Inspection on 25/05/05 for Maudes Meadow

This inspection was carried out on 25th May 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Maudes Meadow 05/05/06

Maudes Meadow 24/11/05

Maudes Meadow 19/01/05

Maudes Meadow 10/11/04

Maudes Meadow 29/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Maudes Meadow Windermere Road Kendal Cumbria LA9 4QJ Lead Inspector Marian Whittam Announced 25 May 2005 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 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. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Maudes Meadow Address Windermere Road Kendal Cumbria LA9 4QJ 01539 773092 01539 773087 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cumbria Care Vacant Care Home 28 Category(ies) of OP - Old Age registration, with number DE(E) - Dementia, over 65 of places Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commision. 2. A maximum of twenty eight older people (OP28) may be accommodated ten of whom may have dementia (DE(E)10). 3. The staffing levels in the home must meet the Residential Forum Care Staffing Formula. 4. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. Date of last inspection 19 January 2005 Brief Description of the Service: Maudes Meadow is a purpose built care home provided by Cumbria Care and is registered to provide care for 28 older people, 10 of whom may have dementia. The home is in a quiet residential area, a short walk away from Kendal town centre and local amenities. There are attractive views from rooms in the home to the hills overlooking the town. The home is accessible to all service users having a passenger lift to the first floor. There is sufficient communal space for the service users to watch television, meet with visitors or take part in any organised activities. All the bedrooms are for single occupancy and some have en-suite facilities. There is car parking to the front of the building and a patio area to the side. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over 5 hours; the inspector examined a number of records, looked around the home and spoke with 7 residents, 4 staff members and 2 visitors. A significant number of comment cards were received back from resident and visitors giving their views and experiences of the home. These were largely positive and where issues were raised on the cards they were looked at during the inspection. What the service does well: What has improved since the last inspection? The reviewing and bringing up to date of care plans has improved so that information and instructions to staff is current and reflect residents changing needs. This needs to continue to make sure all assessments are done. Redecoration in some areas of the home is underway adding to the homely environment and further improvements are planned and budgeted for. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 6 The provision of a permanent manager allows for better planning, supervision and support in the home. 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. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 4 Information was available to prospective residents about the home and written terms and conditions of residency so they knew what was provided. An assessment and care planning system and information from other agencies was in place to provide staff with the information they need to ensure they can meet resident’s needs. EVIDENCE: Clear and up to date information was available about the home for prospective residents and their families in the statement of purpose and service users guide. Terms and conditions of residency were provided to residents during admission so they knew what was included during their stay. Individual care plans showed that new residents needs had been assessed before and following admission and their individual care plans developed from this. The home manager did an individual assessment of needs before admission in addition to the social services care management plan to ensure that the home could meet their needs before they came to live there. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 9 Where appropriate other agencies were involved in making assessments of needs. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 The health and personal care needs of residents were being identified, stated in individual care plans and are being met for residents. Some assessments had not been done for all residents and placed them at risk of not having all healthcare and safety needs identified and met. Although medication practices were generally satisfactory improvements to record keeping would further safeguard resident’s safeguard residents and staff. EVIDENCE: Individual care plans, based on initial assessments, setting out health and personal care needs and had been reviewed and updated, as individual identified needs changed. Healthcare needs were being identified at initial assessment and there were good working relationships with other healthcare agencies. Some care plans did not contain appropriate assessments and instructions for moving and handling, nutrition and pressure areas and this placed residents at risk of not having their health and safety needs properly met and must be addressed. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 11 Residents spoken with said that they felt they were well cared for and that they were treated with proper respect by staff. Residents said that they saw health care professionals in their own rooms and saw their visitors when they wanted to. There were medication policies and procedures in place to safeguard residents but practices for recording applications of creams and lotions were not satisfactory. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14 and 15 The home provides limited regular social activities. The staff supported residents to make choices about their daily life and maintain outside contacts. Menus in the home offered choice and a variety of food to provide a balanced diet for residents. Consultation was needed to get residents views on what they would like to see on the menus . EVIDENCE: The home provided some activities and organised social events, religious events and musical events. Resident’s hobbies and interests are recorded and where they liked to spend time. Residents said that they could come and go as they pleased and see who ever they wanted to. Activities were provided but no one person coordinated them or made sure they suited resident’s preferences, needs and capabilities. Staff on duty on the different units took care of activities during the day. One person should take responsibility for overseeing activities on offer to make sure they went ahead and met expectations. Residents spoken with made a range of comments about the food in the home, Several of those spoken with thought there was “not much variety”, some others thought it was “ not too bad” and smaller number spoken with felt the Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 13 food was good. All agreed there was a choice of food on the menus and that there was plenty to eat and drink. The menus provided by the home showed a diet with fish, meat and vegetables, milk and cheese dishes and some fresh fruit, with lunch as their main meal. The home should consult with the residents to get their views on the food and what kind of things they would like to see on the menu as the home is in the process of changing them. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 14 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 standard(s) 16,17 and 18 The home has a complaint and whistle-blowing procedure and system that was displayed in the home. Residents and visitors felt confident that the manager would listen to them and act to deal any concerns. Staff were aware of Adult Protection processes, the procedures in place and had received training and information on this to safeguard residents from abuse. EVIDENCE: The home has a complaints procedure and logged formal complaints for investigation and the procedure was available to residents. Residents and visitors spoken were confident that the manager would deal with complaints. Advocacy services were available to residents and the home had information on this if they wanted someone to act on their behalf. Since the last inspection the home had investigated 1 complaint and had 2 adult protection investigations. One of these had been fully resolved and action taken and the other are still ongoing with social services. There were procedures in place to protect vulnerable adults and for whistle blowing including multi agency guidance and these were easily available for staff in the home. Staff spoken with were clear what they would do if they suspected abuse and had received training on adult protection and dealing with aggression to promote residents safety and well being. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 15 The home did not deal with any resident’s personal finances only small amounts of spending money for them to spend as they wished. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,24, 25 and 26 The standard of décor in the home was satisfactory. Further improvements are confirmed to further improve the environment for residents. Changes to the smoking facilities would make the environment better for residents. The home provided a clean, homely, adequately maintained and comfortable place for residents to live with the equipment they need to promote personal needs and independence. EVIDENCE: The maintenance plan for the coming year confirmed that improvements were budgeted for in bedrooms and communal areas. The dining and lounge areas on the units were clean, well lit, comfortable and homely and were used for different social occasions. Changes to improve safety had been made to the area where smokers sit and a risk assessment is in place. However the area is small, uncomfortable for more than one person at a time, is very public for residents and there is smell of cigarette smoke as people come into the home Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 17 and along the ground floor corridors. The home must review its facilities for smokers and consult with residents to make sure that comfortable provision is made for them in the home that does not affect the environment for other residents and visitors. Resident’s bedrooms seen by the inspector had satisfactory standard of décor and furnishings. Many rooms had residents own possessions and this made them more personal and homely for residents living there. The home was clean and tidy and there is a range of equipment and adaptations in the home to help residents make the most of their independence and to get about the home. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 The deployment and number of staff available on the evening shift is not sufficient to always safely meet the needs of the residents. Recruitment practices and records are not robust enough to fully protect residents. Training was in progress but individual records and training programmes were not up to date to show that staff had received the training to provide appropriate and safe care for residents. EVIDENCE: Staff shortages over a prolonged period and sickness means there are times when there are not been sufficient care staff on duty to consistently meet the needs of residents. Resident and visitor comment cards raised this issue many times. Records show agency staff and staff working overtime to provide staff cover on shifts. The home must provide sufficient numbers of care staff to consistently and safely meet resident’s personal, social and health needs at all times. Recruitment is continuing. However, although some evidence has been provided to the CSCI there are 5 staff members without evidence of Criminal Records Bureau checks. This was a requirement at the last two inspections and progress on providing these has been too slow to ensure protection of residents and must be done. Although training records have been improved individual records of training, qualifications and a training and continuous development programme for staff Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 19 are not recorded. This was a requirement at the last inspection and although progress can be seen it has been very slow and must be completed. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35,36,37 and 38 Quality monitoring systems are in place and reviews but improvements are needed in resident consultation to make sure their views are presented. Procedures and practices are in place which safeguard resident’s financial interests and promote their health, safety and welfare of residents. EVIDENCE: Formal staff supervision was in progress and regular staff meetings allowed staff feedback, along with internal reviews of policies and procedures and information sharing. Residents said that they saw the manager most days and felt happy to raise issues with her. However regular residents meeting had fallen behind and these must re start to ensure that resident’s views and opinions are formally sought and acted upon to affect the way the service is run. The satisfaction surveys the home does should be published and made available for people to see. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 21 Records looked at were in general good order however all staff files needed to have a photograph of those working in the home as part of proof of identity. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 x 3 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 3 2 3 Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 13 (4) Requirement Assessment must be in place to provide clear guidance to staff on the actions to be taken to meet their health and safety needs. The administration of prescribed creams and lotions must be recorded on administration. Residents must be consulted about the facilities for smoking and these reviewed to make comfortable provision for residents who want to smoke and do not affect other non smoking residents. At all times there must be sufficient staff working in the home to consistantly meet the health and welfare needs of residents. Remaining records pertaining to CRB checks must be found andprovided. (Previous timescales 01.01.05 and 31.03.05) Training records must be brought up to date to show staff training,qualifications and continuous development. ( Previous timescale 31.03.05) Residents meeting must restart Timescale for action 30.6.05 2. 3. OP9 OP20 13 (2) 23 (2) 30.6.05 31.7.05 4. OP27 18 (1) 30.6.05 5. OP29 19 (Schedule 2) 18 (1) (a) (c) 30.6.05 6. OP30 30.6.05 7. OP33 24 (1) (3) 1.7.05 Page 24 Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 8. OP37 17 (Schedule 2) to allow residents a forum to present their views and opinions. A photograph should be kept on file of all persons working in the home. 15.7.05 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. 3. Refer to Standard OP12 OP15 OP33 Good Practice Recommendations One person should coordinate residents activities in the home and make sure they go ahead Residents should be consulted about their views on the new menus and what they would like to see on it. Resident satisfaction surveys should be published and made available to interested parties. Maudes Meadow F58 F10 s35531 maudes meadow v214891 250505 ai stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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. 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