Meadows Edge Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service had a vision statement which had recently been implemented by the new manager. Therefore, this was not yet embedded in the service. The provider did not always take into account the cultural needs of people living at the service. Although there was a new manager in place they had not had time to embed changes identified. There have been several managers in the last year. The provider did not have set systems and processes in place for new managers to follow to ensure there was good governance and oversight.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager at Meadows Edge Care Home shared a Vision statement with us. However, there was no evidence the strategy was actively used to drive improvements in care. It was not visible within the home or embedded within the staff team. Following the assessment the service shared with us their August news letter where the manager is positive about the culture of the home. Additionally a poster celebrating a member of care staff was also shared with us.

The service vision statement which was called, ‘My Vision and strategy’ referenced “Cultural Diversity by fostering an environment of inclusivity and respect, we ensure that everyone feels a sense of belonging and that diverse perspectives enrich our care practices and community life.’ There were people living at the service from several different nationalities However, we were told by staff that the service did not cater for foods from different nationalities and were told that families would bring foods into the home. Following the draft report we were advised that there was a person who preferred the way in which their family member prepared their traditional dishes. There was a handbook to support staff where English was not their first language. However, the handbook was written in English. We were told staff were able to use a translation app on their phone. Following the feedback a QR code was shared with us that had been added to the handbook to enable staff to translate the document into their preferred language.

The manager was new to the service but was a registered manager who managed another service owned by the provider. The manager recognised there were areas of improvement needed and said that they were working with the provider and the staff to make these improvements. The service was yet to see the impact of any sustained or embedded changes.

There has not been a registered manager at the service since 27 September 2023. The service has a history of home managers who do not stay at the service for long periods of time making it difficult for improvements to be sustained or embedded. The provider had failed to implement changes at Meadows Edge that would improve the safety, effectiveness of governance at the service. When the home manager is not at Meadows Edge there is a deputy manager who was formerly referred to as the finance manager and a clinical lead. The current clinical lead had been in post since 1 August 2024 and was being supported in their role by the manager and clinical lead at the sister home. The support from the sister home had not been in place on previous assessments of the service.

Staff told us there was no issues with staff being able to speak up and give feedback. The manager said they were working on empowering and supporting staff to speak up. The provider said they support a horizontal management style where everyone is able to speak up.

The service has a whistleblowing policy in place. The provider said they had spoken to staff during supervision about following a chain of command where staff should approach their line manager first with any concerns. The service had an information board about raising concerns the board had been present at the last assessment. Information displayed told people and staff to go directly to CQC if they had a concern. The manager agreed that this was not correct, staff should talk to their line manager and then the home manager. The manager said that in the long term they had plans to remove information boards such as this from that living areas but that it was not a priority. Although the board was still in place at the time of the assessment the manager had placed posters around the home including in peoples bedrooms introducing themselves and asking people, staff and visitors to reach out with any feedback. These was a risk of these posters causing some confusion as the manager was introducing themselves as the registered manager, when they are not the registered manager for this service and are registered for a service in Yorkshire.

The service has a diverse workforce with staff from several different nationalities. Staff said they were treated equally.

The provider asked staff during supervision if they had any none work related issues that they would like to discuss as well as accommodating staff with different shift patterns to fit in with other commitments. Supporting the staff to maintain a work life balance.

The home manager completed a manager’s report to the provider. We were able to review the report for August 2024 which had been completed by the new manager but were not assured that this had been happening prior to the new manager supporting at the service. As part of this assessment, we were not given an overview of all of the audits carried out at the service. The provider told us that they had been visiting the home and completing their own audits, we asked to see these, but these had not been shared with us when we sent the draft report. Therefore, we were not able to review these documents or be assured by the governance processed in place at the service.

The provider failed to have effective audits in place to be able to recognise and act on issues within the home. There have been continued breaches in relation to governance where we have identified new issues within the home that have not been identified prior to the assessment. For example, the provider had not identified that they had not been following their own risk assessments for disposing of waste when maintenance work had been carried out at the service. There had been a CQC assessment visit on 26 August 2024, this was a Tuesday following a bank holiday. Wood and other waste materials had been left against the side of the building blocking a fire door causing a fire hazard. Any Actions taken are often responsive to areas of improvement identified CQC. The new manager had recognised that there was a lack of suitable governance and oversight at the service. They were starting to put systems and processes in place. However, these were not yet fully embedded.

The service did not always work seamlessly to support people when sharing information. We found people who had not received their mental health medication for prolonged periods of time. The provider had not taken action when changes had been made to a person’s care.

The manager told us they were working to improve relationships with health care professionals but that this was not yet fully effective, and they were continuing to act in order to support this being embedded.

We spoke with health care professionals who said communication was not always effective. They said that they had called the service asking for a person they were going to support with wound care to be on their bed when they arrived. However, this had not happened.

The manager was implementing new ways of working to improve information sharing these were yet to be fully embedded at the service.

The manager had identified that the services approach to lessons learned was not robust because processes used by former managers were not effective. They were implementing a new approach where staff would complete a lesson learned form. We did not find anything innovative at the service. This had been reported on in past CQC reports, but no action had been taken by the provider.

We found that when incidents had happened in the last month, although lessons learnt had been looked at the root cause analysis was not effective. For example, where a person had been involved in an incident when being hoisted the manager had recognised that staff needed manual handling training. However, they had not considered the person’s distress during the incident and what could have been done to reduce this.