Inspection on 06/07/05 for Meadow Grange

This inspection was carried out on 6th July 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 Grange 03/10/07

Meadow Grange 16/01/07

Meadow Grange 09/11/05

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 S18 5WS Lead Inspector Susan Richards Unannounced 06 July 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 Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Meadow Grange Address Holmesfield Road, Dronfield Woodhouse, Sheffield, Derbyshire, S18 5WS 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) 0114 289 1110 0114 289 9199 Mr John Andrew Hill, Mr Simon Cobb Mrs J Biggin Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th November 2004 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 provides a large patio area and seating for service users and their visitors, together with a large car parking facility. The home is maintained to a high standard and there is a choice of lounge and dining rooms for service users. There are 38 single bedrooms, many with en suite facilities and 4 double bedrooms. Bathrooms and toilets are suitably located and equipped. There is a large central kitchen and separate laundry facility. The Registered Manager is supported by a team of nursing, care and hotel services staff and there is a full time activities co-ordinator. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 6 The registered provider should seek to develop the systems for the keeping of service users records in line with current recognised practise, in terms of developing the use of individual care files for each service user, which are more accessible to both service users and staff. It is also imperative that service users records are properly maintained and kept up to date and that nursing staff are reminded of their accountability in relation to records and record keeping, including that of safe storage. 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 Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.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 Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.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) 1, 2, 3, 4 & 5 There were suitable arrangements in place to enable service users and their representatives to make informed choices as to whether to move into the home and also in relation to the care they received. Individual needs assessment information was not always up to date and individual contracts/terms and conditions were not always fully completed. EVIDENCE: The Inspectors case tracked four service users. This process included examination of their care and associated record and discussions were held with them (and their representatives present during the inspection) about their admissions to the home and the care and services provided. Discussions were also held with staff and management about the care and services provided in the home. Service users who were able described how they had chosen the home and said that they received excellent care and support. The Inspector was not able to converse with one service user about their care due to their mental capacity. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 9 Written information about the home and its services was openly available and provided for each service user. Individual contracts/terms and conditions were in place for each service users case tracked, but not all were completed with individual details of fees paid and what they covered. Documented needs assessments were inspected for each of the service users case tracked, together with daily living plans. Needs assessment information was not always up to date, particularly in respect of risk assessed needs. Discussions with management and staff indicated that staff were fully conversant with service users needs and had the skills to meet those needs. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Overall service users felt that their health and social care needs were being met. However, care records were not always reflective of this. There were some omissions evidenced in respect of individual’s health care with serious omissions in the recording of the administration of service users medicines. Suitable arrangements for the return/proper disposal of medicines for service users had not been made in response to recent changes instigated via the PCT. EVIDENCE: Care plans were examined for each of the service users case tracked, including healthy care and daily living plans and discussion were held with service users and their representatives about the care they received. Care plans were not always up to date in that they had not always been reviewed/updated to reflect changes in individual needs and the care interventions actually undertaken by staff. The personal and oral hygiene needs of service users were generally well recorded within individual’s daily living plans. However, examination of records, discussions held and observations made in respect of the pressure Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 11 area care and fluid intake for one service user indicated that there were omissions, both in relation to the frequency of their pressure area care and in the recording of their fluid intake. The records for another service user detailed the requirement to undertake further routine blood screening within a specific time frame, although there was no record to indicate that this had been undertaken. Discussions with staff/manager indicated that this had not been undertaken. There was a recognised approach to clinical risk screening in relation to pressure ulcer prevention, nutrition, use of bedrails, mobility/falls by way of a standardised format for documentation. However, these were not always up to date/regularly reviewed. Records of inputs from outside health care professionals were kept for each of the service users case tracked, including that relating to routine health care screening and visits from their GP. Needs assessment and care planning information for each service user was not held within their own individual files, but divided into various filing systems in accordance with the topic, for instance assessments for all service users were held together in large file. This was the same for care plans, risk assessments and records of visits from outside healthcare professionals – each being within different files. This did not render them easily accessible and service users spoken with had not seen their own care plans. The arrangements for the management and administration of medicines were examined. There were significant gaps in the medicines administration record (MAR) sheet, where staff had not signed to indicate whether medicines had been given as prescribed and there was no agreed code recorded to indicate the reason for not giving a particular medicine. Correcting fluid (tippex) had been used on one MAR sheet. The British National Formulary was in place in the home for the purposes of provided medicines information for staff. However, this was a 2001 edition and as these are produced annually was not up to date. A number of medicines, which required return /proper disposal were stored in a cupboard with other non-medicine items and had been there for a considerable time period. Medicines administration record (MAR) sheets were left out openly in a communal area accessed by both service users and their relatives. The Manager advised that all staff responsible for the management and administration of medicines had received training updates in relation to this. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 There were excellent arrangements in place to enable service users to engage in social, recreational and religious interests and activities of their choice and in accordance with their lifestyle preferences. The arrangements for meals and mealtimes and the quality of food served in the home were to a good standard. EVIDENCE: Inspectors spoke with service users and staff about the arrangements for activities in the home and records were examined in relation to this. During the inspection the activities co-ordinator was present in the home and had organised a crafts sessions for a group of service users. Information regarding activities and entertainments was posted on the communal notice board. The arrangements for activities were comprehensive and service users spoken with said these were more than satisfactory and that they were able to choose as to when, what and how they wished to be involved in these. Two service users spoken with had recently been away on holiday organised by the home and with staff support. They said that this had been most enjoyable. Service users said that visiting to the home was open and that they could choose who and where they saw their visitors. Many service Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 13 users spoken with and whose rooms were seen had their own personal items and furniture they had chosen to bring into the home. Menus were displayed detailed meals for the day. Although a set lunch was itemised, discussions with service users and the cook evidenced that this was by no means the only food available at lunchtime. Service users said that the cook spoke with them each morning to ascertain whether they would prefer an alternative to the main course and said that ‘nothing is too much trouble.’ Records were kept by the cook of alternative food provided to the main lunch, together of individual likes and dislikes, special requirements and records of reviews. Service users said that the quality of food was very good and there was always a comprehensive choice at breakfast and tea-time, with snacks and drinks available between meals. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Whilst service users spoken with were confident at raising any concerns or complaints they may have, the provision of/format of written information did not wholly assist them in doing so. EVIDENCE: Information regarding how to complain was provided for service users and their representatives by way of the statement of purpose for the home and also displayed in the main reception area. That displayed was very small and in small print with potential difficulty for service users to note. Service users spoken with said they had not seen the information, although knew what they would do themselves in the event that they wished to complain. The Manager advised that information on how to complain was verbally given on a regular basis via resident meetings in the home. There was system in place for the recording of complaints, which had been revised since the previous inspection to include details of action taken and outcomes. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 15 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, 20, 21, 22, 23, 24, 25 & 26. The home provides service users with a clean, safe and homely environment, which is well maintained and equipped and furnished and decorated to a high standard. Attention is needed to the arrangements for storage in the home, including that relating to safe storage of records. EVIDENCE: A full tour of the building was undertaken. All areas seen were clean, well lit and ventilated and were well decorated and furnished and equipped to a high standard. Service users have a choice of lounge and dining space and have level access to well kept grounds, including a large patio area with seating provided. Toilets and bathrooms were generally well equipped, although stores incontinence pads were observed to be on the floor two areas as there was no shelving provided. There were two storage cupboards with items stored there. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 16 The doors to these cupboards were not locked, which was contrary to the fire signs thereon. One bathroom was inaccessible to service users as bed frames were stored in here, which the Manager said were awaiting disposal and a bed replacement programme was underway. There was no lock to the office door, where confidential documents/information is stored, some of which was left out openly. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 17 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 The numbers and skill mix of staff were consistent and well sufficient to meet service users needs. EVIDENCE: The arrangements for staff cover were discussed with the manager and service users and duty rotas examined. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 18 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) Standards in this section were not assessed on this occasion. EVIDENCE: Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 3 3 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 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x x Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 20 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 OP2 Regulation 5A (amended 2003) 14(2) Requirement Individual written terms and conditions must be provided for all service users, which are in accordance with the information required by this regulation. The registered person must ensure that the assessment of service users needs (including risk assessments) are up to date, kept under review and revised at any time when it is necessary to do so. The registered person must ensure that the service users plan is available to them, is kept under review and revised as appropriate in consulation with the service user. The registered person must ensure that arrangements for technical procedures are followed up promptly in accordance with medical instructions with the appropriate health care professional. The registered persons must ensure that there is a signed record for all medicines to be administered to any service user. Medicines must be administered as prescribed and where these Timescale for action 31.08.05 2. OP3 & OP7 31.08.05 3. OP7 15(2) 31.08.05 4. OP8 13(1)(b) 01.08.05 5. OP9 13(2) & 17(1)(a), Schedule 3 01.08.05 Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 21 6. OP9 17(1)(a) 7. OP9 13(2) 8. OP9 13(2) 9. OP9 13(2) & 18(1)(a) & (c)(i) 22(2) & (6) 23(2)(l) 17(1)(a), Schedule 3 10. OP16 11. 12. OP22 OP9 (OP37 also applies) are not given the proper coded reason for not doing so is recorded. Correcting fluid (tippex) must not be used on medicines administration record sheets. Changes or errors recorded must be clearly and properly amended in accordance with recognised practise. Up to date medicines information must be provided in the home for staff who are responsible for the administration of medicines. The registered person must ensure that proper arrangements are made for the disposal of medicines received into the care home. The registered persons must ensure that a review of staffs training needs in respect of the management and administration of medicines is undertaken. The complaints procedure displayed must be provided in a format suitable for service users to see, ie large print format. Suitable provision must be made for storage purposes in the home. Records kept in relation to service users care must be safely and securely stored. (In this instance medicines administration record sheets). 01.08.05 31.08.05 31.08.05 31.08.05 31.08.05 30.09.05 310.08.05 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. Meadow Grange C52 C02 S2063 Meadow Grange V232461 060705 Stage 4.doc Version 1.30 Page 22 Refer to Standard Good Practice Recommendations Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT 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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