Archived: Meadow Green

Updated 20 September 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place 29 June and 12 July 2016. The visit on 29 June 2016 was unannounced and the visit on 12 July 2016 was announced.

The inspection team on the first day of our inspection consisted of two adult social care inspectors and an expert by experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The area of expertise for the expert by experience on this inspection was as a family carer of a person living with dementia. On the second day one adult social care inspector visited the service.

Prior to our inspection we reviewed all the information we held about the service. This included information from notifications received from the registered provider and feedback from the local authority safeguarding team and commissioners.

We had not sent the provider a ‘Provider Information Return’ (PIR) form prior to the inspection. This form enables the provider to submit information in advance about their service to inform the inspection.

We used a number of different methods to help us understand the experiences of people who used the service, including observations and speaking with people. We spoke with 15 people who used the service, two relatives, six members of staff, the manager, the operations manager and a quality manager. We looked in the flats of four people who used the service with their permission. During our visit we spent time looking at five people’s care and support records. We also looked at two records relating to staff recruitment, training records, incident records, and a selection of the service’s audits.

Updated 20 September 2016

This inspection took place on 29 June and 12 July 2016. The visit on 29 June 2016 was unannounced and the visit on 12 July 2016 was announced.

We previously inspected the service on 08 and 10 January 2016 and at that time we found the registered provider was not meeting a number of Health and social Care Act regulations relating to person centred care; consent; managing risk; managing medicines; good governance and sufficient staffing, as well as failing to notify the Care Quality Commission (CQC) of safeguarding incidents or allegations.

After the last inspection we issued a warning notice for Regulation 17, good governance and told the registered provider to make improvements. The registered provider sent us an action plan telling us what they were going to do to make sure they were meeting the regulations. On this inspection we checked to see if improvements had been made.

Meadow Green is an extra care housing scheme registered to provide personal care, consisting of 53 one or two bedroom flats. People who live at Meadow Green have their own tenancies. The service also includes Meadow Green Lodge, a separate building of 10 flats which delivers specialist support to people living with Dementia. The extra care scheme has on-site care staff 24 hours a day. The building has an alarm service, lift, lounge, restaurant, garden, an activities room and hairdressing salon. The building is owned by Kirklees Council and managed by Pinnacle Housing, who were responsible for the alarm call system, cleaning, maintaining and security of the building and grounds. At the time of our inspection 29 people were receiving support with personal care.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The current manager had commenced employment with the service in April 2016 and had applied to register with CQC. At the time of this inspection the application had not been finalised.

People who lived at Meadow Green told us they felt safe and said the service had improved greatly in recent months.

The registered provider showed us they had safe recruitment and selection procedures in place and vetted staff before they commenced employment with the service. However, the registered provider had not referred two staff members who were dismissed in November 2015 to the Disclosure and Barring Service (DBS) until May 2016. The DBS helps employers make safer recruitment decisions and reduces the risk of unsuitable people working with vulnerable groups. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, fit and proper persons employed.

Staff had a good understanding about how to safeguard adults from abuse and who to contact if they suspected any abuse.

Individual incidents and accidents were analysed and measures put in place to reduce future risks to people. Risk assessments minimised risk whilst promoting people’s independence.

There were enough suitably trained staff to meet the assessed needs of people who used the service.

Medicines were managed in a safe way for people, although some gaps in recording had not been addressed through the audit system of the service.

Staff had received an induction, supervision, appraisal and specialist training to enable them to provide support to the people who used the service. This ensured they had the knowledge and skills to support the people who lived there.

People’s consent was sought when decisions needed to be made. The registered provider was seeking clarification regarding responsibilities for Mental Capacity Act (2005) assessments and showed us evidence capacity was being considered when decisions needed to be made though they had misinterpreted some aspects of the law.

People were supported to eat a good balanced diet. People were supported to access a range of healthcare professionals as the need arose.

Staff were caring and supported people in a way that maintained their dignity and privacy and people were supported to be as independent as possible throughout their daily lives.

Individual needs were assessed and met through the development of detailed personalised care plans and risk assessments, although one record we sampled had not been updated to reflect the persons current needs. People and their representatives were involved in care planning and reviews.

People told us they knew how to complain and said staff were always approachable.

The manager felt supported by the registered provider and frequent visits were made to the service by the area manager and the registered provider’s quality team. The registered provider had oversight of the service. They audited and monitored the service however the system had not picked up and addressed the problems we found with gaps in recording. This was a breach of regulation 17 (2) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations

The registered provider had not notified CQC of all safeguarding incidents or concerns in line with their registration responsibilities. This was a continuing breach of Regulation 18 (2) (e) of the Care Quality commission (Registration) Regulations 2009 (Part 4).

People who used the service, their relatives and staff told us the service was well-led and they had confidence in the new manager.

Incidents and accidents were analysed across the service for lessons learned in order to mitigate future risks to people.

The manager was visible in the service and knew the needs of the people who used the service.

The manager and the registered provider had introduced a range of quality improvement systems which had a positive impact on people, including audit and oversight of the pendant alarm system used by people living at Meadow Green to summon assistance in an emergency.

The manager held meetings with people who used the service, their relatives and staff to gain feedback about the service they provided to people.

.You can see what action we told the provider to take at the back of the full version of the report.