CQC report explained · a residential care home
What the CQC found at Meadow's Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some time-critical medicines were given between 1 and 3 hours late on more than 10 occasions for one person. Risk assessments for some health conditions also lacked enough detail, although staffing, safeguarding and infection control were found to be in place.
- Effective?
- Good
- This key question was not inspected during this focused visit, so its previous rating was carried forward.
- Caring?
- Good
- This key question was not inspected during this focused visit, so its previous rating was carried forward.
- Responsive?
- Good
- This key question was not inspected during this focused visit, so its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management and communication had improved, but medicines and care-plan audits had not identified important shortfalls. The report said improvements needed time to become sustainable and part of everyday staff practice.
What inspectors found, November 2023
Meadow's Court was rated Requires Improvement; inspectors found delayed time-critical medicines and weaknesses in risk and capacity records.
This was an unannounced focused inspection on 29 August 2023. Inspectors checked whether the home had acted on an earlier improvement plan, focusing on Safe and Well-led. They spoke with people, relatives, staff and a professional, observed care, and reviewed care records, medicines records, recruitment files and management checks.
Some improvements had been made. Staff levels were safe, safeguarding processes were in place, infection control was effective, and people and staff described a warmer and more positive culture. However, some time-critical medicines were given late, and audits had not found or fixed this problem.
Risk assessments for some health conditions and mental capacity assessments needed more detail. The home was in breach of Regulation 12 on safe care and treatment. The overall rating stayed Requires Improvement, and this was the home's third consecutive rating at that level.
Safeguarding
Staff had safeguarding training and knew how to raise concerns. People told inspectors they felt safe.
“Staff had completed safeguarding training and were confident about raising concerns.” from the report
Infection control
Inspectors were assured that the home used protective equipment properly and had processes to prevent and manage infections.
“We were assured that the provider was using PPE effectively and safely.” from the report
Positive atmosphere
People, relatives and staff described a warm atmosphere and found the registered manager approachable and supportive.
“People, relatives and staff described a good, warm atmosphere in the service and felt the registered manager was approachable and supportive.” from the report
Learning from incidents
Accidents, incidents and falls were recorded and reviewed for patterns. Actions were taken and shared with staff.
“Accidents, incidents and falls were recorded in detail. These were analysed monthly to identify trends and themes.” from the report
Late time-critical medicines
seriousOne person's time-critical medicine was given 1 to 3 hours late on more than 10 occasions in August 2023. This created a risk of harm, although inspectors found no evidence that anyone had been harmed.
“People experienced delays in receiving time critical medicines.” from the report
Audits did not fix medicine problems
seriousMedicine audits had identified concerns about late medicines but had not been effective in making improvements.
“Medicine audits reviewed for August 2023 and previous medicine audits, identified this as a concern but had not been effective in making improvements.” from the report
Incomplete risk assessments
needs fixingCare plans existed for people with needs such as diabetes or epilepsy, but the related risk assessments did not always give staff enough guidance.
“The risk assessments were not sufficiently detailed to provide the guidance staff needed.” from the report
Mental capacity records
needs fixingMental capacity assessments were not always specific to the decision being made and did not clearly show when best-interest decisions should be used or who should be involved.
“Mental capacity assessments required further development to ensure these were decision specific and provided clear evidence as to when best interests decisions should be followed and who should be involved.” from the report
- 01How do you now make sure time-critical medicines are given at the prescribed time?
- 02What checks show that late medicines are identified and corrected quickly?
- 03How will you make risk assessments for conditions such as diabetes or epilepsy detailed enough for staff to follow?
- 04How are mental capacity assessments made specific to each decision, and who is involved in best-interest decisions?
- 05What evidence can you show that the recent management improvements have become consistent in everyday care?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2023
Requires Improvement overall; inspectors found unsafe medicines and poor leadership, with the well-led rating Inadequate.
This was an unannounced focused inspection on 26, 27 and 30 January 2023. Inspectors spoke with people living at the home, relatives, staff and a visiting professional. They also checked care records, medicines records, staff files and management records.
The home was rated Requires Improvement overall. Safe was rated Requires Improvement because medicines were not always managed safely and some care plans and risk assessments were out of date. Well-led was rated Inadequate because leadership, staff support and checks on the quality of care were not effective.
There were some positive findings. Staff were safely recruited and there were enough staff to meet people's needs. The home was clean and hygienic, and health and safety checks were completed. However, the provider remained in breach of Regulations 12 and 17, and CQC issued warning notices.
Enough staff
Inspectors found enough staff to meet people's needs and observed staff responding in a timely way.
“There were sufficient staff to meet people's needs. We observed staff responded to people in a timely manner.” from the report
Clean environment
The home, its furnishings and equipment were clean and hygienic. Infection prevention measures were in place.
“The environment, including furnishings and equipment were found to be clean and hygienic.” from the report
Safeguarding action
Staff understood their safeguarding responsibilities, and records showed that reported incidents were investigated and action was taken.
“Safeguarding procedures were followed when incidents had occurred.” from the report
Medicines were not always safe
seriousControlled medicines were not always stored securely. Some medicines were not dated after opening, records could be altered, and people did not always receive medicines as prescribed.
“People's prescribed medicines were not always administered safely and some medicines processes remained unsafe.” from the report
Out-of-date risk information
seriousCare plans and risk assessments did not always reflect changing needs. Inspectors found examples involving falls and choking risks.
“Risks to people were not always kept under review and care plans did not provide up to date guidance for staff to follow to mitigate those risks.” from the report
Weak leadership and checks
seriousThere was no registered manager at the time of the inspection. Provider audits did not identify important medicines, care planning and record-keeping problems.
“The provider failed to effectively monitor the quality and safety of the service.” from the report
Limited involvement
needs fixingPeople were not always involved in their care plans or reviews. Residents' meetings did not take place regularly, limiting opportunities to influence the service.
“There were limited opportunities for people and staff to give feedback on the service.” from the report
Staff support and training
needs fixingSome training was overdue, and staff meetings and supervision did not take place reliably. New staff had not had their practice checked through supervision.
“Staff told us and records showed staff meetings and supervisions also did not take place.” from the report
- 01What immediate changes have been made to medicines storage, dating, recording and administration?
- 02How are care plans and risk assessments now updated when someone's health or needs change?
- 03Who is responsible for the home day to day, and has the manager applied to become registered?
- 04How are overdue staff training, supervision and practice checks being completed and monitored?
- 05How can residents and relatives give feedback, and how will the home show that their views have led to changes?
This was an unannounced focused inspection of Safe and Well-led; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 22 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Meadow's Court
8 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- May 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- May 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- March 2021Goodstayed GoodSafe: Requires improvementWell-led: Good
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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