Inspection on 19/05/06 for Meadbank Nursing Home

This inspection was carried out on 19th May 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

Meadbank Nursing Home 23/10/08

Meadbank Nursing Home 28/04/08

Meadbank Nursing Home 23/07/07

Meadbank Nursing Home 25/01/06

Meadbank Nursing Home 14/09/05

Meadbank Nursing Home 24/02/05

Meadbank Nursing Home 26/07/04

Meadbank Nursing Home 24/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Meadbank Nursing Home 12 Parkgate Road Battersea London SW11 4NN Lead Inspector Janet Pitt Unannounced Inspection 10:30 19th, 24th and 26th May and 6th June 2006 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 Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 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. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Meadbank Nursing Home Address 12 Parkgate Road Battersea London SW11 4NN 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) 020 7801 6000 020 7978 5726 BUPA Care Homes (AKW) Ltd Mary Ann Heavey Care Home 176 Category(ies) of Dementia (176), Mental disorder, excluding registration, with number learning disability or dementia (10), Old age, of places not falling within any other category (176), Physical disability (176), Terminally ill (176) Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Meadbank Care Centre is situated in Battersea, close to bus routes, with some parking available on site. The home provides accommodation for up to 176 residents who may require nursing care. Each resident has their own room, with ensuite facilities; there are sufficient communal spaces on each of the four floors. Additional bathroom and toilet facilities are situated at regular intervals on all the floors. There is a garden area which residents are able to access easily. A range of activities is provided and residents are able to choose how to spend their day. The weekly fee is £1200. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced key inspection, over a period of four days. The site visit lasted a total of twenty hours. During the inspection the inspector met with staff, residents and relatives. Case tracking was carried out on five residents. Forty residents surveys were sent out and eleven were received. Forty relative surveys were sent and twelve were received. Twenty staff surveys were sent and six were received. Information from these surveys has been included in the summary sections and main body of this report. Core Standards were assessed and requirements made at the previous inspection. The inspector was able to speak with seven relatives, five residents and members of staff from each department during the course of the inspection. Meadbank organised a staff lunch for the inspector to meet with staff and a cheese and wine party for relatives. The inspector wishes to thank the home’s management for this, as valuable information and views on Meadbank was gained, which informed the inspection process. What the service does well: What has improved since the last inspection? Communication between the home, residents and relatives has improved since the previous inspection and the staff are continuing to progress in this area. There has been improvement in care plans containing enough detail to make sure that residents care needs can be carried out consistently. The General Manager explained that the care planning system will be changed later in the year to BUPA’s format. Care plans will be reviewed at the next inspection. Monitoring of residents skin condition is now being recorded accurately. There is good detail of wounds and body mapping is undertaken routinely on all admissions, prior to and on return from hospital. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 6 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. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 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 Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Admissions to the home are not made until a needs assessment has been undertaken. Prospective residents and their family have the opportunity to visit the home prior to admission. EVIDENCE: Residents are able to visit the home prior to admission and are informed of terms and conditions of service provision. Evidence from a resident’s survey indicated that the resident’s representative was able to view Meadbank prior to them moving in. The resident commented that whilst they were staying for a short period, known as respite, they had decided to stay permanently which was a ‘good idea and here I am nearly eighteen months later with the room which my [relative] said I must have.’ i.e. the room was appropriate to meet care needs. Another resident survey indicated that ‘[my relative] came to view the home before time.’ i.e. prior to the resident moving in. Two of the four surveys received from residents indicated that they had received a contract, stating the terms and conditions. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 9 The General Manager was working on a revised Statement of Purpose at the time of inspection. The draft document is clear and will detail all aspects of service provision. On touring the premises it was observed that copies of Service User guides were available in each of the residents rooms. Residents care needs are identified prior to admission when an assessment of needs is undertaken. The assessments were seen to include details of specialist equipment needed to meet needs. An assessment is undertaken once a resident has been admitted and the home has acknowledged that the social history and interests of residents are not fully identified within the assessment. Therefore carers as part of their ‘Personal Best’ training have been given the responsibility for completing Life Histories on residents and making sure that this information is available to develop activities offered and other staff can be aware of significant life events of residents. This should make sure that residents are able to lead fulfilling lives. The four residents surveys had differing view of whether social needs were being met. Further information can be found in the section on Daily Life and Social Activities’ in this report. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Each resident has a care plan, but the practice of involving residents in the development and review of the plan is variable. The home seeks professional advice on health care issues and acts upon it. Wishes of residents regarding end of life care and death are not always explored and recorded. EVIDENCE: Residents and their representatives are confident that care needs are generally met; however this is not adequately evidenced. Case tracking was undertaken on five residents. Care plans were noted to lead from assessments and there was evidence of good care planning involving the resident or their representative, but this was not consistent. Preferences for same gender care were noted and adhered to. One care plan on sleeping gave good details of the resident’s night time routine, but could have included sleeping and waking times to give a more accurate picture. Care plans detailed preferences for baths or showers. However there were no consistent entries within the daily records of whether these had been given according to the residents’ wishes. For example one care plan stated that the Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 11 resident ‘prefers a daily body wash and weekly bath’, but there was no evidence of this in the daily records. There was routine evaluation of care plans monthly and as required, when a resident’s condition changed. Other health professionals were consulted when required and their recommendations were noted to be carried out. Good recording of their skin condition and appropriate use of pressure relieving aids protect residents from harm. Wound monitoring was noted to be carried out consistently, with good description of wound condition and monthly photographs being taken, in line with National Institute of Clinical Excellence (NICE) guidance. Religious and cultural needs of residents are not consistently indicated, which could mean that they do not receive individualised treatment. There was some evidence of religious needs being met, whereby a resident was enabled to attend Sunday services if they wanted to. The inspector discussed with one member of staff about meeting relationship needs of residents. The member of staff did not seem comfortable to discuss this, so it was not pursued. The management team acknowledged that work needs to be done to enable staff to discuss residents’ wishes in an open manner, without being judgemental. Residents need to be confident that their end of life wishes are respected and carried out. There was some evidence of residents or their representatives being asked what care they wanted and what was to happen in the event of death, but this was not consistent. One file contained a letter from a resident indicating that they did not wish to have active treatment. Another resident’s file indicated that they wanted active treatment, but did not detail what was to happen in the event of death. Communication between staff and residents has improved in the home, as indicated in a residents survey carried out in the Autumn of 2005, where residents rated how respectful staff were towards them at 99 . Privacy also scored highly with 98 satisfaction rating. Residents can be confident that they will receive the correct medication and there is a clear audit trail in place. Random checks are carried out by staff to make sure that medications are administered correctly and stock levels are monitored. One resident commented that ‘The staff sisters are fantastic. They are always careful to have any of my medication in stock, so that I do not have to bother about them not being on hand when I begin to run out.’ Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Family and friends feel welcome and know they can visit the home at any time. Staff listen to residents and make efforts to provide a flexible service, but this still requires further improvement with regard to choice and activities offered. EVIDENCE: Residents are able to choose what and where to eat. The residents survey undertaken by an independent company on behalf of the home, showed a 92 overall satisfaction rating regarding food. Tastiness of food scored 84 , variety of dishes 85 and personal choice 89 . Residents are able to take their meals in their own rooms or in communal dining rooms, which are attractively set. Comments from surveys sent by CSCI included: ‘Breakfast is excellent, one can choose whatever one wants’, ‘the kitchen staff listen to personal likes and dislikes’ and ‘[my relative] says “The food is good”.’ Suppertime was observed on one unit, residents spoken with confirmed that they were asked what they ordered meals two days in advance. It was noted that staff confirmed these choices prior to serving food. The meal was unhurried and relaxed, providing a social atmosphere. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 13 However, on one unit a resident had to wait for ten minutes for suitable crockery in which to have their soup and was still waiting for their dessert of ice cream when the inspector left them. This is not acceptable, as it puts residents at risk of malnutrition. Relatives’ surveys indicated that generally they were able to be involved in the residents care and were kept informed of changes. One relative commented that they were ‘very impressed by their tailored individual care’, which acknowledged specific needs of the particular resident. However, one relative commented that on occasion there have been issues with communication with staff due to understanding of the specific cultural needs of the resident group, which are predominantly white British. The relative commented that staff ‘were pleasant, but do not always understand and things have to be repeated.’ This was echoed in a resident’s survey. The management team are aware of this and it is one aspect, which is being addressed in the ‘Personal Best’ training. Staff must make sure that they are able to communicate effectively in order that residents’ needs are fully understood and met. Residents are able to choose whether to participate in activities and one activity co-coordinator spoke of the need to make sure that activities reflect choice. The surveys showed a mixed reaction to the range of activities offered with comments such as ‘generally (very satisfied) although there should be more suitable social activities’ and the home could improve by providing ‘suitable and engaging social and recreational activities.’ Positive comments included ‘I always go if there are musical concerts. A harpist came who was wonderful’ and ‘additional services are good-particularly the nurse who does aromatherapy and manicures etc.’ Activities offered must consistently reflect the residents’ choice and provide suitable activities both inside and outside of the home, to make sure links with the community are maintained. Good interactions between staff and residents were observed on one unit. Staff were giving out morning refreshments and one resident said their tea was too strong and this was replaced. A staff nurse was explaining carefully to a resident that they needed to put their shoes on prior to using the wheelchair footrest, as it was safer than stocking feet. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. There has been improvement in handling of concerns at a local level, but this still requires more input from staff to make sure that residents and their relatives are confident in the process. Formal complaints handling and Protection of Vulnerable Adults investigations are handled well and the home is proactive in providing information and assisting with the process. There must be a rigorous system in place for monitoring and evidencing call bell response times, to avoid residents being placed at risk of harm. EVIDENCE: There has been some improvement in dealing with concerns at Meadbank. Comments from surveys included ‘all the senior staff are very accessible’ and ‘there is no-one named, but I know that the sister in charge would listen and would be sure that something would be done about it.’ However, one visitor commented on ‘little niggles’ not being addressed, which could grow into a serious complaint. One relative surveys stated that they had ‘asked for a copy of the complaints procedure, but have not received it.’ Since the previous inspection CSCI received five concerns about Meadbank. The home when approached was open and transparent in the handling of the enquiries made by CSCI. The concerns related to Protection of Vulnerable Adults and complaints made about call bells and care given. One social worker commented at a Protection of Vulnerable Adult meeting, that they were impressed with the ‘openness and transparency of the information received from Meadbank.’ Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 15 CSCI still has serious concerns about call bell monitoring and apparent delays in answering call bells. One complaint received by CSCI was specifically about this issue. It was noted that on the survey carried out independently, that call bell answering was an issue. The inspector noted that forms for call bell monitoring were being used to record sleep patterns of residents. It is not acceptable for residents to be placed at risk when an electronic monitoring system would evidence call bell response times and demonstrate length of waits. This issue must be addressed as a priority. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 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 the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant, safe place to live with rooms that meet the National Minimum Standards or are larger and the majority have ensuite facilities. EVIDENCE: Residents are able to benefit from living in a home, which has a pleasant environment. One health professional survey received stated that they found the home clean and tidy. All residents and relatives surveys indicated that the home was clean. Comments from residents included: ‘At the moment there is a particularly good cleaner and my room looks as if it is spring-cleaned every day. It is dusted and vacuumed. The windows are clean and I am always proud of it.’ Discussion with the manager in relation to the ongoing refurbishment showed that care is being taken to minimise disruption to residents. One resident who was unsettled about being moved for their room to be refurbished, was moved Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 17 back to their old room as soon as the work was completed and commented that they ‘were happier’ and ‘a carer was helping sort their things out.’ Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Management encourage staff members to undertake external qualifications beyond the basic requirements. Residents generally have confidence in the staff that care for them, but attention needs to be given deployment of staff on the units to make sure that care is given in a timely manner. EVIDENCE: Duty rotas evidences that there are sufficient numbers of staff to meet residents needs. Comments from relatives’ surveys stated that there are ‘always plenty of staff on duty’ and ‘the ratio of staff is very good.’ However, one relative’s survey stated that they thought the staff were ‘over-stretched.’ Residents’ surveys showed that staff were usually available, with two stating that staff were always available when needed. Comments from those who replied usually acknowledged that sometimes they have to wait, but response times were reasonable. Information gained from Protection of Vulnerable Adults investigations and complaints indicated that although staff numbers are adequate, there are issues with deployment within the building, particularly on the first floor, which has fifty residents. This was discussed with the management team who said that they would like to create two units on this floor to enable staff to be deployed effectively. This is supported by CSCI and is included as a recommendation in this report. Resident are supported by staff that receive relevant training. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 19 Staff training is appropriate to their needs and records evidence that training is monitored and updates provided as necessary. Staff spoken with during the inspection and surveys received confirmed this. Staff commented particularly on the newly introduced Personal Best training, which emphasises customer satisfaction and exploring how it feels to receive a service. Unit managers are assisting staff on setting themselves specific objectives to improve the work they do and ensure it is resident focused. The general manager indicated that the provider pays staff for six training days per year as standard, which exceeds the minimum requirement. Residents are protected from harm by the home recruitment procedures. Evidence from previous inspections shows that appropriate checks are carried out on staff prior to them being employed in the home. Also, the recruitment policy is followed correctly. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The management team has developed to provide a good structure with clear lines of accountability. Residents’ views are listened to and acted upon to make sure that the home is continually developing in the residents’ best interests. Meadbank must make sure that residents are able to reach their call bells to prevent the residents being placed at risk. EVIDENCE: Residents live in a home, which has a clear management system, which aims to make sure the service is run in the best interests of the residents. The company, which owns Meadbank, carries out independent surveys and the General Manager is responsible for making sure that action is taken if needed. The current manager is leaving the home and during the inspection the Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 21 inspector was introduce to the new manager, who has experience in the care sector and has been a Registered Manager. The home organised a handover period and made sure that residents and relatives were able to meet the new manager. Each unit has a nurse manager and appropriate training is being given to make sure that there are clear lines of accountability and residents can be confident that their views will be heard and care needs will be met. The general manager confirmed that there has been no change to handling of residents’ finances. One relative survey said there could be improvement in updating them of their resident’s finances/allowances, to make sure that the resident has sufficient monies. Residents live in well maintained environment and can be sure that equipment that is used in the home is checked and serviced as required. Care has been taken when building works have been in progress, with areas of the home being shut off from public access and residents being moved to alternative rooms for the duration of the work. However, the home must make sure that individual residents are not placed in positions where they can suffer harm. One resident had been left for a period of time without a call bell, as staff had not made sure that a longer call bell lead was provided when they moved rooms. This was pointed out to the inspector and the staff were requested to rectify this error, before the inspector left the resident’s room. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 16 (2) (m) 15 (1) (c) Requirement The registered person must ensure that social interests and hobbies are identified on admission to the home. The registered person must ensure that residents and their representatives are involved in the care planning process. The registered person must ensure that residents care plans detail actual care required. The registered person must ensure that care given is recorded accurately and consistently. The registered person must ensure that residents’ wishes with regard to end of life care and death and dying are discussed, recorded and carried out. The registered person must ensure that there is a suitable activities programme, wncin reflects residents’ choice and includes outings into the community. DS0000019107.V293600.R01.S.doc Timescale for action 30/10/06 2. OP7 30/10/06 3. OP7 15 (1) & Sch. 3 17 (1) (a) Sch 3 30/10/06 4. OP7 30/10/06 5. OP11 12 (2) 30/10/06 6. OP12 16 (2) (n) 30/10/06 Meadbank Nursing Home Version 5.1 Page 24 7. OP12 12 (4) (b) 8. OP15 16 (1) (g) 9. OP16 12 (5) 10. OP16 13 (4) (c) The registered person must ensure that the religious, cultural and relationship needs of residents are identified. Residents must be enabled to continue with these if they wish. The registered person must ensure that meals are served appropriately in residents’ rooms and there is suitable crockery and aids available. The registered person must ensure that residents and their relatives are confident to discuss concerns at a local level. The registered person must ensure that there is an electronic monitoring system in place for call bells, to evidence that they are answered in a timely manner. The registered person must ensure that there is effective communication at all levels within the home. The registered person must ensure that residents’ representatives are updated in a timely manner with regard to residents’ monies. The registered person must ensure that call bells are placed within reach of residents that are able to use them. 30/10/06 30/10/06 30/10/06 30/10/06 11. OP32 12 (5) 30/10/06 12. OP35 5 (a) 30/10/06 13. OP38 13 (4) (b) 30/10/06 Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 25 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 OP27 Good Practice Recommendations Consideration should be given to dividing the first floor unit into two units to enhance resident care. Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Meadbank Nursing Home DS0000019107.V293600.R01.S.doc Version 5.1 Page 27 - 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. 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