Inspection on 23/07/07 for Meadbank Nursing Home

This inspection was carried out on 23rd July 2007.

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

Other inspections for this house

Meadbank Nursing Home 23/10/08

Meadbank Nursing Home 28/04/08

Meadbank Nursing Home 19/05/06

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 Simon Smith Unannounced Inspection 10:30 23rd July 2007 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.V344801.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. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 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 rayners@bupa.com BUPA Sarah Rayner 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.V344801.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 January 2007 Brief Description of the Service: Meadbank Care Centre provides accommodation for a maximum of 176 residents. The home is situated in Battersea, close to local shops and services. Battersea Park and the River Thames are nearby. Weekly fees range from £900 to £1175 for permanent care and £1275 for respite care. A good standard of decoration has been achieved throughout the home and there is a well-maintained garden. Each resident has a single room with en suite bathroom facilities. Communal lounges and dining areas are provided on each floor. The home is divided administratively into units, each of which has an allocated manager. There is a dedicated dementia unit. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector used evidence from a wide range of sources when making judgements about the home. These included a visit to the home by three inspectors and discussion with residents, relatives, the manager, staff and visiting health professionals. One inspector joined residents and relatives for a meal. A CSCI pharmacy inspector examined the home’s arrangements for medication. A sample of records was examined, including staff and residents’ files. The manager completed an Annual Quality Assurance Assessment. The home met 16 of 26 National Minimum Standards assessed at this visit. Ten Standards were almost met. Five of the Requirements made at this inspection had also been made at the last visit. Residents spoken to were generally positive about the home. One resident said, “They treat you well here - the staff are kind and helpful”. Other comments made by residents included: “Its very good indeed here” “I’m very well looked after” “I have my paper delivered every day”. Almost all the residents spoken to thought the food was good and there was enough choice on the menu. Some residents said that there were no activities that they could take part in and that the programme of activities did not offer enough variety. Family members said that they are kept well informed by the home and that they are consulted about the care their relatives receive. Some family members said that there should be more interaction opportunities for highly dependent residents. A new system for care planning has been introduced since the last inspection and all staff have attended training in its use. Whilst the system has the potential to improve the care provided to residents, the quality of information at this stage is variable. Some care plans contained good, individualised information about residents but others contained significant gaps or insufficient detail. The range of activities available to residents is limited and over reliant on a small number of activities. Residents have few opportunities to go out, either individually with staff or as part of organised outings. There was no evidence that residents have support to pursue the hobbies and interests identified in their care plans. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 6 The home has received 81 complaints in the last twelve months. The majority of these were not related to care but the volume of complaints is a concern and the home should consider how best to tackle this issue. There have been 16 Protection of Vulnerable Adults (POVA) allegations involving staff at the home in the last twelve months. The home acted appropriately at the time the allegations were made, suspending the staff involved and informing relevant agencies, but there was no evidence that staff were referred to the POVA list where this was appropriate. This is a cause for concern and must be addressed urgently to ensure residents’ protection. What the service does well: What has improved since the last inspection? What they could do better: Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 7 Make referrals to the Protection of Vulnerable Adults list where necessary. Address the high volume of complaints. Obtain appropriate Criminal Records Bureau disclosures for all staff. Make sure that all care plans are complete and contain sufficient detail for the provision of care. Make sure the care residents receive reflects their religious and cultural needs. Improve the quality of daily notes. Make sure all records relating to medication are accurate. Improve the range of in-house activities and provide more opportunities for residents to go out. Support residents to pursue the interests and hobbies identified in their care plans. Make arrangements to keep residents’ food hot during mealtimes. Keep the home free from unpleasant odours. Respond to all calls to the call bell system within an acceptable timeframe. 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. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information about the home is available to prospective residents. Residents’ individual needs are effectively assessed at the time of admission. EVIDENCE: BUPA makes available good information about its services to prospective residents and their families. Residents spoken to during the inspection confirmed that they had been given good information about the home before deciding to move there. There was evidence that residents’ needs are assessed before they move in. Assessments also identify any specialist adaptations or equipment needed. The home does not admit residents for intermediate care. Meadbank Nursing Home DS0000019107.V344801.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of information on care plans is generally good but some plans contained inconsistencies that need to be addressed. The quality of recording in daily notes must improve to provide an accurate picture of the care residents receive and what they do during the day. Residents must receive more support to pursue their interests and hobbies. The care residents receive must reflect their religious and cultural needs. Residents feel that staff provide good care. Staff liaise effectively with other healthcare professionals when necessary. Residents receive their medication regularly and there are no missed doses. Some residents are supported to manage their own medication. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 11 Residents have frequent access to their GP’s and medication is reviewed regularly. Records of administration are completed accurately in the majority of cases. Staff follow the home’s medication policies and have a good awareness of medication issues, however there are a small number of issues which need to be addressed. EVIDENCE: A new system for care planning has been introduced since the last inspection and all staff have attended training in its use. The Quest system uses a standard format to record residents’ needs across a range of areas, including communication, lifestyle and preferences about the care they receive. There are useful tools to record important information about residents’ personal history, identifying important events, relationships, hobbies and interests. All care plans also contained a nutritional screening tool and moving and handling assessment, although these were not fully complete in all cases. Care plans should be clearer about the action to be taken when a Waterlow assessment identifies a significant risk. Some records of wound care needed more detail and some care plans were not specific about which equipment was to be used for each resident. Whilst the Quest system is useful and has the potential to improve the care provided to residents, the quality of information at this stage of its implementation is variable. Some care plans contained good, individualised information about residents and had clearly been developed with the input of the resident and/or their family. However others contained significant gaps (for example the Life Map was blank in some plans) or insufficient detail. Some care plans were not signed by the resident or their relative, although the plan indicated that both were present at the time of completion. See Requirement 1. In most cases there was no evidence that the hobbies and interests identified in the care plan had been followed up. For example one resident’s care plan records that his hobbies include “historical books, golf and music” but there was nothing to suggest that the resident had received support to pursue any of these interests. In addition, care plans did not always reflect residents’ religious or cultural needs. For example one resident’s assessment noted that he had specific dietary needs due to his religion but the subsequent care plan made no reference to these needs. See Requirements 2 and 3. Staff record details of care provided in daily notes for each resident. The quality of recording in daily notes must improve to provide an accurate picture Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 12 of the care residents receive and what they do during the day. For example, entries such as “assisted with all needs” and “quiet day” provide little meaningful information. See Requirement 4. Staff spoken to during the inspection had a good knowledge of residents’ healthcare needs. Residents’ care plans illustrated that staff liaise well with other professionals when necessary. Visiting healthcare professionals gave good feedback about the care provided by staff. Medication records for administration, receipts and returns were accurate in the majority of cases. Records for Controlled drugs were accurate. Staff have regular training and retraining in medication and were helpful and knowledgeable on medication issues for their residents. Staff take their time on medication rounds to encourage residents to take their medication and as a result residents do not miss doses of medication and their health conditions are being managed well. The following issues should be addressed (and are outlined in Requirement 5): • The date of receipt and quantity of medication received must be recorded in order to carry out stock checks of medicines the home is keeping on behalf of residents. A small number of receipt quantities were missing. One prescribed item was being offered three times a day instead of twice due to an error by the pharmacy producing the MAR charts The home must check that MAR charts are accurate whenever a new supply of medication is received. Two prescribed items were out of stock for 3 days. One prescribed item which is being kept and self-administered by a resident did not appear on the MAR chart. A means of identifying residents before administering medicines is required, especially in units with residents who have dementia. This is usually achieved by photographs of each resident in the MAR chart folder. Photographs are missing for some residents. On one unit, residents’ room numbers are written on medicine containers and labels. This is not good practice. No information should be added to the labels or containers of dispensed medicines and staff must read the label to identify medication for a resident. Storage facilities are good, and temperature monitoring is carried out in medication storage areas including medication fridges. The maximum daily temperature recorded this month for one fridge was 20C, this appeared to be an issue with the thermometer and needs to be checked. • • • • • • Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 13 Staff were observed to maintain the privacy and dignity of residents throughout the inspection. Personal care needs were met promptly and with discretion. Staff knocked before entering private accommodation and addressed residents with respect. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The range of activities available to residents must improve. Residents receive good support to maintain contact with their friends and relatives. There is a varied menu and most residents enjoy the food provided. EVIDENCE: Residents’ care plans record their participation in activities. The records indicated that the range of activities available to residents is limited. The activities programme is over reliant on a small number of activities, including “balloon patting” and “flower arranging”. There was no evidence that residents are encouraged to maintain interests that they had before entering the home. In addition, residents have few opportunities to go out, either individually with staff or as part of organised outings. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 15 Some residents and relatives identified activities as an area that could be improved. Two residents spoken to said there were no activities that they could take part in and that the programme of activities did not offer enough variety. One relative said that there is not enough stimulation for very dependent residents, who are sometimes left for long periods in the lounge without interaction. As highlighted in the previous section of this report, there was no evidence that residents receive support to pursue the individual interests identified in their care plans. One relative said the television reception in the lounge is always poor. See Requirements 6 and 7. Residents receive good support to maintain contact with their friends and relatives. Family members said that staff welcome them when they visit and make time to speak to them their relatives’ care. Family members also said that the home informs them about any incidents that affect their relative. Religious ceremonies are held regularly at the home and some residents attend local churches. Some residents sat in their wheelchairs throughout the day whilst they spent time in the lounge and the dining room. If this is the residents’ preference, the decision must be recorded on their care plans. See Requirement 8. The manager said that some residents who develop dementia may be moved to the dementia unit. This is only acceptable if residents make the choice to move. See Requirement 9. The quality of food on the day of inspection was good. Almost all the residents spoken to during the visit said they enjoy the food provided by the home. Mealtimes in the communal dining rooms were relaxed and unhurried. Some residents were joined by relatives for lunch. Staff serving lunches were aware of residents’ preferences and dietary needs. Residents and relatives said that there is a choice of dishes each day and that residents can have alternatives to the menu. Residents who ate lunch in their rooms were served three hot courses simultaneously. As a result the later courses were cold by the time they were eaten. Ideally each course should be served separately but if this is not possible, insulated coverings should be used to ensure that residents’ food is still hot when they eat it. The complaints record also contained a number of complaints that residents’ food is sometimes served cold. See Requirement 10. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The volume of complaints is high. The volume of Protection of Vulnerable Adult allegations is a cause for concern. Referrals to the Protection of Vulnerable Adults (POVA) list must be made where appropriate. EVIDENCE: The Annual Quality Assurance Assessment manager completed by the manager indicated that the home has received 81 complaints in the last twelve months. A sample of records relating to complaints was examined. This demonstrated that the majority of complaints were not related to care and that the home responds appropriately when a complaint is made. However the volume of complaints remains high and the home should consider how best to address this issue. See Requirement 11. There have been 16 Protection of Vulnerable Adults (POVA) allegations at the home in the last twelve months. Records provided evidence that the home acted appropriately at the time the allegations were made, suspending the staff involved and informing relevant agencies, including local authorities, the Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 17 CSCI and the Police Community Safety Unit. However there was no evidence that staff were referred to the POVA list where this was appropriate. The sample of records relating to POVA allegations contained sufficient evidence for referrals to the POVA list in at least two cases. This issue was discussed with the manager, who advised that BUPA policies require POVA referrals to be sent to the Employee Relations department in the first instance, who decide whether or not to refer the individual to the list. Referrals must be made to the POVA list where necessary to ensure residents’ protection. See Requirement 12. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 18 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): Standards 19, 20, 21, 22, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is attractively decorated and well maintained. Communal spaces are welcoming and well furnished. Residents’ bedrooms reflect their individual tastes and interests. Residents have access to specialist equipment if they need it. EVIDENCE: The home is situated close to local shops and services and Battersea Park and the River Thames are nearby. A good standard of decoration has been achieved throughout the home and there is a well-maintained garden. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 19 Communal lounges and dining areas are provided on each floor. The home is divided administratively into units, each of which has an allocated manager. There is a dedicated dementia unit. Residents’ bedrooms have en suite bathroom facilities and reflect the tastes and preferences of their occupants. Residents are able to bring personal items with them when they move in and to install a private telephone line should they wish. The home provides specialist equipment and adaptations where necessary to meet residents’ needs. Adapted bath and shower facilities are available and hoists are available to assist transfer. Standards of hygiene at the time of inspection were good but there was a strong smell of urine on one floor of the home. The manager was able to demonstrate that the home has tried to tackle this issue but further efforts are needed to eliminate the problem. See Requirement 13. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents say that staff provide good care. The home’s recruitment procedure is designed to protect residents. Access to training has improved. All staff should attend dementia training. EVIDENCE: There were enough staff on duty to meet residents’ needs during the inspection. Residents said that staff are usually available when they need them, although there are times when they staff “appear extremely busy”. Residents said that staff know their needs and provide good care. One resident described the staff as “kind and helpful” and another resident said, “I’m very well looked after”. Family members also gave good feedback about staff, reporting that they promote residents’ choice and provide good care. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 21 A sample of staff files was examined. These demonstrated that staff are recruited according to an appropriate recruitment process involving application form and interview. The home conducts appropriate pre-employment checks before staff start work, although two staff files did not contain an appropriate Criminal Records Bureau disclosure. See Requirement 14. Staff said that access to training has improved in the last twelve months. The manager said that all staff in the dementia unit have now attended training in dementia. It is recommended that all staff attend dementia training. Records of staff meetings on one unit indicated that the last meeting was held in October 2006. It is recommended that meetings are held at least once a month to facilitate good communication amongst the staff team. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced manager. Residents are able to give their views about the service they receive. Records of residents’ finances are thorough and secure. The home must ensure that the call bell system functions effectively and that all calls receive a response in good time. Standards of health and safety were good, although the home must provide evidence that all outstanding maintenance work has been completed. Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has experience in the delivery of care services to older people and is committed to improving the home. The deputy manager also has much experience of the home and there is a small team of administrative staff. The manager said that she meets with heads of department and unit managers each day to maintain good communication amongst senior staff. BUPA has a commitment to Quality Assurance and residents are able to give their views about the service they receive. Residents said that they are consulted about issues that affect them in the home and knew who to speak to if they wished to make a complaint. The manager said that the home encourages residents to manage their own money for as long as possible, with support from their families if necessary. Where the home does hold residents’ money, there are secure computerised records of all transactions and balances. Statements are produced regularly and provided to residents and their next of kin. A new call bell system was introduced in the week before inspection. The system records the time taken to respond to each call, which enables the home to monitor the service residents receive. The record indicated that call bells were answered quickly (usually around three minutes) during the night and during weekdays but that residents sometimes faced unacceptably long waits (sometimes over ten minutes) for call bells to be answered at other times, notably on Sunday afternoons. There was also a concern that a call made from the dementia unit lounge during the inspection did not register on the mobile pager carried by staff. The home must ensure that all calls receive a response from staff within an acceptable timeframe. See Requirement 15. The home was free of obvious health and safety hazards on the day of inspection. All COSHH products were stored appropriately. Maintenance staff carry out health and safety checks around the home regularly. There is an appropriate fire detection system and staff check the fire alarm, emergency lighting and fire fighting equipment each week. The specialist equipment used by residents is checked and serviced on a regular basis. The gas safety record was issued in February 2007 and there was evidence that the home’s water system has been tested. Some of the work identified at an electrical test in June 2006 is still outstanding. See Requirement 16. Meadbank Nursing Home DS0000019107.V344801.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 3 X 3 X 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 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 15 Timescale for action The Registered Person must 30/09/07 ensure that all care plans are complete and contain sufficient detail for the provision of care. The Registered Person must ensure that residents receive support to pursue the interests and hobbies identified in their care plans. The Registered Person must ensure that the care residents receive reflects their religious and cultural needs. The Registered Person must ensure that daily notes provide an accurate picture of the care residents receive and what they do during the day. This Requirement has been made in previous inspection reports. 5 OP9 13(2) The Registered Provider must ensure that all records relating to medication are accurate, in DS0000019107.V344801.R01.S.doc Requirement 2 OP7 16(2) 30/09/07 3 OP7 12(4) 30/09/07 4 OP7 17(1) 30/09/07 30/09/07 Meadbank Nursing Home Version 5.2 Page 26 particular: • Ensuring the quantity of medication received is recorded. Ensuring all prescribed medication appear on MAR charts Ensuring prescribed medication is given according to the prescriber’s instructions Ensuring all prescribed medication is in stock at all times. Ensuring that action is taken if temperaturemonitoring records show that temperatures are not within acceptable ranges. Ensuring that photographs are available in the MAR chart folder for each resident. 30/09/07 • • • • • 6 OP12 16 The Registered Person must ensure that residents have access to a suitable activities programme, which reflects residents’ choice and includes outings into the community. This Requirement has been made in previous inspection reports. 7 OP12 23(2) The Registered Person must ensure that all communal televisions are fit for use by residents. The Registered Person must ensure that if residents choose to remain in their wheelchairs throughout the day, the decision DS0000019107.V344801.R01.S.doc 30/09/07 8 OP14 12(2) 30/09/07 Meadbank Nursing Home Version 5.2 Page 27 is recorded on their care plans. This Requirement has been made in previous inspection reports. 9 OP14 12(2) The Registered Person must ensure that residents have the option of remaining in their existing rooms. The Registered Person must ensure that there are appropriate arrangements to keep residents’ food hot during mealtimes. The Registered Person must consider how best to address the high volume of complaints. The Registered Person must ensure that referrals are made to the Protection of Vulnerable Adults list where appropriate. The Registered Person must ensure that the home is free from offensive odours. This Requirement has been made in previous inspection reports. 14 OP29 19(1) The Registered Person must ensure that appropriate Criminal Records Bureau disclosures are obtained for all staff. This Requirement has been made in previous inspection reports. 15 OP38 12(1) The Registered Person must ensure that all calls to the call bell system receive a response within an acceptable timeframe. DS0000019107.V344801.R01.S.doc 30/09/07 10 OP15 16(2) 30/09/07 11 OP16 22 30/09/07 12 OP18 19 30/09/07 13 OP26 16(2) 30/09/07 30/09/07 30/09/07 Meadbank Nursing Home Version 5.2 Page 28 This Requirement has been made in previous inspection reports. 16 OP38 23(2) The Registered Person must demonstrate that all work identified at the electrical test in June 2006 is complete. 30/09/07 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 2 Refer to Standard OP30 OP30 Good Practice Recommendations All staff should attend dementia training. Unit team meetings should be held at least once a month Meadbank Nursing Home DS0000019107.V344801.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Meadbank Nursing Home DS0000019107.V344801.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. 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