CQC report explained · a residential care home
What the CQC found at Tendring Meadows
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People received medicines safely and as prescribed. Risks such as choking, falls and pressure ulcers were managed, although one person's fluid and catheter records did not match and some as-needed medicines instructions lacked person-centred detail.
- Effective?
- Good
- The building had undergone major renovation, staff had training and competency checks, and people were supported with food, drink and healthcare. The home worked within the principles of the Mental Capacity Act.
- Caring?
- Good
- Staff were consistently kind and respectful, creating a calm and positive atmosphere. People's views, relationships, privacy and personal preferences were considered, although some older records needed more person-centred language.
- Responsive?
- Good
- Care was updated when people's needs changed, and people took part in activities linked to their interests. Complaints were recorded and responded to, but the home needed to analyse complaint themes more fully.
- Well-led?
- Good
- A registered manager and new directors were in place, with better leadership, staff support and partnership working. Governance systems were in place but still needed to be developed, embedded and sustained.
What inspectors found, October 2023
Rated Good after major improvement; the home is no longer in Special Measures, but new management must sustain its progress.
Inspectors visited unannounced on 30 August and 1 September 2023. They spoke with people, relatives, staff and professionals. They observed care and checked medicines, care plans, risk assessments and management records.
All five areas were rated Good. Inspectors found medicines were given safely, risks were managed, staffing was sufficient and infection controls were effective. They also found kind care, personalised support, meaningful activities and better communication with families.
The home had been rated Inadequate at the previous inspection and had been in Special Measures since March 2022. New directors and a new registered manager had made rapid improvements. The home was no longer in breach of regulations or in Special Measures, although some management systems still needed to be developed and sustained.
Safer medicines
Inspectors reviewed all 16 people's medicine records and found medicines were stored and given safely. Errors and near misses were investigated and used for learning.
“People received their medicines safely and as prescribed. Medicines were stored securely.” from the report
Major improvements
The new directors had invested in the building and grounds. Improvements included repairs, new flooring, bathrooms, heating, fencing and redecoration.
“There had been significant improvement works to the building under the new directors.” from the report
Kind and respectful care
Staff treated people with courtesy and respect. Inspectors described a calm and positive atmosphere, with privacy and dignity taken into account.
“Staff were seen to be consistently caring and kind, treating people with courtesy and respect.” from the report
Personalised activities
The activities coordinator helped people take part in meaningful activities in the home and community, including cinema and circus visits.
“The activities coordinator was proactive and thoughtful in supporting people to take part in meaningful social and leisure activities within their home and community.” from the report
Better leadership
A new registered manager and new directors had improved staff morale, communication and oversight. The home was working more proactively with other professionals.
“Staff morale had improved, and staff were now provided with the resources they needed to successfully carry out their roles.” from the report
Some medicines instructions needed more detail
needs fixingAll as-needed medicine protocols were present, but some did not explain enough about the individual person. Management said this would be addressed.
“However, some lacked person centred information that could support staff to better understand how to effectively use these medicines for the individual.” from the report
One set of records did not match
needs fixingFor one person, fluid intake and catheter output records did not tally. The manager updated the risk assessment during the inspection.
“We identified 1 person where records did not tally for their fluid intake and catheter output.” from the report
Systems still needed embedding
needs fixingThe home had introduced governance systems, but inspectors said these needed to be developed, embedded and sustained by the new management team.
“Improvements to governance systems needed to be developed, embedded, and sustained by the new management team, who told us they were committed to doing so.” from the report
Complaint learning could be stronger
minorComplaints were recorded with responses and outcomes, but the home needed to analyse themes and trends more clearly to show ongoing improvement.
“Further work was required to build on this through analysis of themes and trends in complaints to demonstrate continuous improvement.” from the report
- 01How will you make sure the new governance and audit systems continue to work over time?
- 02What extra person-centred information has been added to the as-needed medicines protocols?
- 03How do you check and correct fluid intake and catheter output records?
- 04Which renovation work remains unfinished, and when will the top floor reopen?
- 05How do you analyse complaints and use any themes to improve the service?
This was an unannounced follow-up inspection covering the five key questions, including infection prevention and control under Safe; the top floor was closed for renovation during the visit. This explanation was written from the published report of 5 October 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, February 2023
Tendring Meadows was rated Inadequate and remains in special measures, with serious safety and management failures despite some improvements.
This was an unannounced follow-up inspection. Inspectors visited on 8, 13 and 14 December 2022. They spoke with people, relatives, staff and other professionals, observed care, and checked records including care plans, medicines records, risk assessments and audits.
The home was still not safe. Medicines were not always given as prescribed, safeguarding concerns were not consistently reported, infection control was poor in some areas, and accidents and incidents were not properly analysed. The building also had safety and repair problems.
There had been improvements in staffing, choking risk assessments, food, complaints handling and some care records. Staff were described as kind and respectful. However, personalised care, people's involvement in care planning, activities, consent processes and the overall management of the home were still not reliable.
The overall rating was Inadequate. Safe and well-led were Inadequate. Effective, caring and responsive were Requires Improvement. The home remains in special measures and will be closely monitored.
Kind and respectful staff
Inspectors saw staff showing warmth and respect. People also said staff were kind and tried to make their lives easier.
“Despite the continued failings identified, staff were kind and caring, and treated people with respect and dignity.” from the report
Staffing had improved
The provider had recruited more staff and deployment had improved while most people were living on one floor. The home was no longer in breach of the staffing regulation.
“Enough improvement had been made at this inspection and the provider was no longer in breach of Regulation 18.” from the report
Food and kitchen improvements
Food and fluid records had improved, people had clearer menu choices, and the food hygiene score had risen to the maximum score.
“This meant the food hygiene rating score had improved from 0 to the maximum of 5.” from the report
Complaints were being handled
People and relatives could raise concerns, and records showed that complaints were logged and answered. However, the home was not yet analysing complaint patterns.
“Records showed complaints were being logged and responded to.” from the report
Unsafe medicines
seriousInspectors found missing administration records, incorrect doses, medicines given despite an allergy or after being stopped, and missing medicines. This placed people at serious risk of harm.
“Medicines management was unsafe, placing people at risk of harm.” from the report
Safeguarding and incident failures
seriousAccidents, injuries and possible abuse were not always recorded, investigated or reported to the right organisations. The provider was not consistently identifying patterns or learning from events.
“Incidents and accidents were not always recorded or raised with the local authority safeguarding team for investigation or notified to the CQC as required by law.” from the report
Unsafe and poorly maintained building
seriousSome areas were unhygienic and parts of the building needed repair. Inspectors found a damaged fence leading towards a busy road, unsafe fixtures and other external defects.
“The fence in the shared back garden was not secure enough to keep people safe, including people living with dementia who might not be able to assess risks, as this led onto a busy country road.” from the report
Care was not personalised
seriousRelatives were not always involved in care planning and reviews. Activities and equipment did not consistently reflect people's interests, needs or wider social and emotional wellbeing.
“People were not supported in a way that was personalised and specifically tailored to meet their needs.” from the report
Weak management oversight
seriousThe provider had no registered manager, frequent management changes and audits that did not always identify problems or lead to action. Improvements were not shown to be sustained.
“The provider had only made limited overall progress on improvement work and was still in breach of multiple regulations.” from the report
- 01What has been done to prevent missed, incorrect or unsafe medicines, and how are these checks now independently reviewed?
- 02How are choking risks monitored and how are the required monthly reports to CQC being completed on time?
- 03Who is currently responsible for managing the home, and when will the registered manager application be completed?
- 04How are relatives now involved in care plan reviews, and how are activities being matched to each person's interests?
- 05What repairs and cleaning work have been completed, including the garden fence, windows, cladding and bathroom equipment?
This was an unannounced follow-up inspection covering all five key questions, with particular attention to infection control, choking, medicines, accidents and incidents; the visit activity ran from 8 to 21 December 2022. This explanation was written from the published report of 3 February 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 Tendring Meadows
6 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2023Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2022Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- May 2021Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementWell-led: Inadequate
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015
Registered with the Care Quality Commission on 4 March 2015.
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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