. The provider sent us confirmation that they had had taken to address the concerns we found. We returned shortly after we found whilst most of the areas had been addressed, some prescribed creams were not locked away and not all hot surfaces had been adequately covered. The provider had not checked that the work undertaken had been completed to a satisfactory standard.

People told us there were not enough staff available to provide the support they needed. One person told us, “Sometimes it’s hard just to get a drink, sometimes they bring me one sometimes they don’t. I can wait a long time. There’s just not enough staff”. Another person said, “They [the staff] come in and leave very quickly. I can’t ask them anything, they are always in a hurry”.

Some staff we spoke with felt there were not enough staff to meet people’s needs. Staff told us “There’s not enough staff to meet people's needs and to manage risks” and “We are constantly understaffed, and everything is rushed here”. Another staff member said, “I feel one more staff is needed upstairs, some people need one to one support at night, and we can’t keep an eye on them”.

We saw staff were task focussed. There was little time spent providing positive engagement with people. Some people waited for a long time to have their lunch taken to them as staff were supporting other people. On the second day of our visit, we arrived early in the morning, there was only one member of staff on the upstairs unit, we saw some people had been up through the night and other people were up and walking around. Some people required the assistance of 2 care staff which meant a member of staff had to be called from the downstairs unit to provide support. Staff told us and we saw that training had not been provided or updated to ensure staff had the relevant skills and knowledge relevant to their role.

Staffing levels in the service were assessed by the provider using a dependency tool. The provider told us they felt there were enough staff to meet people’s needs. The provider told us they felt there were enough staff to meet people’s needs however, their dependency tool was not an accurate reflection of people’s experience or observations. Pre employment checks were not fully completed. We checked 3 staff recruitment files and found 2 had gaps in employment history and one did not contain any references. Ten members of agency staff had not completed an induction and 2 did not have an agency profile with details of their Disclosure and Barring Service (DBS),training records and relevant qualifications. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Training was not managed effectively; most staff did not have up to date required training required to carry out their roles.

People gave us mixed views on the cleanliness and hygiene at the service. One person told us the cleanliness of the home was not very good, they said, “those flowers have been dead over a week, and they have just been left there”. The same person also told us a staff member had offered them a drink out of a carton which had been left on the table for over two weeks. Another person told us “Its dirty sometimes, the corridors are so dirty”. Other people and relatives we spoke with felt the home was clean.

The manager told us infection prevention and control audits were completed and had started to discuss the outcomes of these at staff meetings. Some staff demonstrated a lack of understanding in how to follow safe practices, for example not all staff wore PPE correctly.

Some areas of the service were not clean, we saw food debris had not been cleaned from under some people’s beds, and one person’s mattress was soiled. At the time of our visit, one person was COVID 19 positive. A station for PPE had been set up outside the person’s room. However, we saw some staff were not wearing face masks correctly. We saw that continence products were not always disposed of correctly.

The provider had an up-to-date infection prevention and control (IPC) policy. We requested evidence of effective quality assurance checks in respect of IPC; however, the provider did not provide us with any evidence to review. At the time of our assessment less than 50% of staff had completed IPC training.

We could not be assured people were receiving their medicines safely. We found stock level discrepancies and medicine charts were not fully completed. This meant people may not be receiving their prescribed medicines correctly. Care plans were not in place for people taking short term medicines such as antibiotics. Some people were prescribed medicines to be taken on a when required (PRN) basis. PRN protocols in place to help staff give these medicines did not always contain sufficient guidance. Prescribed creams were not always stored safely. We found most people’s creams in their rooms were not locked away. Creams did not have an open date which meant the provider could not be assured creams were not being used past their effective date. A relative told us they had concerns about how medicines were administered to their loved one and that there was not always the correct gap between each administration. One person we spoke with said they had their medication given to them every day.

The manager told us staff responsible for administering medicines were required to undertake training and have their competencies checked. We asked to look at the competency checks for all staff administering medicines, we found 2 staff members did not have in date competency checks in place. One staff member was on duty and the manager arranged for this to be done on the day before they administered any further medication.

We were unable to assess if the provider's medicines policy reflected best practice and current guidance. We requested a copy of the providers medicines policy to review off site however this was not provided. The system for checking and auditing the administration of medicines had not been effective. Medicine audits were not consistently or fully completed by the provider and concerns we found at this assessment had not been identified by the provider. Systems in place did not ensure people had enough medicines available. We looked at 4 people’s medicines administration records, all 4 had not been given some of their medicines as it was not available. The providers systems did not ensure that medicines were managed in line with NICE guidance.