Inspection on 13/11/06 for Mead Lodge

This inspection was carried out on 13th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Mead Lodge 26/01/06

Mead Lodge 21/07/05

Mead Lodge 13/01/05

Mead Lodge 08/07/04

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

CARE HOMES FOR OLDER PEOPLE Mead Lodge Crown Road Buxton Norwich Norfolk NR10 5EH Lead Inspector Debby Allen Key Unannounced 09:00 13 - 14th November 2006 th 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 Mead Lodge DS0000057375.V320395.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. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mead Lodge Address Crown Road Buxton Norwich Norfolk NR10 5EH 01603 279261 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) meadlodge@clara.co.uk Hillside Commercial Ltd Position Vacant Care Home 24 Category(ies) of Dementia (24) registration, with number of places Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Mead Lodge is a care home providing personal care and accommodation to 24 old people who also have dementia. The home is privately owned. Mead Lodge is located in the Norfolk village of Buxton and is within walking distance of the shops and other facilities. The service is based in an older modernised building with new extension. The home has 24 single bedrooms. All of the bedrooms have en-suite toilets. There is a fully enclosed secure garden. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. following comments from the provider, the report was amended regarding the fact that a new, fuller care plan is in the process of being implemented, a sentence regarding the home’s ability to demonstrate capacity has been withdrawn and the wording of requirement No 4 has been amended. Timescales for action have been extended. This inspection of Mead Lodge was unannounced and took place over a period of one and a half days by two regulatory inspectors, Debby Allen and Hilary Richards. The inspectors were welcomed into the home by the manager and deputy. The registered provider was also on site during the course of the inspection. The inspection included a tour of the premises, inspection of staff and residents’ records as well as the home’s records relating to health and safety. Two staff members were interviewed and discussions took place with the Provider, manager and deputy manager. A total of six relative/visitor’s comment cards were received prior to the inspection and the views expressed have helped to form some of the judgements contained in this report. There has been a complete change to the management team since the last inspection, with a new manager and deputy now in post. Although the feedback received from the staff members was very positive, the manager does need to be more proactive and better organised with regard to staff supervision and ensuring care plans are complete and reviewed/updated regularly. A total of 16 requirements and 10 recommendations were made as a result of this inspection. What the service does well: Mead Lodge is a friendly and welcoming home and the residents are well cared for by a team of dedicated care staff. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 6 The meals are wholesome, nutritious and well prepared from fresh ingredients and mealtimes are a relaxed and unhurried occasion. The communal lounges and dining room are light and airy and nicely decorated, offering residents homely and comfortable surroundings. The service has a very robust system for the storage, handling and administration of medication. 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. Mead Lodge DS0000057375.V320395.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 Mead Lodge DS0000057375.V320395.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, 2, 3, 4, & 5 (standard 6 was not applicable on this occasion) Quality in this outcome area is adequate. The manager needs to improve the assessment and admission process by ensuring all information obtained is clearly recorded in residents’ files and used to compile effective care plans. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home’s published information, training records and three residents’ files/care plans were examined during this inspection. Master copies of the Statement of Purpose and Service User’s Guide were seen to be very detailed with regard to describing the range of needs Mead Lodge intends to meet, its admission criteria and what should be contained within service users’ care plans. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 9 The inspectors were informed that relatives of the service users kept the service users’ copies of these documents and it is recommended that confirmation of receipt of the Service User’s Guide, signed by the service user or a member of their family, should be kept in each of the service user’s care plans. This should also be carried out retrospectively. Service users should, however, have their own copies of the Service User’s Guide wherever possible, especially given the fact that at least one resident receives and reads a daily paper. The information contained in the admissions and needs assessments was also very limited and records were lacking in sufficient detail to make them effective, particularly in areas such as personal history, hobbies, likes & dislikes and daily living needs. All information collected during the assessment process needs to be clearly recorded in residents’ files and used to compile effective care plans. Mead Lodge DS0000057375.V320395.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, 11 Quality in this outcome area is adequate. Care plans need to contain more information with regard to how people like and need to be cared for. Individual risk assessments and weight records need to be co-ordinated and carried out on a regular basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection, the inspectors observed staff at work and also interviewed staff on duty. Staff were observed knocking on doors before entering and appeared to be addressing people appropriately. From this the opinion was formed that service users are treated with respect and have their privacy upheld. A very robust system was in place for the storage, handling and administration of medication and the senior on duty was observed administering medication Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 11 during the lunchtime period and this was carried out professionally, following the correct procedures and each resident was treated individually with dignity and respect. Three care plans were inspected but only limited information was contained in them, especially with regard to personal risk assessments and how people like to be, or need to be, supported. The manager informed the inspectors that a new, fuller care plan was in the process of being implemented and a draft copy of this was submitted to The Commission after the inspection. Meanwhile, some additional information was located in other folders and various areas around the home such as general risk assessments in a folder in the office, likes and dislikes on a list in the kitchen and a bathing/weight/skin record in an exercise book in the office. Reviews of the care plans appeared to have been taking place on a regular basis earlier in the year but the latest reviews, observed at the time of inspection, were dated August 2006. A requirement has been made that the service users’ plans are reviewed by care staff at least once a month. The care plans contained information which identified residents who were at risk of developing pressure sores but guidance and procedures for prevention, identification, treatment and appropriate intervention was minimal. A requirement has been made that service users who have been identified as having developed or being at risk of developing pressure sores have the appropriate intervention recorded in their plan of care. Also, that any incidents of pressure sores, their treatment and outcome, are recorded in the service user’s plan of care and reviewed on a continuing basis. Two separate recordings of residents’ weights were seen during the inspection, one was found in the care plans and the other was recorded in the ‘bathing’ book. These records were not co-ordinated or carried out on a regular basis. There was also no acknowledgement or plan of care regarding one resident whose weight has fallen steadily from 10 stone in June 2006 to 9 stone, as recorded, in October 2006. A requirement has been made that nutritional screening is undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition, including weight gain or loss, and appropriate action taken. One member of staff confirmed that she had experienced sudden and expected deaths over the past few years and was able to give good examples of how the residents and their families had been treated with care, sensitivity and respect. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. All six relative/visitor comment cards returned stated that they were welcome at any time and they could visit their relative/friend in private The meals served during the lunchtime period appeared to be wholesome and nutritious and the mealtime was a relaxed and sociable occasion. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection, some residents were observed playing dominoes in one of the communal areas and a good deal of positive interaction was noted between residents and staff. Meanwhile, another resident was doing a crossword and others were seen watching a film in the top lounge. A selection of activities equipment was noted such as bingo and musical keyboards and the deputy manager described various entertainment and activities which took place on a regular basis. However, the care plans do not underpin residents’ choices with regard to these activities. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 13 It was commented on by some staff that they would like to see residents going out more often – if only locally – as this rarely happens now. Local amenities were described as options such as the park, pub, shop and pond. A recommendation has been made that residents should be supported to access local amenities. Although some improvement has been made with regard to a more structured approach to activities, the recommendation has been repeated that the service use designated staffing hours to offer a varied programme of stimulation and meaningful activity to service users. The employment of an activities coordinator could also be considered. The lunchtime period was observed and staff were seen to be speaking pleasantly to residents and treating them with dignity and respect. Individuality was also noted with regard to people’s choices of where they sat and whether they wore aprons or not. The meals served on this occasion appeared to be wholesome and nutritious and the mealtime did not appear to be hurried in any way. Staff needing to assist residents with eating their meals did so respectfully. The meals for people who required pureed food appeared to have been blended all together and a recommendation has been made that each food item is pureed and served separately on a dish. This will make the meal look more appetising as well as enabling different flavours to be experienced. The weekly menus were looked at and were also seen to be wholesome and nutritious. The deputy manager gave good examples of how the residents were assisted to make choices with regard to their meals and acknowledged some recent confusion experienced when residents were assisted to choose their meals from a selection for the following day, although he confirmed that this issue had now been addressed. A list was seen in the kitchen, showing residents’ likes, dislikes or whether no-preference had been indicated. This confirmed a positive individual and person centred approach. Hot and cold drinks were observed to available at various intervals throughout the day and it was confirmed by staff that residents could request and have additional drinks or snacks if they wished. Staff and management stated that residents were encouraged to bring their own furniture and other personal possessions into the home. A number of residents’ rooms were seen during the inspection and the individuality of each room confirmed this fact. It was confirmed by the provider that the home does not have any dealings with the residents’ finances at all. These are dealt with by the residents’ families. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 14 The service continues to have open visiting and all of the relatives who expressed their views stated that they were welcomed into the home by staff and management. Mead Lodge DS0000057375.V320395.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. All six comment cards received from relatives/visitors stated that they were aware of the home’s complaints procedure. One said they had made a complaint but also confirmed that they were satisfied with the overall care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is clearly laid out in the service user guide and all of the relative’s comment cards stated that they were aware of the home’s complaints procedure. The complaints book was looked at and held appropriate information with regard to the complaint, action taken and whether the complaint had been resolved. Members of staff spoken to confirmed that they were aware of, and understood, the whistleblowing policy and that they had attended training for the protection of vulnerable adults. Mead Lodge DS0000057375.V320395.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, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is adequate. The communal lounges were seen to be clean, bright and in good order. There are plans for the refurbishment and redecoration of the kitchen and hallway in 2007, which the residents will benefit greatly from. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of areas seen by the inspectors were clean, tidy, in good order and without unwanted or unpleasant odours. However, unpleasant odours were noted near the foyer and front lounge, also in the corridor near the top lounge. A recommendation has been made that consideration be given to the cause and elimination of these odours, as they are quite clearly contained within these two areas. All rooms were bright and a number of visual aids were noted for toilets, bathrooms and bedrooms. Residents appeared to be quite comfortable and Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 17 familiar with regard to their surroundings and those observed mobilising independently seemed confident. The residents’ rooms that were seen by the inspectors had clean and adequate en-suite facilities. There was some concern that the carpet was quite worn and rucked in the sloped part of the corridor near the laundry room and the stair carpet was very worn in places. A requirement has been made for the carpets to be made good or replaced as soon as possible. The proprietor confirmed plans for replacing the carpets and redecorating the hallway in the near future. There was also some concern that the five bedrooms upstairs can only be accessed via the lobby, the door to which is kept locked, thus preventing residents access to their rooms as and when they wish. A further concern was that there was a large stair gate fitted at the top of the stairs to prevent residents from going downstairs without assistance. The inspectors were informed that night staff carry out checks every two hours and there are pressure pads in place on the floors upstairs which will alert staff when residents get out of bed. The inspectors had concerns about the isolation of the residents accommodated in these rooms. Clear risk assessments, particularly regarding fire safety, need to be in place for this area, together with confirmation of how residents are able to access their rooms. A recommendation has been made that consideration be given to this situation and possibilities for improvements should be explored. The inspector was informed that there is no call system in the front lounge, which means leaving the area to get assistance if needed. A Requirement has been made that a call system, with an accessible alarm facility is provided in every room intended for use by residents. A number of heaters/radiators were observed to be quite warm but unguarded and a requirement has been made that radiator covers are fitted to all radiators, commencing with those deemed a high risk of harm to residents. The manager and proprietor confirmed that the kitchen is due to undergo extensive refurbishment during 2007. However, it was noted that the kitchen door has recently been removed and, as this area is very close to the staff entrance and the laundry room, a recommendation has been made to provide and fit a screen for the kitchen doorway. During the tour of the premises, it was noted that communal toilets had bars of soap and cloth towels for hand washing. Disposable gloves and aprons were not observed as being readily available, especially in areas such as the Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 18 communal toilets. A recommendation has been made to provide paper towels, soap dispensers and disposable gloves & aprons in the communal toilets for the purposes of infection control. Mead Lodge DS0000057375.V320395.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. More robust recruitment practices and induction processes are required to ensure residents are supported and protected at all times and that staff are trained and competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although staff confirmed they received a basic induction on commencing their employment, the home could not evidence that this was able to meet the induction requirements of the National Minimum Standards that implement the Care Standards Act 2000. However, the manager informed the inspectors that she has recently obtained information for the ‘Passport to Care’ induction programme, which she plans to commence as soon as possible. A requirement has been made that all staff receive induction and foundation training and updates that meet the requirements of the National Minimum Standards. The home does not currently meet Government targets for NVQ trained staff but this will be met when the staff currently working towards their NVQ have completed their assessments and achieved their qualification. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 20 Staff observed at work appeared competent and understanding of residents’ needs and wants and displayed a professional, respectful, warm and patient approach towards residents. Staff confirmed that they had received training on protection of vulnerable adults but there was a lack of evidence to show that staff and management have received appropriate training to meet the needs of older people with dementia and a recommendation has been made for staff and management to undergo training in Dementia Care. Staff and management said that they felt the staffing levels were much better now and only one relative’s comment card was returned with comments about low staffing level. During the two days the inspection was carried out, the levels of staff on duty were considered appropriate by the inspectors, with an average of five staff on duty during the day, and the rotas showed consistency in respect of these levels. There was some concern that new staff were commencing employment on receipt of a POVA 1st check whilst awaiting CRB clearance as, what appeared to be, standard practice and it was difficult to evidence that these members of staff were supervised at all times prior to receiving CRB clearance. The staff files that were inspected showed only one professional reference had been obtained, the second references were character references from friends and, in one instance, the current deputy manager had provided a reference for someone he had line-managed in a previous job. A recommendation has been made that, as best practice, CRB clearance should be obtained for all staff prior to commencing employment and two written references from previous employers should be obtained and character references should be from sources other than friends or family. Mead Lodge DS0000057375.V320395.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. Quality in this outcome area is adequate. There has been a complete change to the management team since the last inspection, with a new manager and deputy now in post. the manager does need to be more proactive and better organised with regard to staff inductions, supervision and ensuring residents’ care plans are complete and reviewed/updated regularly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager is not currently registered although her application has been received by CSCI and is being processed. There has been a considerable change to the management team in the last seven months, with both a new manager and deputy manager. The inspectors Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 22 were not able to inspect the staff files relating to the manager or deputy manager on this occasion, as they are kept at the proprietors’ home. A requirement has been made that records and files must be available for inspection at all times and recommend that the personnel files for the management are kept in a locked cabinet at Mead Lodge and that the proprietor holds the key. Staff spoken to all commented that they felt very supported by the proprietors, manager and deputy manager and felt they could approach them at any time. Only one supervision session had taken place during the last six months, although these did appear to have been taking place on a regular basis previously. There was no record of any appraisals having taken place, although the manager stated that she intended to carry out appraisals for staff in the near future. A requirement has been made that all care staff receive formal supervision at least six times per year. It was confirmed that the two proprietors each visit the home, separately, on a weekly basis. It was also confirmed that the home does not handle the residents’ finances at all. If required, the home makes purchases on behalf of the residents and invoices are periodically sent to the residents’ families as appropriate. Visits, as required under regulation 26, have not been happening and a requirement has been made that the proprietor makes arrangements for these to commence as soon as possible. A number of recent incidents were noted by inspection of residents’ and the home’s records but The Commission had not been notified of these. A requirement has been made that all accidents, injuries and incidents of illness or communicable disease are recorded and reported to The Commission. Accidents are being recorded using accident forms and these forms are being removed completely and placed in the residents’ care plans which means effective monitoring of accidents is not possible. A recommendation has been made for an accident summary log to be maintained. The home carries out a quality assurance survey annually and nine responses were received in November 2005 from relatives and visitors. However, although a number of comments had been made, there was no evidence or record of any development plan, or action taken to address the issues raised. A requirement has been made that the home must produce an annual development plan. The home’s policies and procedures are currently being reviewed and updated and evidence of this was observed. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 23 All fire records, electrical testing and equipment checks were found to be in order and up to date. Some risk assessments are in place but those observed were not being reviewed or updated on a regular basis. A requirement has been made that risk assessments are carried out and regularly monitored and reviewed. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 24 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 2 2 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 1 2 2 Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 25 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 OP3 OP4 OP8 Regulation 17 Requirement Timescale for action 31/03/07 2 OP7 15 3 OP8 13 4 OP8 13 The Registered Person must ensure each Service User’s health, personal and social care needs are set out in a more detailed, individual plan of care. The Registered Person must 28/02/07 ensure each Service User’s plan is reviewed at least once a month. 31/03/07 The Registered Person must ensure Service Users who have been identified as having developed or being at risk of developing pressure sores have the appropriate intervention recorded in their plan of care. Also, that incidents of pressure sores, their treatment and outcome, are recorded in the service user’s plan of care and reviewed on a continuing basis. The Registered Person must 31/03/07 ensure that a clear record of the nutritional screening, which is undertaken on admission, is kept on the service user’s file. Nutritional screening should DS0000057375.V320395.R01.S.doc Version 5.2 Mead Lodge Page 26 5 OP19 OP25 24 6 7 OP38 OP30 23 18 8 OP31 9 9 OP36 18 10 OP37 26 11 OP37 OP38 37 12 13 OP33 OP7 OP8 OP18 OP38 OP29 24 13 14 19 subsequently take place on a periodic basis and records maintained, which include weight gain or loss and the appropriate action taken. The Registered Person must ensure all carpets which are worn, uneven or threadbare are replaced. The Registered Person must ensure that radiator covers are fitted to all radiators The Registered Person must ensure that all staff receive formal induction and foundation training and updates that meet the induction requirements of the National Minimum Standards The Registered Person must ensure records and files are available for inspection at all times. The Registered Person must ensure that all care staff receive formal supervision at least six times per year. The Registered Person must visit the home in accordance with regulation 26. A written report must be prepared and submitted to The Commission on a monthly basis. The Registered Person must ensure all accidents, injuries and incidents of illness or communicable disease are recorded and reported to The Commission. The Registered Person must ensure the home produces an annual development plan. The Registered Person must ensure risk assessments are carried out and regularly monitored and reviewed. The Registered Person must ensure that CRB clearance has been obtained for all staff prior DS0000057375.V320395.R01.S.doc 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 28/02/07 Mead Lodge Version 5.2 Page 27 15 OP29 19 16 OP30 18 to commencing employment. Staff who commence employment upon receipt of a POVA 1st check must be supervised at all times by a nominated staff member who has received CRB clearance. The Registered Person must ensure that two written references are obtained from previous employers. Character references should be from sources other than friends or family. The Registered Person must ensure that care staff and management undergo training in dementia care. 28/02/07 31/03/07 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 Refer to Standard OP2 Good Practice Recommendations The Registered Person is recommended to obtain confirmation of receipt of the Service User’s Guide, which should be signed by the service user or a member of their family and a copy of this should be placed in their care plan. Where appropriate, service users should keep their own copy of the Service User’s Guide. The Registered Person is recommended to provide paper towels, soap dispensers and disposable gloves and aprons, in communal toilets. The Registered Person is recommended to enable Service Users to access local amenities. The Registered Person is recommended to use designated staffing hours to offer a varied programme of stimulation and meaningful activity to service users. The Registered Person is recommended to present Pureed/liquified meals in a manner which is attractive and appealing in terms of texture, flavour and appearance. The Registered Person is recommended to give DS0000057375.V320395.R01.S.doc Version 5.2 Page 28 2 3 4 5 6 OP26 OP38 OP12 OP13 OP12 OP15 OP26 Mead Lodge 7 8 9 10 OP19 OP22 OP26 OP37 OP38 consideration to the cause and elimination of the unpleasant odours noted in the corridors near the front lounge and top lounge. The Registered Person is recommended to give consideration to improve access for service users accommodating the upstairs rooms. The Registered Person is recommended to provide a call system, with an accessible alarm facility in every room intended for use by service users. The Registered Person is recommended to provide and fit a screen to the kitchen door. The Registered Person is recommended to keep a summary of accidents & incidents for monitoring purposes. Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI Mead Lodge DS0000057375.V320395.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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