Meadowview Care Home

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• 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 identified 2 breaches of the legal regulations under this key question: relating to safe care and treatment, and governance. Family members consistently felt informed about changes in their relatives’ needs and expressed confidence that concerns were promptly addressed. Staff demonstrated an understanding of accident reporting and protocols, but lessons learned from incidents were not effectively shared, and some reviews were delayed. The admissions process was generally thorough, but short notice and inconsistent communication with staff affected preparation. Fire safety posed significant risks, with damaged fire doors, obstructed fire exits, and unresolved hazards, despite previous assessments identifying issues. The environment had additional safety concerns, such as damaged flooring and excessive wiring, which sometimes complicated care delivery. Infection prevention and control (IPC) measures were inconsistent, with malodorous rooms, damaged sealant, and gaps in cleaning schedules. The management team were informed about these concerns throughout our visit, and action was taken to escalate and schedule dates for work to commence. Staff were well-trained in safeguarding and familiar with policies. Medication management had notable gaps, including missed doses, insufficient guidance for ‘when required’ medications, and incomplete records for thickened fluids. Audits failed to address medication discrepancies or identify errors. There were enough staff to meet people’s needs, although some staff raised concerns about staffing levels of an evening. Recruitment practices were not always safe, with gaps in employment checks and incomplete inductions for agency staff. Family members and external professionals generally praised the staff’s competence and caring approach, but there were systemic issues in risk management and quality assurance.

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.

Family members shared they were kept informed about any changes in their relatives' needs. One family member commented, "I know I will always be informed if there are any problems. They let me know straight away." Additionally, people expressed confidence that any concerns they raised were promptly addressed and not repeated. This is reflected in the internal resident survey results, where 100% of respondents selected either strongly agree or agree to the related question.

Staff demonstrated a clear understanding of the procedures for reporting and recording accidents and incidents. They confidently explained the falls protocol and the steps to follow when someone experiences a fall. However, some staff noted debriefs were not conducted after incidents, and there was no formal sharing of learning among the team.

A falls protocol was in place and was consistently followed after each incident. However, not all accidents and incidents were reviewed by the registered manager in a timely manner. For example, one person experienced an unwitnessed fall, but the incident was not investigated by the registered manager until 3 months later. There was limited evidence of lessons learned being effectively communicated to the team through supervision or team meetings. Although incident reports indicated that lessons learned were shared verbally, team meeting minutes did not reflect any discussions regarding recent incidents. Additionally, there was no evidence of a review of accident and incident data to identify trends or promote learning to improve the service. Since the assessment, further evidence has been provided to show how accidents and incidents for the home are analysed.

Family members told us they primarily supported their relatives to hospital appointments. However, they noted in emergencies or when their relatives were unwell, staff acted promptly by contacting a doctor or emergency services. We spoke with family members whose relatives had transferred to the home following hospital discharge. They described the transition as smooth, expressed satisfaction with the care provided, and confirmed their family members’ needs were met. However, one family member highlighted, “The provider did not complete a pre-assessment.”

The registered manager provided a clear explanation of the pre-admission and admission processes. However, some staff reported they were not always informed about new admissions until the day they occurred. This short notice limited their ability to adequately prepare and ensure all necessary safety measures were in place. Staff we spoke with told us they learned about the needs of new admissions through the handover system and by reviewing care plans.

External professionals expressed positive views about the staff team. One health professional commented, “Staff here will come to me and ask if there is anything we can do to improve.”

The pre-admission paperwork for the five most recent admissions was comprehensive. There was evidence of multidisciplinary team (MDT) involvement, including input from family members. This thorough documentation ensured a safe and effective assessment of each individual's needs prior to admission. Additionally, hospital passports were in place for individuals requiring hospital admission, supporting continuity of care. Systems were in place to support the continuous monitoring of individuals' needs.

People and their families reported feeling confident in the safety of the home. Family members expressed staff had a good understanding of their relatives’ needs and knew how to ensure their safety. One family member shared, “The staff know all about [person] and what she is capable of.”

Staff reported being familiar with safeguarding policies and procedures, confidently explaining how they would report any safeguarding concerns. One staff member stated, “I would go straight to the manager.”

During our observations in communal areas, most people received appropriate and safe care. However, we noted some unsafe moving and handling practices. For instance, one person was pulled by the back of their legs to reposition their wheelchair away from a doorway. We raised this concern with the manager, who advised she would discuss with staff and take appropriate action. She also confirmed moving and handling training was being refreshed for most staff that day and competencies would be refreshed. We observed this training session taking place.

Staff received safeguarding training and consistently adhered to the established safeguarding policy. The safeguarding log demonstrated incidents were referred to the local authority when appropriate. However, we identified some safeguarding measures for people were not always followed. For example, the required 15 minute observations for one person was not always carried out in a timely manner. This was fed back to the management team who advised they would review this as they had been having some difficulties with alerts on the system they were using.

People reported feeling safe when staff supported them, and family members confirmed the necessary equipment was always available to assist their relatives when needed. For example, one family member shared that after a fall from the bed, “Everything has been put in place. [Name] has a sensor mat and the bed is lowered.”

Staff reported they could easily access risk assessments and care plans for people on their electronic handheld devices. In addition to using these assessments, staff shared examples of how they kept people safe, such as through regular observations, ensuring personal hygiene, using keypads on doors, and refreshing knowledge via staff training. All staff confirmed they had received training on the use of equipment. The registered manager outlined how peoples' changing needs were addressed through monthly reviews of care plans and risk assessments. Additionally, two people were designated as ‘residents of the day,’ and were asked by the registered manager if any changes were needed. They also spoke with all heads of departments to identify any changes in the person’s needs.

We observed staff providing appropriate support, such as assisting one person back to the lounge with the help of two staff members. However, we noted an instance of incorrect equipment use, where a sling intended for one person was used for a different person within the home.

Daily handover meetings were regularly held between shifts and documented, ensuring important information was shared effectively among staff members. However, we found risk assessments and care plans were not always consistent and lacked sufficient detail to effectively mitigate risk. For example, risk assessments were missing for people on modified diets who were at significant risk of choking. We raised the concern with the registered manager, and the missing assessments were implemented immediately.

Both people and their families expressed they felt the home was safe and met their needs effectively.

Some staff felt the home was safe to meet the needs of people. However, others expressed concerns about the safety of the environment . For example, excessive call bell and sensor wires under the beds obstructed care delivery. One staff member explained, “wires under the beds get in the way of moving beds when wanting to pull the bed out and safely reposition a resident,” while another added, “Wires under the bed get in the way.” These concerns were confirmed during our observations and raised with the registered manager. Most staff members told us they had participated in fire evacuations in the past. However, one staff member stated, “No, I have not been involved in any evacuations.”

Our observations raised concerns about the safety of the environment, particularly regarding fire safety compliance. Several fire doors were damaged, or did not close fully, and some fire exits were obstructed by items such as trolleys and external furniture. While some issues were addressed during our visit, others remained unresolved. However, since our visit, work has commenced to replace the damaged fire doors. Parts of the building were in disrepair, such as damaged flooring near a fire exit, posing a trip hazard. Despite these concerns being previously raised in a health and safety meeting, no remedial action had been taken by the time of our visit. We fed back these observations to the maintenance operative and registered manager who escalated to the provider. We referred these issues to the local Fire and Rescue Service who visited the home following our assessment. The outcome of their audit was broadly compliant/above average and they were happy that work was being carried out to rectify any issues.

Some fire safety checks were found to be ineffective, with significant concerns unaddressed. Despite a 2022 fire risk assessment and internal fire door audits in 2024 identifying fire doors as high risk, replacements had not been scheduled by the time of our visit. While a quote to replace the doors was obtained in August 2024, we were not provided with evidence to confirm that further action had been taken. Since the assessment, evidence has been provided confirming that communication had been ongoing since August 2024 with a contractor to confirm start dates for work to commence. The director confirmed work to replace the doors had been arranged to start on 12 November 2024. The registered manager acknowledged the need for improvements throughout the home but confirmed there was no formal improvement plan with timelines in place. She told us that this would be escalated to the provider. Since the assessment, the provider has evidenced that there is an action plan in place which the home is working towards.

People and their families felt there were always enough staff on duty, and staff appeared well-trained to perform their roles effectively. Feedback included comments such as, “Nothing is ever too much” and “They have been great, cannot fault the staff. Not one of them worry me.”

Staff reported they had received inductions and regular supervisions. Some staff felt there was enough staff, while others expressed concerns about staffing levels during certain times of the day, such as at night or later in the afternoon. One staff member stated, “There is not enough staff, especially later on in the afternoon after tea when staff are trying to put them [people] to bed.” Another commented, “Not enough staff on nights because of the needs of the residents in the home.” This was fed back to the registered manager who advised a review would be undertaken. She explained staffing levels were determined using a dependency tool, which was reviewed with each admission, discharge, or change in persons’ needs. Records of out of hours visits undertaken by the manager have been provided which highlight sufficient staffing levels throughout the night.

During both days of the assessment, there were sufficient staffing levels to meet people’s needs.

A review of 4 recruitment files revealed staff were not always recruited safely. While all staff had undergone Disclosure and Barring Service (DBS) checks before starting, gaps in employment and medical declarations were not always explored. The registered manager acknowledged no system was in place to address this issue but said she would add a question to the recruitment forms to collect this information. Induction records were not consistently maintained. For instance, there was no evidence of inductions for agency staff. This issue was raised with the registered manager, who said they would ensure inductions for agency staff were completed. The supervision matrix showed staff were receiving regular supervisions and appraisals.

People and their families confirmed staff consistently wore appropriate Personal Protective Equipment (PPE) when providing care. One relative stated, “Staff always wear gloves and aprons.” Family members shared they were kept informed of any outbreaks within the home and measures were implemented to reduce risk, such as COVID testing.

Staff we spoke with told us there was enough PPE available in the home. Staff did not think the building was clean. One staff member commented, “The cleaning could be a bit better” and another stated, “I don’t think the home is very clean at all.”

The service was not consistently clean, with some rooms having malodours. PPE dispensers were empty, requiring staff to access PPE from a central location instead of at the point of care. Stains were observed on toilet bases and flooring, and damaged sealant in some areas posed a risk of infection. Additionally, the sluice room was out of operation, which the registered manager told us was an ongoing issue.

Daily cleaning records were completed, though there were gaps in the daily kitchen cleaning schedule. All staff had completed infection prevention and control (IPC) training. A comprehensive IPC policy was in place, covering areas such as hand hygiene, PPE use, and safe management of care equipment. Regular IPC audits were conducted, including observations of staff practice. However, they were not effective in identifying the concerns we found during our assessment.

People felt fully supported with their medication, and family members were unaware of any medication errors.

Staff confirmed they had completed training in medicines management and had their competencies checked 2 to 3 times a year. They were able to explain the process for reporting medication errors, with one staff member stating, “I would report to the manager or deputy, and pharmacy or GP are called. If there is an overdose; then a competency check is done again.”

Medicines were not always managed safely, and people did not always receive their medication as prescribed. For example, one person missed their medication for two consecutive weeks. Some people required thickened fluids for safe swallowing, but there were no records to confirm if the correct amount of thickener was added to the drinks of all these people. There were also issues identified with the handling of prescribed thickeners; instead of being administered on an individual basis, the same pot of thickener was used for all people who required it. Following our visit, fluid charts were implemented for all people who were prescribed thickener to record the amount administered. Medication Audits failed to identify the concerns we found, and stock discrepancies with medication were not always documented or investigated. We found staff did not always follow the process for reporting medication errors, meaning no action was taken in some cases. Guidance for medications to be taken ‘when required’ was not always available or lacked sufficient detail. This meant individuals who were unable to communicate their pain might be left untreated, as staff had no clear guidance to follow. This was implemented immediately following our visit.