Inspection on 15/07/08 for Home Meadow

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Home Meadow 24/07/07

Home Meadow 28/07/06

Home Meadow 14/10/05

Home Meadow 17/06/05

Home Meadow 18/10/04

Home Meadow 24/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Home Meadow Comberton Road Toft Cambridgeshire CB23 7RY Lead Inspector Shirley Christopher Unannounced Inspection 15th July 2008 9:10 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Home Meadow Address Comberton Road Toft Cambridgeshire CB23 7RY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01223 263282 01223 264201 admin@homemeadow.healthcarehomes.co.uk Home Meadow Limited Susan Kerry Care Home 42 Category(ies) of Dementia (42), Old age, not falling within any registration, with number other category (42) of places Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Minimum staffing at night must be 3 staff Date of last inspection 24th July 2007 Brief Description of the Service: Home Meadow is situated in the village of Toft approximately seven miles from the centre of Cambridge. There is a public house in the village and a shop that provides a wide range of services including a post office. A limited bus service operates between Toft and Cambridge. The building is single storey and is divided into five flats. Each flat accommodates between five and eight people. Two of the flats are for people who have dementia and another flat accommodates short stay residents. Each flat has a bathroom with WC, a further WC, a kitchenette, and a lounge/dining area and between five and eight single bedrooms. The home has a day centre with a large lounge and service users in the home use this for communal gatherings when the day centre is not in use. The home has well maintained gardens. Fees for the service vary. They are between £575 and £633 a week. A copy of CSCI’ s inspection report is available on request. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We the Commission for Social Care inspection carried out an unannounced key inspection on 15 July 2008. The inspection lasted 7.5 hours and was carried out by two inspectors. Before the inspection we asked the manager to complete an Annual Quality Assurance Assessment, (AQAA) which gives us information about how is meeting the National Minimum Standards. It also identifies areas where they have improved and areas where improvements are necessary. This self-audit tool forms part of our evidence. Surveys were circulated to staff, residents and visitors. This also forms part of our evidence. On the day of inspection we spoke to the manager, staff, residents and visitors. We looked at a number of records and did some case tracking, which means we looked at residents care records and spoke to residents and staff about what the residents needs were. We carried out a piece of observation known as ‘SOFI’ (short observational framework for inspection), for 1.5 hours. In this time we observed a number of residents in the dementia care unit and recorded their state of being, ranging from positive to negative, withdrawn or asleep. We also recorded staff’s interaction with residents and whether it was positive or negative. Feedback was given at the end of inspection. A tour of the home was undertaken and staff were observed as they undertook tasks, such as serving up meals. After the inspection we wrote to the home regarding a serious concern we had identified during our inspection. Although discussed at the time of inspection we wanted the home to let us know as soon as possible what actions they had taken to address these concerns. We received a full and detailed response from the manager before the given timescale and were satisfied that the home has addressed this matter. What the service does well: The manager has been in post for less than a year. In that time recruitment has improved and the home is now fully staffed with minimum use of agency staff. Staff are well trained and supported through good induction, supervision and staff appraisal. Consultation about practices within the home takes place through regular staff, relative and residents meetings. The AQAA was well written and clearly identified areas requiring further development and areas where the homes performance had improved. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is adequate. People’s needs are not always thoroughly assessed before they move into the home which means that staff may not be able to care for them properly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that the statement of purpose has been updated and that all residents or their families are issued with a service user guide. We looked at a number of files for people who had been recently admitted to the home. This provided us with evidence that staff complete a pre admission assessment. Pre admission information was considered poor for the residents receiving respite care. Of the two files inspected, one contained two assessments, which related to a previous stay. Information from the latest assessment completed by the local authority stated that the persons needs had Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 9 changed. They required more assistance with washing and dressing than on previous stays, however there was no care plan in place for this. There were other records in this file relating to risks and manual handling, but these had not been updated after each new admission. The second file showed evidence that other agencies had been involved with the assessment and the information was up to date, although the initial information contained significant gaps such as no information about next of kin, very little social or family history, little information about patterns of daily living or what the person needed assistance with to promote or maintain their independence. A third file relating to a permanent resident provided evidence that a pre admission assessment had been carried out but again the information was poor. It did not give clear reasons for admission and there was very little family history or social background. It was noted on two of the three files that weight and height had not been recorded. Assessments from other agencies were also available. On the day of inspection a new resident had been admitted for a short period of time. This was their first stay. The relative accompanying them was spoken to and had not been given some basic information about the home such as the need to label clothing, laundry arrangements or the routines of the home. She had not seen a copy of the service user guide. The resident was helped to settle in by the relative and made welcome by other residents receiving respite care. The resident was unclear about the routines of the home such as mealtimes and staff did not spend time orientating him within the first few hours of his stay. The home does not provide intermediate care. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. People using the service can expect staff to understand their needs and meet them according to their expressed wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made at the last inspection about care plans and the manager has worked hard to improve them. This was evidenced through looking at care plans which had been updated, and looking at a few that had not. Gaps were clearly identified in the old style care plan, but were much more detailed in the updated ones. From the care plans we identified that in the improved care plan information was presented in a much more person centred way. It was written in the first person, and stated ‘how I would like to be assisted.’ It gave information about the strengths and needs of the person. An involvement sheet indicated who had been involved with drawing up the care plan. It had been reviewed monthly. From the care plan we were able to Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 11 identify the residents needs and know what their preferred routines of daily living were. It gave us insight about meeting the resident’s needs from when they woke up in the morning until they retired to bed. There was a separate night care plan in place. A life story and family history was also included. Issues around maintaining the person’s privacy and dignity clearly identified how staff were to conduct themselves. Risk assessments were in place and were regularly assessed. This persons record did not address their nutritional needs. The persons weight showed large variations. Although an explanation was given for this, a nutritional assessment or referral to a GP or dietician was not recorded. A room risk assessment had been completed because the person was prone to fall in their room. It was noted that people are not assessed to see if they are able to use the call bell and this should be included as part of the risk assessment. We spent time in the dementia care unit observing interaction between staff and residents, looking at care plans and asking staff about meeting resident’s needs. The care plans on this unit had been updated and gave good information about the persons needs. They were written in the first person and clearly explained what they may have difficulty with and how staff can help them with it. There was some evidence that the care plan is not always followed. For example there were details in the care plan that one person liked to wear dresses, but staff said she was always dressed in trousers. The care plan stated she likes to be helped to say grace before meals. Staff stated this is not done. Another lady needed assistance to get ready before going to church. The relative stated that staff are not always available and the volunteer has to get her ready. Care plans for residents coming in for a period of respite care were seen. Some basic information was missing such as photograph and weight on admission. The base line assessment was limited to yes/no answers and there were no descriptors for behaviour. A person was described as ‘restless, agitated’ without explaining how the behaviour manifests itself. Care plans also lacked any substance such as needs assistance with personal care, but did not state what assistance. The daily notes gave information about daily needs, for which there were no care plans in place. One person was described as being depressed and having early onset of dementia. The care plan in place stated they needed a lot of reassurance to maintain their well-being. Daily notes recorded very little social interaction or activity but showed this person spending time in their room or in the lounge with very little reference to maintaining positive well-being. The daily notes also indicated the person wore pads, but the care plan stated that they could use the toilet with prompts and made no reference to incontinence pads. No action has been taken regarding their fluctuating weight although the daily records indicated that the person is not always willing to eat/drink. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 12 Health care needs are adequately met, but we expressed concerns about resident’s nutritional needs. Monthly menus show that the home provides a balanced diet and residents are given plenty of opportunity to eat fresh fruit and vegetables. A number of resident’s files showed that weight loss had not been responded to and nutritional assessments were not in place. It was not always made clear to the chef what, if any, special dietary requirements residents had. There was no written information held in the kitchen about residents nutritional or dietary needs, although catering staff were told about them verbally. Evidence of consultation with other professionals was provided. The manager stated that the home had regular input from two separate doctors surgeries and they were currently reviewing resident’s medication to ensure it was still required. The district nurse and community psychiatric nurses visit on request. The manager stated that the falls prevention co coordinator had been contacted with regards to two resident who were identified at risk of frequent falls. Risk assessments tended to state. ‘Check hourly’ and other measures had not been recorded even when the person was clearly prone to falls. Incidents such as minor aggression between residents were recorded but did not include any follow up action. Medication was administered at lunchtime. We observed medication being given and signed for without staff watching that medication had been swallowed. Medication was checked and was adequately recorded with no gaps. Medication supplies are audited. Drugs were kept in an orderly fashion, individually prescribed and a record of the temperature of the drugs cupboard kept. Stock records were up to date and there was a record of homely medicines, individually prescribed. Medication had been reviewed and a few people were responsible for taking their own medication with appropriate risk assessments in place for this. Medication was administered close to the prescribers instruction and administration times were flexible. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. People’s individual preferences and routines are recorded and the home is run in the interest of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs two part time activities co coordinators. There are different activities provided every day and these are clearly displayed around the home. Examples included poetry, baking, exercise, stitching and gardening. There is a visiting ‘Pat dog’ and other community groups visit the home. The AQAA stated that a monthly church service is held in the home and celebrates all faiths. Special dates in the calendar are celebrated. The home has a weekly sweet trolley and a visiting library. Special occasions are marked and there are regular planned events. The manager stated in the AQAA that a list of monthly activities is circulated to all residents so they know what’s available and can decide whether to attend. Social histories have been updated since the care plans have been revised. These give a good insight into peoples social interests and life histories. One Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 14 staff member said routines in the home are flexible and residents can get up as they wish. This was supported by a number of residents spoken to and in care plans. The manager stated in the AQAA that practices are changing and residents individual wishes are known and respected, such as meal times and times of rising and retiring. One resident said that staffing levels were not appropriate to need. Several visitors who completed surveys supported this statement. One person stated that “other than meal times you do not see staff unless you use your call bell”, that there was little interaction outside the normal routines and that there is very little opportunity to go outside and some residents are never taken out. On the day of inspection it was a lovely day and all the residents were inside. A visitor arrived and took her relative outside. She was spoken to and felt the home was good in meeting her relative’s needs, and what she described as her difficult behaviour. Throughout our period of observation particularly around mealtime it was noted that tables were appropriately laid out. Resident’s chose where they sat and staff were attentive. Menus were displayed and residents have a choice of meal. On the day of inspection the meal on the menu did not tally with what was provided. Staff explained what the meal was but did not check with each resident that they wanted the food before it was served up. In the dementia care unit residents had to wait for their food, and when the trolley arrived several residents were asleep. A choice was offered at breakfast and residents were given breakfast as and when they wanted it. Staff on the dementia care unit had a good rapport with residents and offered choice in a way that residents could understand. Fresh fruit was available at the breakfast table. Staff were observed engaging residents in daily tasks such as laying and clearing the table. Information could not be provided about resident’s dietary needs, particularly in relation to people coming in for respite care who may require a special diet. Information sharing between staff and catering staff was described as a ‘hit and miss’ affair. Staff were observed offering residents a choice in terms of activities of daily living and staff asked residents if they wanted the television on or music. Staff interacted with residents in an appropriate way, meeting their requests and spending time talking with them. Residents were offered newspapers. Limited interaction was observed in the unit offering respite care. A member of staff served up the resident’s meal and left. The unit was left unattended for the time we were there talking to residents and visitors. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. Safeguards are in place to protect people’s rights and deal efficiently with any complaints or concerns people using the service may have. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home keeps a record of complaints and recent complaints were inspected. There is a clear complaints procedure. The AQAA stated that the home have received a low number of complaints and positive feedback. Recent training has been provided to staff on safeguarding adults and safeguarding protocols were easy at hand. Recent loss of property was dealt with by the home and relevant authorities had been notified. The Commission has not received any complaints about the home. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. People using the service benefit from a well maintained and purpose built unit. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Good levels of cleanliness were observed throughout the home. Unpleasant odours were confined to a number of bedrooms and should be dealt with. The home had photographs of residents and staff participating in activities in the corridors. Artwork is displayed on the walls. The manager stated that access to the garden had been improved and the garden is fully accessible. Residents had been involved in choosing colour schemes in the home and flooring had been replaced. No maintenance issues were identified. The registration of the home has recently changed to increase Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 17 the number of people with a diagnosis of dementia. There are two dementia care units accommodating up to eighteen people, (sixteen permanent and two respite care beds). The proposal is to knock the dementia care units into one large unit. Before this is done there must be consultation with other authorities such as the fire services and the registration team, (CSCI). There should also be consultation with people using the service and their relatives. The effects that a change to the environment may create for the people living in the home must also be considered. The manager is advised to review the staffing levels and consult with specialist agencies such as the Alzheimer’s Society and the falls prevention coordinator to ensure that there are sufficient safeguards are in place. The storage room by the kitchen was left unlocked. This room stored industrial cleaning materials and one resident was observed walking towards the kitchen having lost their way. On this occasion staff quickly intervened. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. People using the service can be confident that staff receive all the required training and induction to ensure they are able to fulfil their duties properly. Shortfalls in recruitment procedures undermine this process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We inspected four staff training records, which showed staff completed all their statutory training and records were up to date. Some staff had completed specialist training such as dementia care. We spoke to staff and were told that they were well supported and had plenty of opportunities to undertake training. Staff received regular supervision and felt that the manager and senior staff were supportive and they felt able to make suggestions or raise concerns. Staff spoken to felt residents were treated well and staff demonstrated a good understanding of their needs and how these should be met. Two staff files inspected showed the homes records were adequate. Training and induction were up to date. The home had completed necessary checks Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 19 before employment commenced. One person had completed a curriculum vita but not the application form. The requirement is for a completed application form. No references were seen. This person had been employed through a recruitment agency, but the home must ensure all the required information is available. Concerns have been expressed about the staffing levels. Issues were raised before the inspection to the contact centre, during the inspection and comments were received back from surveys received by the CSCI. Some staff felt that the increased numbers of people with dementia had put pressure on staff during the day and night and it was felt consequently some resident’s needs would not be met. One resident stated ‘you do not see staff from one hour to the next’. One relative commented on ‘residents sitting for long periods of time’ unsupervised by staff. A relative stated ‘problems occur when they do not have enough staff to cover. Mum often feels hurried because they don’t have enough time.’ The home must keep staffing ratios under review. This was discussed with the manager and she stated that additional staff at night were being looked at, but she considered staffing levels during the day sufficient. On the day of inspection the manager confirmed that they were fully staffed. Several staff had been appointed to vacant posts and the manager was just waiting for all the recruitment checks to be received. Staffing rotas were inspected and staffing levels were being maintained. The use of agency staff is kept to a minimum. On the day of inspection there were six care staff, 1 senior and the manager. There was also a team of ancillary staff; 2 cleaners, 1 house keeper, 1 cook, 1 catering assistant, 1 administrator, I maintenance person, 2 activities persons and a laundry assistant. There are three night staff on duty and they are all based in the dementia care unit but two do hourly checks in the other areas of the home. This arrangement needs to be reviewed along side the accident/incident records and any other relevant evidence. At the weekend there are no cleaning staff. This is of concern and should be reviewed. Staffing levels at the weekend should not be different to levels maintained in the week. Catering staff had received appropriate training. Several relatives and one staff member stated that there is sometimes a language barrier between staff who do not speak English as their first language, and residents who may already have a communication difficulty. The manager stated that staff complete English classes once they are employed. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is good. People receiving a service benefit from a well planned and well managed service which is responsive to their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has recently been registered with the Commission and said she has employed a deputy manager. The home is fully staffed and is well run. Staff spoken to felt supported and there are systems in place to improve staff’s performance, such as regular training, supervision and staff meetings. Relatives meetings also take place. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 21 A number of records were checked and were satisfactory. This included staff and resident’s records, medication, and resident’s finances for which there is a clear audit trail. The area manager undertakes regular visits to the service and completes a report of the findings. The manager completes a number of audits such as health and safety and infection control. Although these were satisfactory some had not been completed by the due date and others did not state if action identified had been completed. The infection control policy had not been updated for several years. Other policies were not inspected. Maintenance was up to date according to records and no maintenance issues were identified. Fire records were satisfactory and up to date. The manager was asked to contact the fire officer to update the fire risk assessment and discuss changes to the building to ensure fire escape routes remain appropriate and the plans of the building up to date. Recent evacuation drills had been completed. Health Care Homes have their own quality audit system. The home has achieved the Investors in People Award within the last twelve months. Staff are well supported and supervision and appraisal are good. The manager does complete some audits and was able to evidence consultation with relatives, residents and staff. The manager stated that residents meetings are held monthly for which minutes are available. Yearly audits are sent out by Health Care Homes, but evidence of this was not requested. The CSCI received a low number of completed surveys. Six in total were completed out of a possible 20. Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 2 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 2 Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12(1)(a) (b) Requirement Unintentional weight loss must be monitored and appropriate nutritional screening must be undertaken and referrals made to the dietician and GP when necessary to ensure the health of residents. Falls must be closely monitored and action taken to minimise risks (particularly when a person is identified at greater risk from falls), to ensure the safety of residents. Other agencies must be consulted before making building alterations to the dementia care unit to ensure regulations are followed. Staffing levels must be reviewed in accordance with the identified dependency levels of residents in each unit, which may be different between the day and night. Staffing levels at weekends must be maintained to ensure standards of cleanliness within the home. Timescale for action 15/07/08 2 OP8 13(4)(a)( b)(c) 15/08/08 3 OP19 23(1)(a) (b) 30/08/08 4 OP27 18(1)(a) 30/08/08 Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 24 5 OP29 19(1)(b) (i) 6 OP38 23(4)(a)( b)(c) 7 OP38 13(4)(a) (b)(c) Two written references must be in place for all staff and kept in the home to ensure the safety of residents. The fire risk assessment must be updated after consultation with the fire officer to take into account proposed changes to the building and registration. All chemicals must be locked away to ensure the safety of residents. 15/07/08 30/08/08 15/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP3 Good Practice Recommendations The home should ensure that all residents are able to use the call bell to summons assistance and this information should be included as part of the risk assessment. Pre admission assessments should be completed before every new admission and care plans updated accordingly Home Meadow DS0000015160.V368457.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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