Ensuring ‘Confidence in Care’
through proactive and positive change
Ensuring ‘Confidence in Care’
through proactive and positive change
Thank you for taking an interest in finding out more about all the good work and superb progress that has been underway at Meadow Rose since the last CQC inspection, undertaken some 36 months ago.
The following information has been collated to provide transparency and assurance for those considering residential care at Meadow Rose for a loved one, to help ensure that such an important choice is fully informed.
About CQC methodology
The CQC is currently undertaking a whole system review of its inspection services, with new methodology yet to be published but expected to come into force in the latter part of 2023.
For the MACC Care Group this means that services are no longer being inspected based on CQC’s frequency model in line with the current gradings.
CQC continues to regularly inspect services whilst it undergoes transformation and its current decision to inspect is based on knowledge of their locations and through that knowledge, perceived ‘risk.’
Date of last CQC published inspection report – 1 October 2020 (This inspection focused on only two key lines of enquiry ‘Safe’ and ‘Well Led’ – there are five in total).
Ratings from a previous inspection for the key lines of enquiry, ‘Effective,’ ‘Caring’ and ‘Responsive’ were automatically generated from the last inspection which was published on 28 August 2019.
Overall rating: Requires Improvement
Key findings indicated that:
- Risks in relation to restraint had not been adequately assessed, monitored and reviewed and staff had not received the appropriate training and documentation to record these events consistently.
- Staff were inconsistent in how they described the techniques they used and had not considered whether a safeguarding alert should have been made when used.
- Some staff needed specific training on how to use restraint techniques.
- Systems to monitor the quality and safety of the service had not identified the areas for improvement found at this inspection.
- Lack of recording found in some staff files.
Highlights from the CQC report
The report also identified many positive examples of best practice:
- Staff told the inspectors there were enough staff to meet people’s needs.
- People were supported with their medicines safely.
- Systems were in place to ensure medicines were stored safely and regular audits were in place.
- The environment was clean and tidy.
- Good infection prevention control practices were in place and observed to be used.
- There was evidence that the Manager shared learning from incidents to reduce the risk of these happening again.
- Regular analysis took place to ensure that people were responded to in a timely way if they used their call bell to summon assistance.
- There was a Dignity Champion in place and regular audits were undertaken.
- Residents and relatives knew who the registered Manager was and spoke very positively about them.
- The management team were open throughout the inspection and showed a willingness to address concerns identified.
- The provider had systems in place to share learning across their services.
- There were regular staff meetings.
- Staff spoke positively about the management team, and felt able to raise concerns that would be listened to and addressed.
Driving changes for the better
Following the CQC inspection, MACC Care has taken the following steps to improve the service:
- A comprehensive action plan was provided to CQC detailing how we planned to make the required improvements.
- The Registered Manager continued to work with the staff team.
- The Group established its own internal review processes to measure and benchmark its services against MACC Care’s own expectations. These reviews are conducted by ex CQC Inspectors, a Dementia Care Specialist and an experienced Nurse Auditor.
- The Group established a Quality & Compliance Working Group to review the quality of the audit processes for all care services.
- Lessons learnt were written and shared with other Managers within the Group so that insights could be shared. Changes in practice (where identified) were made to further improve and drive quality.
- Since the last CQC inspection, we have undertaken a Survey with families and friends who rated our responsiveness as either ‘Good’ or ‘Outstanding’.
- Training was provided for staff in the use of restraint whilst this resident continued to reside at the home.
- Since this inspection, the provider has instigated a ‘NO RESTRAINT’ policy across all of its services.
Other key themes from their survey feedback included:
- 82% of staff rated the training they received as good or outstanding.
- 91% of staff rated their manager’s ability to share best practice as good or outstanding.
- 89% felt that the Manager was open to new ideas.
- 89% of the staff felt that the Manager was visible within the service and led by example.
- Professionals rated the communication and responsiveness of the home and its staff team as outstanding.
Internal Review processes
Frequent and thorough appraisal of services for your peace of mind
- Internal support teams at MACC Care are on hand to individually support our homes to deliver the best quality resident experience. Additionally, a range of audits are regularly undertaken at both home and organisational level to offer additional quality assurance.
- Internal home audits are completed in line with MACC Care’s Internal Governance Schedule – any patterns or trends are reviewed and added to the home’s service progression plan. This is regularly reviewed to ensure actions are sustained and embedded before they are authorised as closed.
- Insight Reviews have been developed and rolled out (MACC Care’s internal review methodology mapped to CQC’s methodology and regulations) and these are undertaken every six months.
- Follow-up Reviews are undertaken in between Insight Reviews to ensure that any areas for focus are addressed and the change in practice embedded.
- Regular Operational Visits are conducted to support the home Manager in service development and a reporting structure is in place to provide organisational assurance.
- Regular visits are also conducted by the Director of Regulation and Director of Operations.
- Regular ‘Meet the Manager’ events are held for families and friends of Meadow Rose.
Meadow Rose is currently rated 9.6/10 by significant others
We welcome feedback from our residents and relatives. To view the most recent comments, please the Meadow Rose page at carehome.co.uk
“I absolutely love it. Working in this field, you make a lot of friends and being able to put a smile on people’s faces and make a difference is very special for me personally and for all in the team.”
Steven Kazembe, Meadow Rose Manager
To find out more about the great things that are happening at Meadow Rose and the compassionate care and support available to your loved one, please email Steven or call him on 0121 476 9808.
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