Inspection on 21/08/06 for Little Meadows

This inspection was carried out on 21st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Little Meadows 30/03/10

Little Meadows 08/05/09

Little Meadows 14/05/07

Little Meadows 03/02/06

Little Meadows 13/07/05

Little Meadows 25/01/05

Little Meadows 30/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Little Meadows 1 Poplar Avenue Cross Heath Newcastle Staffordshire ST5 9HR Lead Inspector Peter Dawson Key Unannounced Inspection 21 August, 2006 09:00 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 Little Meadows DS0000004974.V304121.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. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Meadows Address 1 Poplar Avenue Cross Heath Newcastle Staffordshire ST5 9HR 01782 711669 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) Mr Rashid Baserat-Ahari Mrs Jennifer Diane Baserat-Ahari Mrs Jennifer Diane Baserat-Ahari Care Home 19 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (19), Physical disability over 65 years of age (8) Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 Brief Description of the Service: Little Meadows is a large detached house which has been extended over the years to provide high standard accommodation. It is conveniently situated on the outskirts of Newcastle served by public transport. The resident proprietors have operated the home since original registration in 1987.Accommodation is on 2 floors with shaft lift access to the first floor. There are 3 lounges and separate dining area. There are 17 single and 1 shared bedroom, all have ensuite facility, the shared room also has walk-in shower. furnishings and equipment are to an exceptionally high standard. The home is registered for up to 19 residents, 4 of whom may require dementia care and 8 may have a physical disability.The exterior of the building provides a very pleasant safe garden area with patio and sitting areas attractively laid out, there are ramps/handrails for safety. There is CCTV to protect the home. Both the internal and external areas of the building are maintained to a high standard. The proprietors have constantly sought to further extend the already high standards of the total environment. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this unannounced inspection there were 14 people in residence. There were 5 vacancies. The inspection was carried out between 9a.m. – 2.30 pm by one inspector. All residents were seen and several spoken to. No visitors were seen during the inspection, which is unusual for this home. One visiting District Nurse was spoken to but had not visited previously. There were discussions with the Manager and 2 staff on duty. A pre-inspection questionnaire provided useful information and written feedback was received directly by the Commission from 8 relatives, 5 residents and two GP practices. There was an inspection of the environment and sample of care planning and personal records relating to residents. Additional documents were inspected relating to the inspection process. Two new residents were spoken to and said that they had been helped to settle into the home by staff who were helpful and supportive. They confirmed that their preferences and choices were known and acted upon by staff. There was evidence of chosen lifestyles. One lady said that although she has received visitors she has not been out of the home. She previously attended the Methodist Church. This was discussed with the Manager who will arranged for the lady to attend the local Methodist church some 50 metres from the home. Written comments from residents were very positive and included: “very satisfied, couldn’t ask for more” “I have been here over 12 months, have been quite happy and comfortable, the staff are very kind to me”. Written comments from relatives included “we are very pleased with the care and attention that mum receives – all staff are great”. There were no negative comments or suggested areas for improvement in the comments received from residents or relatives. Two feedback forms were received from visiting GP’s. One who has the majority of residents registered with him and is a very regular visitor said that he was entirely satisfied with the care his patients received and their health care needs were met. Another GP practice who said they had “little involvement with the home had recollections of visiting at lunch time and the telephone being in the midst of a smoking area”. This matter is referred to in this report and the Manager will check the views of all non-smoking residents and visitors in relation to the arrangements for smoking. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 6 Staff were seen to appropriately support and deal with a resident with dementia who wanders within the home and have in place a night care plan for similar needs. Some actions are needed in areas concerning recording complaints, reporting accidents, documents for staff recruitment, pre-admission assessments and providing pastoral care for all. The home generally provides a good standard of care matched by a high standard environment. Current fees charged by the home as reported in the pre-inspection questionnaire are £278 - £347 per week. What the service does well: What has improved since the last inspection? The ongoing redecoration, replacement programme continues. Five bedrooms have been redecorated and re-carpeted. Two en-suite toilet areas previously fitted with carpets have been replaced with glazed floor tiles to ensure good odour control. The ground floor bathroom has been redecorated. Activities in the home have been extended and record kept of activities undertaken. There have been external visits locally with others planned. All residents are now weighed upon admission. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 7 The home have applied for and been granted additional category of registration to admit up to 4 people over the age of 65 years with mental health needs. Staff have received specific training in this area of work. 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. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 8 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 Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 The quality of this outcome is satisfactory This judgement is made using available evidence and a visit to the service. There is adequate information available to make a decision about admission. Pre-admission assessments are carried out but not always recorded. Confirmation in writing is required to confirm needs can be met. EVIDENCE: There is a copy of the statement of purpose/service users guide available in the home for residents and prospective residents and their families. The home are presently reprinting their expensive presentation brochure. At the time of the last inspection a resident had been admitted out of category (MD) for which the home did not have approved category. A requirement to make application for MD category for admission has been completed and approved. It is the home preferred option wherever possible for prospective residents to visit to view the home prior to admission with their relatives. This had been Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 10 done in relation to two recently admitted residents. This applies both to permanent and respite care residents. All prospective residents are seen in their current environment for assessment purposes prior to admission. This had been carried out by the Manager in relation to two recently admitted residents, but the assessment had not been recorded. This should be done in all instances. A suitable assessment form is available but not always used. The home do not confirm to people in writing prior to admission that their needs can be met. This should be the usual practice in all future admissions, to comply with Regulation 14. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 11 The quality of this outcome is good This judgement is made using the information available and a visit to the service. Care plans are comprehensive, clear and regularly reviewed. Health care needs are well documented and actioned as required. There is a safe system of medication in the home. EVIDENCE: Care plans were sampled and found to be to a good standard. The home uses a pre-printed book which incorporates regular reviews. Information was comprehensive and contained all required information to provide care and meet needs. Plans are established from pre-admission assessments and residents/relatives are involved. Signatures of relatives were seen on care planning documents. Two recently admitted residents were spoken to and their care planning and personal information reviewed during the inspection. There were adequate descriptions of health care needs including medical diagnoses. Health care records recorded all interventions by health care professionals including GP, Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 12 CPN, District Nurses, Opticians, Dentists and Chiropodists. There was some doubt about the category for admission in relation to one resident (MD or DE) but adequate information was available in reports to indicate a dual diagnosis. This could be made clearer. Excellent social histories were recorded with the required detail to provide a knowledgeable base for carers to provide social, emotional and recreational support. Daily entries are to a good standard and provide necessary information. Residents are checked at half-hourly intervals throughout the night and recorded on daily notes. The home intend to provide a format for recording and keeping information regarding night checks. There was good information concerning a recently admitted resident with disrupted sleeping patterns, but a care plan was in place to address the issues in an appropriate way. A requirement of the last report to weigh all residents upon admission had been complied with – instanced in records seen. There are no pressure area management problems in the home at this time. District nurses currently visiting only in relation to leg dressings for two residents. Notes are kept in the home by the District Nursing service. A visiting nurse was seen during the inspection. Care plans are all regularly reviewed as required and recorded. Information included risk assessments relating to nutrition and falls. The home have a good record of early referral to health care professionals where health issues are identified. Medication is provided in Nomad cassette form by local pharmacy. The system was inspected and indicated accurate recording on MAR sheets and returns to the pharmacy countersigned. There was strong evidence of recent medication reviews with GP’s. Some long-standing anti-psychotic medication had been discontinued without any negative results. There is a list of prescribed medication for each resident with dates commenced/ceased. Some were crossed out and these could be improved/updated. Residents were well-presented and looked well-cared for. The hairdresser who visits weekly confirmed that most residents use the service and benefit from it physically and socially. Residents confirmed this also. Little Meadows DS0000004974.V304121.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12- 15 The quality of this outcome is good. This judgement is made using the information available and a visit to the service. There is evidence of chosen lifestyles being accommodated and residents making decisions about daily life. The range of activities has improved but pastoral care must be provided also. The smoking area to be reviewed with all non-smokers. High standards of food provision. EVIDENCE: There is evidence of chosen lifestyles being known and accommodated. A resident admitted last year prefers to spend time in her bedroom, she receives visitors there, has meals delivered to her room and chooses to socialise as she wishes. Residents were seen rising for breakfast later in the morning of the inspection day. Three people had had breakfast served in their bedrooms on that morning. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 14 A recently admitted resident was still having reservations about her home being sold and possessions disposed of. Family are dealing with this and involving her as the move progresses. The resident felt that she had been received well into the home and staff were supporting and assisting her in the difficult adjustment period. She had previously been socially active at home visiting local Methodist church and also local social club. She clearly missed the social contacts and enjoyed just talking to people. She has not gone outside the home since her admission. This was discussed with the Manager who confirmed that offers had been made by staff to take her to local shops but she had declined. It was agreed that as the local Methodist Church is some 50 metres from the home arrangements would be made for her to attend. One other resident does attend weekly. It became clear that clergy do not presently visit the home meaning that residents do not have the opportunities for pastoral care. Arrangements must be made therefore to provide a service to the home to suit the spiritual needs of residents. There are 3 lounge areas with 2 lounges on the ground floor which provide a choice of company and seating. The lounge on the first floor is of excellent standard, comfort and décor but attracts few residents and is often used to receive visitors. This is a relatively small home (14 people in residence at the time of this inspection) and the lounge facilities on the ground floor are quite adequate, comfortable and homely where residents socialise throughout the day. The large separate dining area which is also the designated smoking area doubles as a social setting also. Residents with dementia care needs, seen to wander in the home were sensitively diverted and positively engaged by staff. A GP practice in written feedback but with little knowledge of the home suggested that a separate smoking area would be appropriate. There are rules that people cannot smoke in the dining room 1 hour before or after a meal. There are currently 2 residents who smoke and it was good to see that staff who smoke in their break-times, sit and converse with residents smoking in the dining area. This arrangement does seem to work well, given that the dining area is the designated smoking area (and no other obviously available). There have been no complaints from non-smokers in the home or relatives and the Manager was advised to further check with all residents to ensure there were no objections to these arrangements. The home does not handle residents finances which are managed entirely by residents with support from relatives. Bedrooms seen and occupied indicated good personalisation reflecting individuality. There have been consistent good reports about food provision at Little Meadows – no complaints. Sample menus were seen and indicated a varied Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 15 and interesting diet, with choice of dishes. Two residents said that the food was good and they enjoyed their meals. In written feedback a person having monthly respite care stated “The food is delightful”. Another said “ I sometimes like the food too much”. Many comments were made in written feedback indicating satisfaction with their expectations of the home and the choices available. These included: “clean and comfortable, staff helpful and kind”. “I’m happy with it all, its very good” “ I went to see a few places, this is the best” “I am happy here, I do not want to leave, we can do anything we want to”. At a previous inspection residents indicated that the range of activities could be improved. The home have listened and addressed the matter. Activities by staff with residents have been stepped up, there are more activities which apart from the usual range include Tai Chi which most residents engage in, reminiscence sessions, nail-care and 1:1 interactions needed by many residents. Activities are now recorded and there is evidence of activities in the home at least 4 times each week and additionally monthly entertainment is provided in the form of mobility to music and musical and other entertainers. There has been fund raising by staff for the comforts fund which has financed visits to local pubs/restaurants and local places of interest. Many residents go out with relatives which is strongly promoted. Some progress has been made in providing additional activities. One resident in feedback said “I don’t always take part (in activities) but I can if I want to” This clearly indicates residents making choices about activities. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18 The quality of this outcome is satisfactory. This judgement is made using the available information and a visit to the service. The complaints procedures is concise and available. Some complaints had not been appropriately recorded. Polices/procedures and staff knowledge ensure protection of residents. EVIDENCE: There is a complaints procedure posted in the reception area of the home available to all residents and visitors. The procedure is clear and concise. A complaint made by resident regarding missing monies (later found having been mislaid) was dealt with and recorded in the residents daily notes. All complaints of this nature received must be recorded in the complaints book with a written account of the investigation and outcome of the complaint. There is a written policy/procedure relating to abuse and clear instructions to staff concerning the reporting of suspected or actual abuse. It is stated (and confirmed by staff) that all are aware of the procedures and new staff are given specific written information. Staff read, date and sign all policies/procedures. There is a copy of the vulnerable adults procedures in the home. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 The quality of this outcome is excellent. This judgement was made using the information available and a visit to the service. The home meets all National Minimum Standards and can only be described as excellent. This include internal and external areas. Standards are maintained with constant scrutiny and re-investment. EVIDENCE: This is a high standard environment which meets all National Minimum Standards which is also exceptionally well maintained. Furnishings, fittings, equipment and décor are all to a very high standard. There has been an on-going re-investment programme by the proprietors over the years. All areas are regularly decorated and upgraded as required. All bedrooms have en-suite facilities and when vacated all bedrooms are completely redecorated and fitted with new carpets, regardless of wear/use. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 18 Since the last inspection 2 en-suite floor toilet areas have been tiledpreviously carpeted but to ensure total odour management have been re-tiled. Four bedrooms have been redecorated and re-carpeted. The ground floor bathroom has been redecorated also. The Deputy Manager carries out regular audits of the environment with a check-list from décor to electrics. Any areas identified requiring attention are actioned immediately, including any damage or hazards. This is particularly good quality control and ensures the high standards of the environment maintained. Cost is never a consideration. The external garden and patio areas reflect those inside the home and particularly noticeable in the neighbourhood. There is good access to the garden from the home and good quality seating areas located in the different parts of the garden area. The area is used extensively by residents during the summer months. Many remark that they engage in conversation with members of the public passing the home, which is located on a major road out of Newcastle. Although there is CCTV external surveillance, there have recently been 2 windows broken with stones hurled from the external pavement area. This has been reported to relevant agencies. The home is safe for access both internally and externally. There are adequate hand/grab rails in en-suite and toilet and bathroom areas. There is an assisted bathing facility on each floor. The laundry is small but well equipped, adequate for the number of residents and COSHH items stored in locked cupboards. The standards of hygiene throughout the home are excellent with swift critical action if they are not so maintained. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The quality of this outcome is good. This judgement is made using the information available and a visit to the service. Staffing levels are adequate. Staff training is good with numbers of NVQ trained exceeding the minimum. Recruitment procedures can be improved with provision of all documents under Schedule 2. EVIDENCE: The staffing levels remain constant at the required level. There are 275 care staffing hours per week with a minimum of 2 care staff on duty during the day and invariably an additional person 10 – 6 (influenced mainly by staff absences). Care staff and Manager are involved in food preparation – there are no catering staff. Adequate domestic hours are provided. The providers live on-site and available to be called as necessary. There is one waking night care worker and senior person sleeping in and oncall. The Manager and Deputy (both live on-site) are rostered to cover all sleeping-in duties and readily available if called. These arrangements have been strengthened following previous concerns about the availability of night staff. A portable telephone is carried by the waking night care assistant to ensure immediate access to the person sleeping in and on-call. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 20 Staffing levels are adequate at this time for the perceived dependency levels of residents (there are 14 people in residence). Over 66 of care staff have been trained to NVQ 2 standard or above. This requirement was met prior to 2005. There has been staff training in safe handling of medicines, falls awareness & prevention, dementia awareness, challenging behaviours and moving & handling since the last inspection. NVQ training is ongoing. All staff are regularly supervised as recommended and records seen of supervision were detailed and impressive. Staff recruitment procedures were required to be strengthened at the time of the last inspection. POVA first checks, although carried out were destroyed after CRB records were received. This has been changed and POVA first records seen for 2 staff recently recruited. A requirement to provide all documents in Schedule 2 of the Regulations was made to include birth certificate and recent photographs of all staff. There has been some confusion about the need to provide these documents (questioned by staff) but these must be provided in accordance with Schedule 2. A further requirement is therefore made. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The Registered Manager has the required experience and qualifications to run the home. The Manager is also proprietor and therefore has the necessary authority to run the home. The Deputy Manager is presently studying NVQ4 in Care & Management. This is a small home with close and open working relationships between staff, manager and proprietors. Regular staff meetings are held approximately 3 monthly (minutes not seen on this visit) Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 22 The home does not manage financial matters on behalf of residents. All are encouraged to manage their own affairs with assistance from relatives if required. This seems to work very well. Moving & Handling training has been provided for all staff. The Deputy Manager is to undertake a trainers course for this in the future, allowing swifter training for new staff. Fire records were inspected and all checks and servicing of equipment had been carried out as required. There is a fire risk assessment in place which is currently being revised to accord with the new fire regulations to be brought into operation from October this year. The home keep a readily available list of residents with their levels of awareness and mobility in the event of fire. This states room numbers and other factors including hearing and comprehension levels. There has been recent staff training in medication administration and first aid. Eleven staff have current first-aid certificates. COSHH items are locked securely in cupboards in the laundry area. Risk assessments are in place relating to resident activity and the building. Records seen were clearly written and to a good professional standard. Accident records were examined and it was found that not all accidents had been reported as required to the Commission. It was re-iterated that all accidents to residents resulting in head injuries or medical attention must be reported to the Commission. Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 N/A 4 4 4 3 3 3 3 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x 3 3 3 2 Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement All pre-admission assessments must be recorded and confirmation given in writing that needs can be met. Residents must have the opportunity to attend religious services of their choice and have the necessary spiritual support. All complaints must be recorded with details of investigations and outcomes. All documents defined in Schedule 2 must be provided for all new staff. All accidents to residents resulting in had injuries or medical attention must be report to the Commission. Timescale for action 22/08/06 2 OP12 16(3) 22/08/06 3 4 5 OP16 OP29 OP38 22 & Sched 4(11) 19(1) Sched. 2 37 22/08/06 22/08/06 22/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Little Meadows DS0000004974.V304121.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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