CQC report explained · a residential care home
What the CQC found at Meadows Court Care Home
Not yet rated: the CQC has not published a rated inspection for this home, which is usual for a new registration.
What inspectors found, November 2023
Rated Inadequate and placed in special measures; inspectors found serious safety and management failures that put people at risk.
This was an unannounced focused inspection after concerns about medicines, risk management and people's care needs. Inspectors visited on 2 and 4 October 2023, spoke with people, relatives, staff and professionals, and checked care records, medicine records, staff files and audits.
The home was rated Inadequate for Safe and Well-led. Inspectors found poor risk assessments, unsafe medicine records, weak incident reporting, gaps in recruitment checks, maintenance problems and ineffective quality checks. These problems had continued despite concerns at four previous inspections.
People and relatives generally said they were happy with the care and felt safe. However, the inspection found that the systems behind the care were not reliable enough to protect people from avoidable harm. The overall rating changed from Requires Improvement to Inadequate.
Kind and caring staff
Inspectors found that the registered manager and staff were generally kind and wanted to provide good care. People and relatives also gave positive feedback about the staff team.
“The registered manager and staff were overall kind and caring and showed a desire to provide good care.” from the report
People felt safe
People and relatives told inspectors they felt safe and cared for, despite the serious problems found in the home's systems.
“One person told us, "I feel cared for, secure and safe.” from the report
Basic staffing levels
Inspectors found there were enough staff to meet people's basic needs, and people did not have to wait long for call bells to be answered.
“The provider had enough staff to meet people's basic needs.” from the report
Safeguarding awareness
Staff understood what abuse could look like, how to report concerns and how to safeguard people.
“Staff had a good understanding of what abuse would look like in practice and how to safeguard people.” from the report
Unsafe risk management
seriousImportant risks, including epilepsy, diabetes, bed rails, fire evacuation and moving and handling, were not assessed or managed well. Inspectors said this put people at risk of avoidable harm.
“Risks to people with significant health conditions had not been assessed.” from the report
Medicines not safely managed
seriousFour of the nine medicine records checked had incorrect stock counts. Inspectors said this suggested people may have received too much or too little medicine.
“This suggested people were either being given too much or too little medicine.” from the report
Poor recruitment checks
seriousThere were gaps in employment histories, concerns from DBS checks had not been explored and one staff member had no evidence of a DBS application. Agency staff were also living at the home without the related risks being assessed.
“A member of staff had no evidence of a DBS ever having been applied for.” from the report
Weak quality oversight
seriousAudits repeated earlier comments and failed to identify problems found during the inspection. The provider had not made or sustained improvements across five previous inspections.
“Audits had failed to identify any of the concerns we found during this inspection.” from the report
Poor environment and infection control
needs fixingInspectors found sticky furniture and floors, strong smells of urine, a dirty oven and damaged flooring that could increase the spread of bacteria. Infection control audits had not led to effective action.
“The laundry and shower room floors required repair or replacement as they posed a risk to the spread of bacteria.” from the report
Care records were too generic
needs fixingRecords used identical information for different people and did not properly describe individual needs, interests or preferences. People also reported limited activities and poor use of shared spaces.
“Documents were often generic and identical information carried across different people's care records.” from the report
- 01What specific changes have been made to assess and manage risks for people with epilepsy, diabetes and other serious health conditions?
- 02How do you now check that medicines are given correctly and that medicine stock counts and records are accurate?
- 03Have all DBS checks, employment histories and suitability checks for permanent and agency staff been completed and reviewed?
- 04What repairs, cleaning and infection control improvements have been completed, and how are these now checked?
- 05What evidence can you show that the action plan is being completed, with named people responsible and target dates?
This was a focused inspection of Safe and Well-led only; the ratings for the other key questions were carried over from the last inspection. This explanation was written from the published report of 8 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 2022
Meadows Court Care Home was Rated Requires Improvement; inspectors found risks were not always managed and quality checks were not reliable.
This was an unannounced inspection on 23 and 28 February 2022. One inspector spoke with people, staff and the manager, observed care, and checked care plans, medicines records, recruitment files, training information and quality records.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. Inspectors found that some care plans did not reflect people's current needs, some risks had not been properly assessed, and windows were not adequately restricted.
There were also weaknesses in the home's checks and oversight. The provider had started developing systems to analyse incidents and monitor quality, but these had not yet shown that they were effective. The inspection was prompted partly by an incident involving a person's death, but the inspection did not examine the circumstances of that incident because it was subject to a coronial investigation.
Enough staff
Inspectors found enough staff to meet people's needs. People said staff responded when they needed help.
“We found enough staff to meet people's needs. People told us there was enough staff and they responded when they required assistance.” from the report
Medicines
Medicines were given as prescribed and stored safely. Staff were trained and their competence was checked.
“People received their medicines as prescribed and in their preferred way. Medicines were stored safely in a locked room with access for trained staff only.” from the report
Safeguarding knowledge
Staff knew how to recognise and report abuse. Safeguarding training and a safeguarding policy were in place.
“Staff demonstrated knowledge of how to keep people safe from abuse and described how they would raise a concern with the registered manager or other external agencies.” from the report
Feedback
People, relatives and staff had ways to give feedback. Surveys and resident meetings were used to identify and respond to concerns.
“Systems were in place for people staff and relatives to feedback on the care provided.” from the report
Care plans and risk assessments
seriousSome people's risks and current needs were not fully recorded. This included catheter care, a risk of leaving the home and changed mobility needs.
“People who required support with catheter care did not have care plans or guidance in place.” from the report
Unsafe windows
seriousWindows were not adequately restricted and could be opened by hand. Inspectors said this created a risk of harm or injury.
“We found environmental risk were not assessed. For example, windows were not adequately restricted.” from the report
Infection control
seriousSome staff were seen wearing masks below their noses, including after this was raised with the manager. The provider also failed to check inspectors' COVID vaccination evidence before entry.
“We found staff not always wearing Personal Protective Equipment (PPE) correctly, we witnessed masks were often worn below the nose.” from the report
Quality checks
seriousThe home's audits and risk assessments did not identify all environmental and safety problems. The provider's admission policy also did not clearly set out what information was needed.
“The provider had failed to ensure there were effective quality monitoring systems and processes in place to monitor quality and safety of the service and maintain oversight.” from the report
CCTV information
needs fixingThe report found no documented evidence that CCTV had been discussed with people or their representatives when people lacked capacity.
“We found no documented evidence the use of CCTV was discussed with people or their representatives if they lacked capacity.” from the report
- 01What has been done to make sure every care plan reflects the person's current needs, including mobility and catheter care?
- 02What changes have been made to restrict the windows and check other environmental risks?
- 03How do you now check that staff wear PPE correctly and that required entry checks are completed?
- 04How are incidents analysed now, and how do you show that lessons have led to improvements?
- 05How is CCTV explained and agreed with residents or their representatives when someone lacks capacity?
This was an unannounced focused inspection of Safe and Well-led; the report did not give separate ratings for Effective, Caring or Responsive. This explanation was written from the published report of 29 April 2022 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 Meadows Court Care Home
5 rated inspections over 4 years: the service has slipped, from Requires improvement to Inadequate.
- November 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- April 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- February 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- August 2019Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018
Registered with the Care Quality Commission on 12 June 2018.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.