Meadows Edge Care 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 identified 2 breaches of the legal regulations. Staff did not always assess risks to people's health and safety or mitigate them where identified and medicines were not safely managed. The environment was not maintained to a standard to ensure people remained safe. The provider had made improvements in 2 areas and was no longer in breach of regulation relating to safeguarding people from abuse and having enough staff to meet people’s needs.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives did not give any feedback on how the learning culture affected their experience in the service.

The manager had introduced a new system to analyse and learn lessons from events that happened such as accidents or complaints. Nursing staff said that lessons learned were shared with them through team meetings and other meetings known as, ‘safety huddles’. People’s care records were updated to reflect the lessons learned which helped to minimise risk. Care staff completed incident forms and that issues were escalated, and action taken to keep people safe.

Systems were in place and action plans identified where further staff training was required to embed learning, for example, falls prevention training. However, the systems were not sufficiently embedded, and the analysis had not fully reviewed the causes of incidents to enable effective learning. For example, analysis of incidents when people slid out of chairs did not identify the initial cause of the incidents. This meant learning had not been clearly identified which increased the risk of this happening with other people. The manager had introduced lead roles for staff in areas such as tissue viability, and training was planned to enhance their skills and knowledge in those areas. This meant named staff could support the staff team with up-to-date information and promote good practice.

Relatives told us their loved ones received the support from healthcare professionals they needed. One relative told us, “I have come in and seen that my relative has swollen feet and I have told the staff about this and straight away they have acted by getting the GP in and putting cream on and doing everything they have been told to do to get my relative’s swollen legs to reduce.”

Nursing staff knew which external professionals supported people and how to refer for specialist support services when needed. Communication with healthcare professionals was not always supportive of people’s care. This had resulted in delays in people receiving necessary treatment and advice from healthcare professionals. The manager was confident that referrals were now made to appropriate support services. They told us how a new electronic record keeping system should improve the sharing of information with external professionals. However, as the systems had not yet been used for this purpose we could not be fully assured this would resolve any issues.

Health care professionals told us their working relationships with the clinical staff in the home were good. However, they noted that at times there were some communication issues between themselves and the leadership team in the home. In addition, they said at time staff were not up to date with people’s needs and some staff’s command of English impeded their communication regarding people’s medical needs.

Processes to support people to transition between services were inconsistent. This was identified by the new manager. For example, one person’s medicine had been changed and staff had not realised the person had not been receiving an alternative medication for several months. The person had experienced an extreme change in their behaviour and well-being and staff were struggling to meet their needs. However, routine referrals to specialist support services were made about people’s health needs. Records showed involvement of, for example, Speech and Language teams (SALT). In addition, staff had worked with healthcare professionals to ensure continuity of care for a person recently discharged from hospital.

Relative’s views of safety were mixed. One person told us, “I am not sure if I think my relative is safe here.” They explained their loved one had fallen and they had not been told how or why the fall had happened. Another relative told us, “[Family members] go to see our relative every week. They always look clean, clean clothes and have their hair done.”

Staff had received training in safeguarding people from abuse. They were clear on the different types of abuse which may harm people. Staff had identified people may not always be able to tell them about any harm so were aware they needed to be vigilant for any signs of abuse. Staff were clear on how to report abuse both within the home and to external agencies.

Whilst people were not able to tell us about their experience of care, we saw they looked comfortable in the company of staff and staff were kind when speaking with them.

Processes were now in place to ensure any suspected or actual abuse was reported in the correct way. The manager kept an accurate log of safeguarding concerns and worked collaboratively with the local authority safeguarding team to investigate reports.

Relatives told us they felt the care provided met people’s needs. One relative told us, “[Name’s] personal care seems to be good, they have not had any bed sores and always have cream on their face when I kiss them.” Another relative said, “I have not been told that my relative has had any falls and I have not seen any evidence of falls such as bruising. I am reassured that my relative is safe here.”

Nursing staff demonstrated an understanding of the risks identified for people and how those risks were managed. They explained how they monitored weight and pressure areas to ensure planned care met people’s needs, and any new or increased risks were identified quickly. Staff provided pressure reliving care to people at risk of developing pressure ulcers. However, consistent care was not always provided for people. For example, one person had a pressure ulcer and needed to be repositioned every 2 hours. Records showed there had been times when they had not been repositioned for between 3 and 6 hours. This put the person at potential risk of developing further pressure ulcers and could impact on the healing of existing pressure ulcers.

Some people were being supported to manage identified risks. For example, where people needed help to mobilise or with eating and drinking. The staff followed risk assessments and had equipment in place to support this such as hoists, specialist mattresses and sensor mats. However, staff did not consider the risks of leaving people living with dementia unsupervised. We saw one person sat at the table waiting for their lunch, there were no staff in the dining room area. The person took the top off a salt pot and started to tip the contents into their mouth. Staff had to be alerted to this risk by the inspector.

Some risk assessments and care plans were in place and generally reflected people’s needs. For example, the specific slings people needed to stay safe when being hoisted were clearly recorded. However, other risk assessments, such as for bedrails, contained minimal information and did not provide clear guidance for staff about how to manage the risk. Some care staff lacked insight about when to reassess risks and the care provided. The report of a recent incident where a person fell from a sling whilst being assisted to move showed the person was not cooperating fully with the move. They were moving around the sling making the transfer unsafe. Staff failed to stop and reassess the situation to see if action could be taken to make the transfer safer. The manager identified that staff needed to have competency checks in moving and handling people. However, there were no records to show this had taken place. In addition, the manager identified the sling in use was not appropriate and ensured it was not used in the future. The provider was in the process of moving care records to an electronic recording system. Some care information had been transferred to the electronic system and some remained in a paper format. This meant some information was difficult to locate and not always easily accessible. The manager told us, “The care plans are still half and half until everyone is on the system.” They confirmed they had a deadline to get all the information on the new system. This did not fully support staff in providing consistent care for people’s current needs. Nationally recognised tools were used to assess risks related to needs such as skin integrity and continence.

Relative’s told us they were happy with the environment. One relative said, “I believe that [Name] is now living in a nice environment, not a care home which is awesome for me. This is a nice place to be, giving people the respect and dignity they deserve.” Whilst the people we spoke with expressed they were generally happy with the environment it did not meet the expected standards.

We discussed the currently available accommodation with the manager and deputy manager. They explained that upstairs was currently not available to use as it was waiting on refurbishment and a number of rooms downstairs were also undergoing refurbishment.

Waste material from the demolition of a flat roof had been piled up against the outside of the building. This was a fire risk. In addition, we saw access to this area had not been restricted by way of safety fencing. This increased the risk of people, some of whom may live with dementia, accessing the area and experiencing harm. Flammable materials were stored under a staircase. This increased the fire risk in this part of the building. The courtyard had a safety surface which was made of rubber to reduce the risk of injury in people fell over. However, we saw this surface had lifted in numerous places which presented a tripping hazard. This had not been identified by the provider as a maintenance issue. The bedrooms on 2 ground floor corridors had patio doors into the courtyards, the frame were in need of repair. In addition, there was a wire hanging loose in the courtyard area which was a ligature risk. The home was registered for 48 people, with bedrooms upstairs and downstairs. Upstairs accommodation was not in use because some of the bedrooms and bathrooms needed attention for them to be safe. This was identified at our last assessment in April 2024. No work had been completed upstairs since our last assessment. In addition, a further 6 bedrooms on the ground floor also required refurbishment. This meant the service could only safely accommodate 22 people.

The provider identified in their vision statement they prioritised the safety of residents, staff and visitors. However, the systems the provider had in place were not effective in identifying or managing the environmental risks in the home. The provider’s 6 monthly check of maintenance requirements completed on 22 May 2024 had failed to identity risks noted above. In addition, they had a risk assessment in place to ensure building works were carried out safely. The risk assessment was completed by the manager and dated 12 August 2024. In relation to fire risk, it identified the combustible materials that could be a hazard, and the additional measures needed to keep people safe during the building works. This included ensuring combustible waste was regularly cleared from the site and stored away from the building. During the assessment we saw the provider had not ensured work was carried out in line with their risk assessment which increased the risk of a fire.

Relatives had mixed views on the effective ness of staffing in the home. One person said, “All the staff including the kitchen staff are approachable, visible and caring not only for my relative but also for myself and my partner.” However, another relative commented on the communication skills of staff. They said, “I know there is a language difference… The staff now don’t seem so engaging.”

There were enough staff on duty to meet people’s needs. The staff were confident they had the training needed to meet people’s needs safely.

We saw where a person had been identified as needing continuous support and supervision this was in place. Staff were aware they could not leave this person unattended and ensured they had passed the responsibility to another member of staff before leaving them.

The provider had a dependency tool to calculate the needs of people living at the home and to provide assurance that they had enough staff on duty to meet people’s needs safely. However, we saw that the dependency tool used for August 2024 had not correctly identified people’s needs. For example, people had been identified as low needs but on reviewing their care plans against the dependency profile this indicated their needs were medium or high needs. This meant there was a risk that the provider’s systems may not support safe staffing levels for people. The provider had a training policy in place which identified the training staff needed to provide safe care to people. However, the training matrix provided showed there were some gaps in people’s training needs. For example, only 5 out of 30 staff had completed required training in the control of substances hazardous to health. The provider had systems in place to check people’s references and completed Disclosure and Barring checks (DBS). However, recruitment records showed the provider had not ensured they had received a full employment history to enable them to be confident staff were suitable to work with people.

Relatives told us the home was clean when they visited. One person said, “[Name]’s bedroom is clean.”

We spoke with nursing staff about how they managed infection prevention and control when carrying out nursing tasks such as dressings. They described in detail the processes they followed from preparation to disposal of contaminated items, which were in line with good practice. In addition, they described how they would manage and report any outbreaks which was in line with the provider’s policies and procedures.

We observed nursing and care staff using personal protective equipment (PPE) in line with good practice and carrying out good handwashing procedures at appropriate times. On both days of this assessment, we saw that the housekeepers had 2 mops on their trolley but only one bucket. Housekeepers told us they would not use both mops in the same bucket. However, this increased the risk of them not working in line with good practice guidance regarding cross infection.

The provider had systems in place to support staff to work in line with infection control guidance. For example, staff completed training in infection prevention and control. Regular audits were undertaken to identify areas where improvements were needed. For example, mattress and pillow audits were completed for each person when care plans were reviewed.

Care plans for people who were given medicines to help support them when they were distressed did not provide sufficient information for staff to identify triggers or de-escalation techniques they could try. Some people were prescribed these medicines regularly and this had not been appropriately reviewed by the GP. Behavioural records for people contained limited information and therefore could not be relied upon to understand whether these medicines were required. These medicines can cause sedation, increasing the risk of falls.

Staff felt supported by senior leaders at the service. They received feedback regarding incidents in staff meetings.

During the previous assessment care plans did not always contain sufficient information for staff to support people with complex conditions such as diabetes. On this assessment we saw that improvements had not been made, and in some care plans there was conflicting information about how diabetes should be managed. We reviewed records for one person whose blood glucose levels were consistently above what was documented as their normal range. There was no evidence that this had been escalated appropriately. This meant that people’s medical conditions were not always being managed effectively. Staff did not always monitor bowels for people. This meant that staff were unaware if people were constipated and required treatment, or if existing treatment was effective and was a risk of harm to people. A medicines policy was in place. However, we requested medicines related audits after the assessment, but none were received at the time of sending this draft report.