Inspection on 25/10/05 for Meadow Court

This inspection was carried out on 25th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Meadow Court 06/06/07

Meadow Court 22/06/06

Meadow Court 23/06/05

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 West Yorkshire HD7 5EL Lead Inspector John Gregory Announced Inspection 25th October 2005 08:30 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 Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 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. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Meadow Court Address Meal Hill Lane Hill Top Slaithwaite Huddersfield West Yorkshire HD7 5EL 01484 840366 01484 840366 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) Mr Ian Douglas Whitehead Mrs Ann Jennifer Whitehead, Mr Roger Wagstaff Ms Susan Linda Haigh Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 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 single occupancy; two rooms are for double occupancy. Most of the bedrooms have en-suite facilities. There are three lounges and a designated dining room; the accommodation is built over two floors that are joined by a shaft lift. Persons who live in adjacent accommodation privately own the enterprise. The home is located at Hill Top, above Slaithwaite, in the Colne Valley approximately five miles from the centre of Huddersfield. The home has large gardens and ample car parking provision. The home is a short walk from a local bus route and railway station. Most of the service users admitted to Meadow Court are from the local area and have common knowledge and experiences. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over the course of one day in October 2005, lasting seven hours. The inspection concentrated on those standards the CSCI determine are central to the caring process. A pre-inspection questionnaire was received from the service provider and preinspection letters were received from both service users and their families. A sample of policies, procedures and records were examined that were relevant to the standards inspected. Seven case files were examined, 3 of which were examined in detail. Interviews were held with six service users in private. Six staffing files were examined and private interviews held with four staff. A tour of the accommodation was undertaken. The manager and two of the owners assisted the inspector on the inspection. The inspector would like to thank the service users, staff, owners and manager of Meadow Court for their time, co-operation and hospitality during this inspection. What the service does well: What has improved since the last inspection? The good decorative condition of the home has been maintained. The provider has taken action to address many of the requirements and recommendations made in the previous report. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 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. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 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 Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 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&3 The registration details of the home must be made available to inform all stakeholders of the basic facilities of the home. The arrangements for the assessment of service users should be made clearer. All the service users’ needs are currently met. EVIDENCE: The service provider must display both pages of the registration certificate to inform all stakeholders of the basic facilities of the home. Of the seven service users’ files examined only two contained a detailed preadmission assessment, in both cases under the care management arrangements. All the service users interviewed stated that their needs were currently being met. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9 &10 The care planning system is good, although all service users should be actively involved in the review process and subject to a risk assessment for falls. Health care is good and would be enhanced by nutritional assessments being routinely undertaken on all service users. The medication system needs further development to ensure that service users are fully protected. Service users are treated with respect and their privacy is respected. EVIDENCE: The seven case files examined contained detailed care plans which were reviewed monthly by care staff. Service users were, in the main, aware of the existence of the care plan but did not feel they were actively involved in its review and development. The bulk of the files contained risk assessments for falls. These need to be extended to all service users irrespective of the degree of risk that is likely to occur to ensure the safety of all service users. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 10 There was good evidence on file, confirmed by service users, that there was good medical care organised by the local primary health care team. Good access is available to medical ancillaries. Nutritional assessments are currently undertaken on new admissions to the home. Examination revealed that three of the longer-term service users had suffered significant weight loss in the past twelve months and had not been subject to nutritional assessment. The nutritional assessment should be extended to all service users to assist in maintaining their nutritional state. Service users would be better protected if the medication procedure were extended to cover all areas noted in the Royal Pharmaceutical Society guidance for care homes. The medication system was audited and, although basically sound, it was noted that the controlled medication was not subject to two signatures in the drugs register. The numbers of all drugs received were not recorded on the MAR (medication administration record). Service users’ care is based in their single rooms; a married couple share the only double room in use. Transactions between staff and service users were positive and respectful. All service users wear their own well-laundered clothing. The home has a public phone and some service users have their own phone. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 11 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 &15 Service users were happy with their lifestyles and the range of activities available for their participation. All took the open visiting facilities as a matter of course. A range of choices are available to all service users, the limits to choice in the main meal was not an issue for service users. The meals served are nutritious and of good quality and served in a convivial atmosphere. EVIDENCE: The service provider offers a range of activities for service users to become involved with, including concerts held in the dining room. All the service users were aware of these activities and could choose to become involved to supplement their personal choice of lifestyle. Service users interviewed all took the open visiting arrangements as a matter of course and some spent time away from the home in the company of their extended family. Service users choose where to spend their days, bring personal possessions into the home and choose their own companions, activities and, to a lesser extent, their meals. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 12 The main meal of the day was seen and the menu examined. Service users have access to a varied nutritious diet which is well presented, and the main meal served in a convivial atmosphere. Breakfast is served in the service users’ own room if they wish. The absence of a true choice of main meal was not a major issue for service users although two commented that they would sometimes like a choice but felt this would overburden the staff. The service provider should bear this perspective in mind when planning future menus. The meal process would be enhanced if the choices available for breakfast were added to the menu. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 13 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 & 18 The service provider has a good complaints procedure which the service users have confidence in and the staff know how to operate. The service users are protected from abuse, a process that would be further enhanced by the development of a whistle blowing procedure. EVIDENCE: The service provider has a complaints procedure that is robust. Staff understand how to operate the procedure and deal effectively with any complaints they receive. On interview, service users were confident that staff and managers would effectively deal with any concerns they may have. The procedure for the protection of vulnerable adults is comprehensive and staff have access to the local joint agency procedure. Staff understood the procedure and were confident in its initial use. The procedure would be enhanced by the development of a whistle blowing procedure that staff were trained in and supported to understand. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 14 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 & 26 The service users live in an environment that is safe, well-maintained, clean, tidy and furnished in a domestic manner EVIDENCE: The accommodation is large, well decorated and maintained, clean and tidy. The furnishings are of a domestic nature and the rooms have a good level of personalisation. The laundry is equipped with washers capable of sluicing, separate sluicing and hand washing facilities. The walls and ceiling of the laundry are of an impervious nature. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 15 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 &30 The service is run with a staffing level and training sufficient to provide for the basic needs of service users. The recruitment process needs further development to ensure that service users are fully supported and protected. EVIDENCE: The rota was examined and the manager, and observations, confirmed the traditional staffing level of the home. This staffing level consists of four care staff on a morning shift, three on an afternoon shift and two waking night staff. The manager and deputy manager are supernumery to the rota. The care staff are supported by ancillary laundry, catering and cleaning staff. Six staffing files were examined and, whilst improvements have taken place, it was clear that not all staff have been subject to a CRB check prior to commencing work. Should it be necessary to start staff before receipt of a satisfactory CRB check, a POVA First check and two references must be obtained prior to starting. This issue has been the subject of two previous statutory requirements, the timescale of which have now been exceeded. In view of the progress made, a new short timescale is given for compliance. Failure to achieve this target will result in the CSCI taking enforcement action to ensure that service users are properly protected. In order to further protect service users, staff should make a statement of their emotional and physical health prior to their appointment. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 16 Seven of the seventeen staff have achieved the NVQ level two and training is in progress to ensure that the target of 50 qualification is achieved by the end of the year. Staff confirmed the written record that they had achieved all the required training in health and safety and fire issues. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 17 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): 31,33,35,36 & 38 The manager should continue to complete her formal training. The home does not ensure that service users’ best interests are served through the use of a quality assurance system. Service users’ finance needs further protection. The supervision process needs further development. Improvements are necessary to the risk assessments in what is an otherwise safe home. EVIDENCE: The manager reported that she has not yet completed her NVQ level 4 and should do so by the end of the year to obtain professional qualification. The service provider does not have a quality assurance system by which means the service users’ needs should underpin development of the home. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 18 The service users’ financial records for day-to-day expenditure were sample audited and the amounts of money seen to balance. Receipts did not accompany the bulk of expenditures made on behalf of service users. This must be rectified to ensure that service users are fully protected. Supervision has now become part of the home’s management systems but has not yet reached the level necessary to ensure that staff are appropriately supervised. The home’s health safety and COSHH records were in order. However the home’s risk assessments for fire and health and safety were not fully recorded and should be to ensure that service users are fully protected. Staff and service users felt safe working and living in the home. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 19 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 1 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 2 X 2 Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP1 OP3 Regulation CSA 2000 Requirement Timescale for action 01/12/05 01/12/05 3. OP29 4 OP29 5 OP33 The service provider must display both pages of the registration Certificate. 14 The service provider must not provide accommodation for a service user unless their needs have been assessed, a copy of the assessment obtained. 19(b)(c) & The manager must not employ a Sch 2 person to work at the home without the information & documents specified in Schedule 2. Staff must not commence employment at the home without a current enhanced Criminal Records Bureau (or POVA First check pending receipt of CRB). This requirement was identified on the last 2 inspection reports. Failure to comply may lead to further action being taken. 19 The service provider must obtain Sch 2 a statement by the staff as to their emotional and physical health prior their appointment. 24 The service provider must establish and maintain a system for reviewing at appropriate DS0000026279.V258710.R01.S.doc 01/12/05 01/01/06 01/04/06 Meadow Court Version 5.0 Page 21 intervals; and improving the quality of care in the care home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3. 4 5 6 7 8 9. 10. 11 12. 13 Refer to Standard OP7 OP7 OP8 OP9 OP9 OP9 OP15 OP18 OP28 OP31 OP35 OP36 OP38 Good Practice Recommendations Service users should be actively involved in reviews of their care. All service users should be subject of a risk assessment for falls Nutritional screening should be undertaken on all service users using a recognised assessment tool, and reviewed. The medication procedure should be developed to include all area covered in the Royal Pharmaceutical Society Guidance for care homes. All controlled drugs dispensed should be witnessed by two signatures in the controlled drugs book The amounts of medication received should be recorded on the MAR sheet The breakfast choices should be recorded on the Menu The service provider should develop a whistle blowing procedure and train staff in its use. A minimum ratio of 50 trained members of care staff to achieve an NVQ level 2 or equivalent, by 31st December, 2005. The registered manager should hold an NVQ 4 in management and care by December 31st 2005. Receipts should accompany all expenditure of service users money. Care staff should have formal supervision 6 times a year. Workplace and fire risk assessments should be fully recorded. Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Brighouse Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Meadow Court DS0000026279.V258710.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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