The Meadowcroft 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

This is the first inspection of this newly registered service and therefore, we assessed all 7 quality statements from this key question. Based on the findings of this assessment, our rating for this key question is requires improvement. This meant the service was not consistently managed and well-led.. This was because we identified issues in relation to the effectiveness of how the provider operated their governance systems and how records had been managed. The provider's governance systems had failed to pick up and/or address a number of issues we identified during this inspection including, how medicines and risks were managed, and staff not being routinely supervised. We also found the record keeping in relation to managing risks to people needed to improve. These represented a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. The managers had the skills, knowledge, experience to lead effectively. The provider’s culture was positive, open, and honest, with leadership and management that was clearly identifiable and transparent. The provider worked collaboratively with external health and social care agencies and professionals to plan and deliver people’s packages of care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers and staff told us they aimed to give people they supported the best quality person-centred care they could. The managers had a clear vision for the service and told us they routinely used individual supervision and appraisal meetings to remind staff about the provider’s underlying core values and principles.

The service aimed to give people consistently good care and staff worked together to try and achieve this. Individual, group staff meetings, and work performance appraisal was routinely used by the provider to remind staff about their organisations underlying core values and principles.

Staff told us the care home was well-led by suitably competent and approachable managers. The feedback we received from staff about the new manager was generally positive. Typical comments included, “I prefer the new manager who has a better understanding of clinical matters as a qualified nurse”, “The new manager is very good. It helps she’s a nurse I think” and “She [new manager] is supportive and always around to offer her professional advice.”

The managers had the relevant skills, knowledge, and experience to effectively lead the service, which they did so with integrity, openness and honesty. A relative told us, “The new manager is suitably qualified and experienced. She has set high standards for the service to achieve, which we’re confident she will make.” Another relative added, “I think the new manager is a good listener, handles situations well and has already begun to improve the care home.” The provider demonstrated they were adhering to workers’ rights legislation concerning sick, parental and compassionate leave. They worked with an external occupational health company to ensure they made any reasonable adjustments to role responsibilities or the working environment. However, the provider needed to ensure that their processes are robust and that any identified shortfalls are addressed. We noticed that, even though audits were being carried out by trained professionals, actions were not consistently followed up.

The provider valued and listened to the views of staff. Staff told us they were encouraged to contribute their ideas about what the service did well and what they could do better during regular meetings with their managers and fellow co-workers.

The provider promoted an open and inclusive culture which sought the views of people using the service, their relatives, and staff who worked for them. They used a range of methods to gather people’s views about the quality of the care they received from this provider. For example, people living in the care home and their relatives were routinely invited to join in meetings with the managers and staff and participate in the providers own customer satisfaction surveys. A relative told us, “I feel comfortable to approach the new care home manager with any concerns and I am more confident they will be dealt with quickly.” Another relative added, “The new manager has been holding regular meetings with us, so we’ve now got more opportunities to share our opinions about the standard of care they provide. The manager is much better at responding to any concerns we raise.”

Staff told us they were treated well and not discriminated against. They also said they worked well together as part of a varied and diverse workforce which reflected the local community.

The provider valued and listened to the views of staff and they were encouraged to contribute their ideas about what the service did well and what they could do better.

It was clear from the feedback we received from the care homes new manager that they recognised the importance of learning lessons and continuous improvement to ensure they maintained good quality and safe care and support for people living at the care home. The managers and nursing staff acknowledged that some of the issues we identified as part of this assessment were areas they needed to improve upon including, how they operated their oversight and scrutiny systems.

We found the providers governance processes were not robust in identifying issues that were picked up during the inspection. For example, the provider’s medicines audits failed to identify the significant numbers of missed medicines errors we found. We found the providers governance processes were not robust in following up on issues that were identified during their own quality assurance and auditing processes. For example, the provider’s medicines audits identified some issues with regards to nurse training/competency assessments and the recording of medicines fridge temperature checks. However, there was no follow-up action plan to rectify this, even though some these issues had been identified in 3 consecutive monthly audits going back to April 2024. Some of the manager's assurance checks were not taking place regularly. For example, the daily manager walkaround records were only completed 18 times in May 2024, 11 times in June 2024 and twice in July. There were no records seen for the Months of February, March and April 2024. The provider submitted a record of all the incidents and accidents records. When we reviewed these during the assessment, there were a number of outstanding incident and accident reports that were pending sign off. We queried the outstanding reports with the manager and the regional manager who acknowledged that the process around this was ‘not set up properly’ and needed improvement. Despite this, staff did record any incidents and accidents that occurred within the service. We could not be assured that the provider had established effective systems or processes to ensure the overall management of the regulated activity. This represented a breach of regulation 17.

People told us staff supported them to stay in contact with external health and social care professionals and agencies as and when they needed them. A relative told us, “The provider and the GP work well together to put in good protocols for what staff should do to keep my [family member] safe.”

The managers and staff told us they regularly consulted external health and social care professionals and agencies, welcomed their views and advice, and shared best care practice ideas with their staff team. Staff told us they worked with a number of community teams to support people. One member of staff said, “The GP, various out-reach teams including district nurses, regularly visit us to offer their advice and support.”

External health and social care professionals expressed being generally satisfied with the way the provider collaborated with them. An external health care professional told us, “Staff listen and act upon any professional advice you give them and work in partnership with us.” Another added, “The working relationship we have with this care home has significantly improved since the new manager took over and is now very good. We have noted they now call and engage with us much better than before, which has helped prevent people from being admitted to hospital unnecessarily.”

The provider worked closely with various external health and social care professionals and bodies including, GPs, district nurses, Behaviour and Communication Needs Team, social workers and Local Authorities. For example, monthly meetings between senior nurses working in the care home and a local GP had recently been introduced by the new manager and covered a wide range of clinical topics including, falls, infection control, ambulance call outs, weekend out of hours support and end of life care.

It was clear from the feedback we received from managers and staff they recognised the importance of learning lessons and continuous improvement to ensure they maintained person-centred and safe care for people they supported.

The provider worked closely with various external health and social care professionals and bodies including, GPs, district nurses, Behaviour and Communication Needs Team, social workers and Local Authorities. For example, monthly meetings between senior nurses working in the care home and a local GP had recently been introduced by the new manager and covered a wide range of clinical topics including, falls, infection control, ambulance call outs, weekend out of hours support and end of life care.