Inspection on 23/06/05 for Meadow Court

This inspection was carried out on 23rd June 2005.

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

Meadow Court 06/06/07

Meadow Court 22/06/06

Meadow Court 25/10/05

Meadow Court 10/12/04

Meadow Court 14/07/04

Meadow Court 12/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Meadow Court Meal Hill Lane Hill Top Slaithwaite Huddersfield HD7 5EL Lead Inspector Karen Summers Unannounced 23 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Meadow Court Address Meal Hill Lane Hill Top Slaithwaite Huddersfield HD7 5EL 01484 840366 01484 840366 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ian Whitehead, Mrs Ann Whitehead and Mr Roger Wagstaff Ms Susan Haigh Care home 37 Category(ies) of 37 Old age registration, with number of places Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 10 December 2004 Brief Description of the Service: Meadow Court is a care home, which is registered to provide care and accommodation for up to thirty-seven older people. Most of the rooms are for permanent residents, however two rooms are for single occupancy. Most of the bedrooms have en-suite facilities. The home is located at Hill Top, above Slaithwaite, in the Colne Valley. It is approximately five miles from the centre of Huddersfield. The home has ample car parking provision and it is a short walk from a local bus route. Most of the service users admitted to Meadow Court are from the local area and have common knowledge and experiences. The home promotes social inclusion and is becoming an established part of the community. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at Meadow Court on Thursday 23rd June 2005, commencing at 8.50am, and the duration of the inspection was 6.25 hours. The deputy manager, Mrs L Balmforth, was present at the inspection. The following methods have been used in the production of this report: sampling of records, care plans, individual discussion with 5 service users and 3 staff, 1 relative, a district nurse, tour of the premises and document reading. What the service does well: What has improved since the last inspection? What they could do better: The person who has written information a about a service user should also sign the documentation. The home needs to develop ways of assessing risk to service users of developing pressure sores, of people’s movement and handling needs and in relation to eating and drinking. In the laundry room there should be paper towels, liquid soap and a waste paper bin. The home’s management needs to continue to achieve 50 of staff with NVQ level 2 by 31st December 2005. The recruitment procedures are insufficiently robust. Staff files need to contain all the information required in the Cares Homes Regulations 2001. Staff must receive training in fire prevention and take part in drills. Some staff need updated movement and handling training. In order to minimise risks to service users the management must take action to address these outstanding issues. Failure to comply may lead to further action being taken. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 6 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. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 5 No service user moves into the home without having had his/ her needs assessed. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: All service users are admitted following a full assessment undertaken by people trained to do so, and to which prospective service user, his/ her representative (if any) and relevant professionals have been party. Each service user then has a plan of care for daily living, and longer-term outcomes based on the pre admission assessment. Prospective service users and their relatives are encouraged to have a look around the home, and the service users is also encouraged to visit and spend a day there before deciding to move in. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 - 10 Progress has been made in the development of the care documentation however, until movement & handling & tissue viability assessments, and nutritional screening is included in that documentation, the registered person cannot ensure that the needs of the service user have been assessed and therefore met. There is evidence of good multi disciplinary working taking place, and the district nurse commented positively about the care that service users receive. EVIDENCE: The care documentation has improved, as staff are now recording in more detail the care needs of the individual service user. The daily record also reflects the care that the service user has received that day. The author of the care plan should sign the documentation. The plans have been reviewed monthly or more frequently as the needs of the service user have changed. In relation to movement & handling and tissue viability assessments, and nutritional screening, they should be carried out on admission and reviewed at regular intervals or as the needs of the service user change. The district nurses visit at regular intervals throughout the week, and one of the nurses spoken with said, “the staff are lovely, and everyone is well cared for.” The nurse also said that she has a good relationship with the staff and that they contact her if they have concerns. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15 The lifestyle the service users receive match their expectations and preferences. Service users are encouraged to maintain contact with family and friends, and they are made to feel welcome. A variety of meals are offered that take into account the likes and dislikes of the service users. EVIDENCE: Entertainers visit the home approximately twice per month, and an activities co-ordinator carries out structured activities two and a half days a week. The activities reflect the expectations and preferences of the service users. A relative commented, that she was always welcome, and happy with the care that her mother receives. The menus offered variety and choice, and the food preferences and diets were also taken into consideration. When a service user has a variation to the menu the variation should be recorded, as the records would show that individual needs are catered for, and also should there be an outbreak of food poisoning then the food served that day could be traced. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed at this inspection. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 The home is in a good state of repair and decorative condition, and service users’ individual needs are met in a comfortable and homely way. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: The home is decorated and furnished to a good standard, and a number of areas have been redecorated since the last inspection. Service users are encouraged to bring small items of furniture and memorabilia into the home. A number of bedrooms had been individualised with belongings, and reflected the personalities and tastes of the people living there. The premises are kept clean, and staff have training in infection control. The manager also contacts the Infection Control nurse when she needs advice. The laundry room has been recently fitted with a hand wash basin, however in order to use the facilities there should be paper towels, liquid soap and a waste paper bin. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 - 30 The staffing levels and skill mix were sufficient to meet the number and needs of service users. The recruitment procedures are not robust enough to provide the safeguards that offer protection to people living in the home. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. One member of staff has a NVQ level 2, and a further 8 staff have commenced the training. The home has had National Training Organisation specification (NTO) documentation since the last inspection however; they have not as yet chose to use it. In relation to recruitment, not all staff had the relevant documentation in their files, and it could not be confirmed that all staff that commenced in post since July 26th 2004 had had a satisfactory POVA check. CRB checks are no longer transferable. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 & 38 In relation to the views of service user, the home is run in their best interest. As there isn’t documented evidence regarding supervision it cannot be determined that staff are appropriately supervised. As all staff have not had relevant fire and movement and handling training, the health, safety and welfare of service users and staff cannot be protected. EVIDENCE: The manager has commenced the registered managers award and NVQ level 4. Feedback is actively sought from service users and their family and friends about services provided through anonymous satisfaction questionnaires, and the latest results when collated will be included in the service user’s guide. Supervision takes place on a formal basis daily however; all care staff should be formally supervised 6 times a year. A member of staff said that she had not had a fire lecture or drill in the last three years. All staff must receive suitable training in fire prevention and have fire drills. Not all care staff have up to date movement and handling training. This training is mandatory and therefore must be addressed. Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 x 3 x x 2 x 1 Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 16 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29.3 Regulation 19.-(b)(c) & Schedule 2 Requirement The manager must not employ a person to work at the home without the information & documents specified in Schedule 2. The employment files must include proof of the persons identity, including a recent photograph, and an up to date enhanced Criminal Records Bureau & POVA Check. This requirement was identified on the last 2 inspection reports. Failure to comply may lead to further action being taken. 23.-(4)(d)Fire: The registered person shall - Make arrangements for persons working at the home to receive suitable training in fire prevention; and (e) to ensure, by means of fire drills and practices at suitable intervals, that the persons working at the home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life. 13.-(5)The registered person shall make suitable Timescale for action 31st July 2005 2. 38.2 23. -(4) (d)&(e) 15th July 2005 3. 38.2 13.(5)&18 (1)(c)(i). 31st July 2005 Page 17 Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 arrangements to provide a safe system for moving and handling service users. and 18. -(1)(c) ensure that persons employed by the registerd person to work at the care home receive - (i) training appropriate to the work that they are to peform. 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 7 7.3 Good Practice Recommendations The care plan documentation should be signed by the author. Movement & handling - Service users should all have a movement and handling assessment that is reviewed at regular intervals or as the needs of the service user change. Tissue Viability - you are advised to use a recognised tissue viability tool to identify those service users who are at risk of developing a pressure sore. Nutitional screening should be undertaken on admission using a recognised assessment tool, and reviewed. Where a service user receives a variation to the menu the variation should be recorded. Laundry room, new hand wash sink - There should be paper towels, liquid soap and a waste paper bin. A minimum ratio of 50 trained members of care staff to achieved an NVQ level 2 or equivalent, by 31st December, 2005. As recommended at the previous inspection, the NTO induction booklets should be used for all new staff. The registered manager should have an NVQ 4 in management and care by December 31st 2005. Care staff should have formal supervision 6 times a year. All staff should have two fire lectures and two fire drills per year, and the names of the staff that attend should be recorded. 3. 4. 5. 6. 7. 8. 9. 10. 11. 8.3 8.9 15 26.3 28.1 30 31.2 36 38.2 Meadow Court J51J01_s26279_Meadow Court_v220856_240605.doc Version 1.30 Page 18 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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