Inspection on 16/01/07 for Meadow Grange

This inspection was carried out on 16th January 2007.

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 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 Grange 03/10/07

Meadow Grange 09/11/05

Meadow Grange 06/07/05

Meadow Grange 11/11/04

Meadow Grange 30/06/04

Meadow Grange 11/03/04

Similar services:

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Byars Care Home

St Marys Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Meadow Grange Holmesfield Road Dronfield Woodhouse Sheffield Derbyshire S18 5WS Lead Inspector Susan Richards Key Unannounced Inspection 16th January 2007 09:30 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 Grange DS0000002063.V324377.R02.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. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadow Grange Address Holmesfield Road Dronfield Woodhouse Sheffield Derbyshire S18 5WS 0114 2891110 0114 2891068 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 John Andrew Hill Mr Simon Cobb Mrs Sheila Bacon Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider is registered to provide nursing and personal care for service users whose primary care needs fall within the following category: 1. Old age not falling within any other category (OP) 46. 2. The maximum number of persons to be accommodated at Meadow Grange is 46. 16th November 2006 Date of last inspection Brief Description of the Service: Meadow Grange provides nursing and personal care and support for up to 46 older persons. It is a converted building with a later extension and is close to the village centre, with access to local shops, pubs and church. There is level access to extensive grounds, which provide a large patio area, together with a large car parking facility. The environment is maintained to a high standard and there is a choice of lounge and dining rooms for service users. There are thirty-eight single bedrooms, many with en suite facilities and four double bedrooms. Bathrooms and toilets are suitably located and equipped. There is a large central kitchen and separate laundry facility. The Registered Manager directs a team of nursing, care and hotel services staff, including a full time dedicated activities co-ordinator with registered provider support via external management arrangements. The range of weekly charges as at 16 January 2007 is as follows: £308.50 - £440.00 personal care only. £450.00 - £532.00 nursing care. Fees are determined in accordance with assessed needs set out wither by way of individual private contract/funding agreement or via social services funding arrangements. The next fee review date is 01 April 2007. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the site visit to the home there were forty-five service users accommodated. The deputy manager assisted in the absence of the registered manager. For the purposes of this inspection account is taken of all information held by the Commission about the service, particularly that received over the last twelve months. The home completed and pre-inspection questionnaire in October 2006 and written surveys were completed and returned from eight out ten service users surveyed. Case tracking was also used as part of the methodology. This involved the random sampling of a small number of service users who care and service provision was examined more closely. Where possible, discussions were held with them and/or their representatives and also staff about their care and their written care plans and associated care records were examined. Their private and communal accommodation was also inspected. What the service does well: Service users live in a spotlessly clean and comfortable environment, which is decorated, furnished to a high standard and generally well equipped. Service users are well supported and informed throughout their admission to the home and their needs are effectively assessed, wherever possible in consultation with them before they enter the home. Service users health care needs are well met and promoted and staff are courteous and respectful towards service users. Regular contact with family and friends is well promoted and encouraged and there is a consistent approach to the organisation of activities. Service user receive a wholesome and balanced diet in accordance with their assessed dietary needs and individual preferences. Service users know how to complain and there are suitable systems and arrangements in place to promote the protection of service users from abuse. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 6 Service users needs are met by staff who are suitably recruited, inducted and trained and overall the health, safety and welfare of service users is promoted and protected. What has improved since the last inspection? What they could do better: Review how information is provided for service users in respect of their admission and the terms and conditions of the home. On completion of the current management review of service users needs assessments, ensure that their needs continue to be reviewed with them on a ongoing basis and that in future records of these are revised as necessary. Ensure that the home’s record keeping in respect of care planning and medicines administration best promotes its evidence of and accountability for professionally based practise. Ensure more regular provision of information and individual consultation with service users in respect of their lifestyle expectations. Review the arrangements and organisation of lunch and tea time meals and ensure these are more flexibly organised in accordance with service users wishes and expectations in that they are not left waiting for long periods and that the duration of these is not excessive. Ensure that staff recognised systems and practise for good infection control are always followed. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 7 Provide suitable locks to service users own rooms thereby promoting rights to choice, independence, privacy and dignity. Review staffing arrangements/provision and skill mix and ensure that these are consistent and satisfactory and are in service users best interests. Develop a consistent quality monitoring and assurance system based on seeking the views of service users. 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. Meadow Grange DS0000002063.V324377.R02.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 Meadow Grange DS0000002063.V324377.R02.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): 1, 2, 3, 5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are well supported and informed throughout their admission process, although written information via individual written terms and conditions is not always sufficient. Service users needs are properly assessed before they enter the home, and the continued and timely completion of the management review of these should ensure that they are fully reviewed and revised to accurately reflect service users current needs. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 10 EVIDENCE: Information collated from eight service user surveys returned and also via case tracking indicated some variances in the provision of information provided for service users or their representatives to enable them to make a choice as to live in the home. The majority said that they had received enough information about the home before they moved in so they could decide whether it was the right place for them, although two said they did not. One had not received a contract and one was unable to recall. Others had received them (see below re content). Three said they had visited the home before their admission and one who was too poorly said the manager visited them in their own home where they had opportunity to discuss the home and to ask any questions they may have. Written information was also provided by way of a ‘guide.’ The rest said their relatives/carers visited the home and dealt with information on their behalf. At the previous inspection of this service a requirement was made to ensure that all service users were provided with individual terms and conditions (or contracts for private funding arrangements) between the home and individual service user which detailed full and proper information including as to their fees in accordance as is required by the Care Homes Regulations 2001 (as amended 2003). These were not inspected at this site visit in respect of their content for service users case tracked, as they were not accessible in the absence of the registered manager. Recorded needs assessments of service users case tracked were examined and their needs were discussed with staff and with one of the service users. Due to the given capacities/illnesses of the other two the Inspector was unable to hold meaningful discussions with them about their needs. The accuracy of individual’s needs assessment information varied. Two reasonably well recorded, including personal safety and risk, although for one of those their risk assessment for falls did not correspond with a recently recorded fall. Recorded needs assessment information for the third, particularly with in respect of personal risk and safety were not up to date. Written information provided to the Commission in December 2006 by social services responsible for the placement and funding of a number of service users detailed that needs assessment and care plans were not being kept up to date/effectively recorded. The recently appointed deputy manager and registered manager had commenced a systematic plan for the review and update of all individual’s needs assessment and care planning information with progress records kept. At the date of the inspection, around twenty reviews and updates had been completed, with those remaining planned. The home does not provide for intermediate care. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 11 Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health care needs are well met and promoted. However, the home’s record keeping in respect of care planning and medicines administration and practise undermines its evidence of and accountability for professionally based practise. EVIDENCE: The written care plans of service users case tracked were examined and discussions were held about their care with staff. Due to the given capacities of two of those service users, the Inspector was only able to discuss their care plans with one of them. Comments made under Section One of this report regarding recorded needs assessment information also apply in respect of some care plans not being Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 13 kept up to date, including the management review and arrangements for the update these. Care plans for two of the three service users case tracked were up to date and formulated in accordance with their risk assessed needs, with the exception of one whose risk assessed needs and care planning information did not reflect information recently recorded within their daily care and accident records in respect of falls. The recorded care plans of the third service user case tracked, was not up to date, with some areas of care planning not reviewed or revised since 2005 and not being in accordance with their recorded risk assessed needs. However, discussions with staff, together with observations and discussions with service users indicated that staff is conversant with service users needs. Out of eight written surveys completed, five said that they always received the care and support they needed and three said they usually did. (Comments made in relation to those who ‘usually’ received the care and support they needed referred to staffing levels/arrangements as an influencing factor – see Staffing section of this report). Discussions with service users indicated that they were not routinely provided with copies of their care plans, although all said that aspects of their care were discussed and agreed with them. These included daily living routines and preferences, the use of bed rails and the arrangements for their medication. Records of those discussions and where relevant signed consents were kept in the care records of those service users case tracked. The arrangements for service users to access outside health care professionals, including for the purposes of routine health care screening were examined and were well accounted for and upheld. Seven service user surveys said that they always received the medical support they needed and one said they usually did. One comment received said that ‘the medical support has been superb.’ There are established systems in place for clinical auditing in respect of pressure ulcers, falls and general health. The arrangements for the management and administration of medicines were inspected. The newly appointed deputy manager had recently undertaken a full medicines audit in respect of each service user, with satisfactory arrangements put into place for ensuring the proper ordering, receipt, storage and return of medicines. However, medicines administration record (MAR) sheets examined for service users case tracked and a number of others randomly selected, had areas of significant omissions of recording, which were highlighted and discussed with the deputy manager and registered nurse on duty at the time of the inspection visit. Service users spoken with said they always received their medicines, but some said that they were sometimes late in receiving them, which they felt were due to pressures of staffing. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 14 There were no service users accommodated with diverse cultural or religious needs/backgrounds. Service users spoken with said that staff were always polite and treated them with dignity and respect. Comments made either directly or via the service user survey, included: “ Staff are incredibly kind and courteous.” “ I am delighted with the care I received and cannot speak too highly about it and the staff” “Staff are always very pleasant.” “Staff are first class, always ready to help in any way.” “Staff are very caring and dedicated.” Other comments made in respect of the care and commitment of staff, included: “My grandmother has made a miraculous recovery in the eight months she has been at Meadow Grange.” “Thanks to the dedication of the staff she is now happy and confident and able to walk after four months of not being able to.” “When I arrive here I was bedridden for some months in hospital. My leg was completely immobile. I am now able to walk with a frame and supervision and I am very happy here.” “My legs were terrible and ulcerated when I came, they are now almost completely healed.” Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users regular contact with family and friends is well promoted and supported and there is a consistent approach to the organisation of activities. However, more regular provision of information and consultation with each service user in respect of their lifestyle expectations may more accurately determine their expectations, capacities and preferences and better promote autonomy and choice. Service users are provided with a wholesome and balanced diet in accordance with their assessed dietary needs and individual preferences, although the duration and organisation of the lunch and teatime meals are not always satisfactory or in accordance with service users wishes and expectations. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 16 EVIDENCE: At the time of this inspection, there were no service users accommodating with diverse religious or cultural needs. The home employs a full time activities co-ordinator organises a variety of in house activities together with outings. Activities regularly organised in the home, include arts and crafts, board games, arm-chair aerobics and knitting. Entertainment is regularly provided and periodic outings are sometimes arranged with service users. Some service users spoken with/surveyed felt that there should be more regular trips out. A regular church service is also held in the home. The majority of service users spoken with and surveyed said there was always a range of activities provided, although two persons surveyed, whose identity is unknown felt that these were only sometimes available. Individuals’ know lifestyle preferences and family/social histories were recorded in consultation with service users and their families. However, these records were usually completed on or following individual’s admission to the home and there were no records regarding regular consultation in respect of on going arrangements for social and recreational activities planning with each service user. Records were kept of activities provided. Information is displayed in the home regarding activities and residents and relatives meetings are held at fairly regular intervals. There are also regular fund raising activities on behalf of an established residents fund. Visiting to the home is open. However, not all service users were provided with information regarding activities. Service users spoken with said they particularly enjoyed the Christmas festivities with a choice of three pantomimes to visit and also spoke highly of the activities co-ordinator. They all said they were able to bring in their own personal possessions/items of furniture into the home and records were kept of these within individual’s care files. The majority of service users spoken with and also relatives said that the standard of food provided in the home was good, with choices and alternatives always provided. Menus were also displayed and service users said that the cook always consulted with them on daily basis as to their choice of food/meals. However, comments were received from a number of service users regarding the organisation of meals and mealtimes. All said that breakfast arrangements worked well as these were flexible, but that lunches and dinner were often stressful and inflexible for service users who were unable to attend and leave the dining room independently in that they have to Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 17 wait for long periods whilst everyone is seated, fed and ready to leave. One person said they would like a quieter area for eating. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 18 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): NMS 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives know how to complain and there are suitable systems and arrangements in place to promote the protection service users from abuse. EVIDENCE: Service users and their representatives who were consulted with said they knew how to complain. Some service users said they would not do so unless a particularly serious matter arose. Information provided on the pre-inspection questionnaire completed by the home on 10 October 2006 indicated that there had been one complaint during the last twelve months. The newly appointed deputy manager was unable to locate the complaints record in the absence of the registered manager. However, records of internal weekly management reports were provided. These did not indicate any recent complaints. The complaints procedure was openly displayed, although information provided on this regarding the contact details of the Commission were incorrect. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 19 Discussions held with staff included the policies and practises of the home in relation the protection of service users from abuse. Staff has undertaken training in respect of these and abuse awareness and were conversant with their responsibilities. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service uses live in a safe, clean, comfortable, well maintained home, which is decorated and furnished to a very high standard. However, recognised systems and practise for good infection control are not always being consistently followed, which may place service users at risk. EVIDENCE: Service users live in a clean, comfortable and safe environment, which is decorated and furnished to a very high standard and is suitably equipped, although locks are not routinely provided to bedroom doors. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 21 Examination of the weekly management reports indicate that a door lock requested for one service users own room has been outstanding for a considerable time period. The private and communal facilities of service users case tracked were inspected. These were well furnished and decorated and suitably equipped, and service users spoken with said they were satisfied with their rooms. All said the home was always clean and odour free as seen on inspection. The Inspector was advised of requests by families of two service users, who had made requests in respect of a review/change of bedroom. The grounds are well maintained, and accessible to service users. There are separate suitable laundry facilities and hand washing facilities for staff. The home was spotlessly clean, although one of the domestic staff on duty in the home at the time of the inspection was not wearing and routinely did not wear any protective clothing whilst cleaning and handling clinical and domestic waste although these were provided. There was also no cleaning trolley for the first floor. A number of waste bins in toilet and bathroom areas did not have lids to them. This was discussed with the deputy manager. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 22 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): NMS 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by staff who are suitably recruited, inducted and trained, although the arrangements for staff provision and skill mix are not always consistent, satisfactory or in service users best interests. EVIDENCE: At the time of the inspection there were forty-five service users accommodated, although accurate information was not available in the home as to the number of service users receiving nursing care or as service users general dependencies. For service users case tracked a dependency scoring record was introduced in their care records in November 2006. Two of these detailed high dependences and one medium, although the first two had not been reviewed since November 2006. Information provided on the pre-inspection questionnaire submitted on 10 October regarding service users needs and dependencies indicated at that time that there were three service users with low dependency needs, twenty one with medium and twenty one with high dependency needs. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 23 Staff duty rotas were examined. These usually provided one registered nurse and seven or eight care staff during the morning and one registered nurse and five care staff during the afternoon, although there were times when care staff provision during the afternoon dropped to four and occasionally three, which after four or five pm on those occasions left 1 nurse and either three or four care staff. The activities co-ordinator works in the home Monday to Saturday and is additional to the above, as is the registered manager. There are sufficient hotel services staff. Waitress/waiter cover is also provided at mealtimes. Discussions were held with staff, service users and their representatives regarding the staffing arrangements in the home and eight service user surveys gave views regarding staffing. Three service users said that that staff were always available when they needed them. However, the rest said that staff was usually or sometimes available and comments were received indicating that there were regular times where there were insufficient staff. All said they received the care and support they needed and that staff worked very hard and were always polite, caring and conscientious, but said that times of insufficiency led to tablets being late and long periods waiting between calling for assistance and staff arriving. Discussions held with staff indicated that a review of skill mix was needed to provide a second nurse and that additional care staff were needed for the afternoon shift. It was felt that the very recent appointment of the deputy manager would assist, although her hours and pattern of work were to be formalised. She was covering for the registered manager’s hours, who was on annual leave at the time of the inspection. Information provided on the pre inspection questionnaire detailed a total of 22 staff (nursing, care and hotel services) had left since the last inspection 14 months previously. Regular agency nurses were being used for night cover. Details of the arrangements for staff recruitment, induction and training were examined and were satisfactory. This included discussions with staff and examination of relevant records. Staff said that access and arrangements for training were good. To date fifty four percent of staff have achieved NVQ level 2 or above. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 24 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): NMS 31, 33, 35, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using evidence available, including a visit to the home. Overall the health, safety and welfare of service users is promoted and protected. Although development of a more robust and comprehensive system for quality monitoring and assurance, based on seeking the views of service users, should better promote their best interests and provide an internal measure as to the home’s success in meeting its aims and objectives and statement of purpose. EVIDENCE: The registered manager is a registered general nurse. She has a NVQ level 4 in management and care/registered managers award. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 25 Discussions were held with the deputy manager regarding quality assurance and monitoring systems in the home. She was not aware of any formal system of quality monitoring and assurance, although advised that a representative of the registered provider visited the home on a monthly basis and provided reports of those visits, although these were not available for inspection. The most recent report undertaken by the regional manager on this basis has been forwarded to the Commission since the inspection. Records of the most recent weekly management reports of the registered manager were examined. The deputy was unaware of the operation of any formal methods of consultation with service users as to their satisfaction, such as anonymous satisfaction surveys, other than meetings and care plan reviews or of the existence of any annual development plan for the home. The arrangements for the management and handling of service users monies were examined for those service users case tracked. These were satisfactory. Comments are made under the Health Care section of this report regarding records and record keeping in respect of care plans and medicines records, which were not always properly maintained, up to date or accurate and also the arrangements for service users access to those records. The arrangements to ensure safe working practises were discussed with staff, observations were made during inspection of the environment and training records examined of four staff employed, together with the staff-training matrix devised by the registered manager. These were satisfactory, with further training in respect of infection control identified. Comments are made under the Environment section of this report in respect infection control. Details of the maintenance of equipment in the home were provided in the preinspection questionnaire and are satisfactory. The system for the reporting and recording of accidents/untoward incidents were examined via case tracking and were satisfactory. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 26 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 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 3 Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 27 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 OP2 Regulation 5A Requirement Individual written terms and conditions, which are between the home and individual, must detail information in accordance with Regulation 5A (amended 2003) Contracts for those service users who are private funded must detail all information in accordance with the above regulation. 2. OP7 15 Written care plans must be kept under review, and where necessary revised in consultation with the service user. There must be satisfactory arrangements for the recording of the administration of medicines. Medicines administered to any service user must be signed for on the MAR sheet by the staff member responsible or the appropriate coded reason recorded indicating their non-administration. A summary of complaints made during the last twelve months DS0000002063.V324377.R02.S.doc Timescale for action 01/04/07 28/02/07 3. OP9 13 28/02/07 4. OP16 22 28/02/07 Meadow Grange Version 5.2 Page 28 5. OP26 13 6. OP27 18 7. OP37 17 and the action taken in response must be forwarded to the Commission. Suitable arrangements must be ensured to prevent infection, toxic conditions and the spread of infection. In this instance ensuring that staff wear protective clothing in accordance with their duties and responsibilities, provision of an additional cleaning trolley for the first floor and ensuring that all waste bins are fully occlusive and with lids. It must be ensured that there are consistently (at all times) suitably qualified (competent and experienced) persons working at the home in such numbers as are appropriate to meet the needs and best interests of service users accommodated. Records required by regulation for the protection of service users and for the effective running of the business must be maintained and be up to date and accurate. In this instance reference to care plans and medicines administration records. 28/02/07 28/02/07 28/02/07 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 OP7 OP7 Good Practice Recommendations Care plans should be reviewed at monthly intervals. Care plans should be drawn up with the service user, recorded in a style accessible to that service user and DS0000002063.V324377.R02.S.doc Version 5.2 Page 29 Meadow Grange 3. OP12 4. 5. OP12 OP15 6. OP22 7. 8. OP24 OP33 agreed and signed by them whenever capable (or a representative if otherwise). (NMS 14 also applies). Service users should be regularly consulted regarding their lifestyle expectations and their social, cultural, religious and recreational interests and a record maintained of these. Up to date information about activities should be circulated to all service users (in formats suited to their capacities). A review of the arrangements for the serving of meals at lunch and tea time should be undertaken to ensure that service users do not wait for long periods for assistance or to be served. The complaints procedure should be amended to provide correct contact details for service users and/or their representatives who may wish to contact the Commission in respect of any complaint. (East Midlands Central Compliance and Registration Team). Doors to service users own rooms should be routinely fitted with locks suited to their capabilities and accessible to staff in emergencies. More consistent and robust quality assurance and quality monitoring systems should be developed, which are based on seeking the views of service users and which provide an ongoing measure as to the home’s success in meeting its aims and objectives and statement of purpose. Meadow Grange DS0000002063.V324377.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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