Inspection on 09/11/05 for Meadow Grange

This inspection was carried out on 9th November 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 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 Unannounced Inspection 8th November 2005 10:00 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.V263723.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 Grange DS0000002063.V263723.R01.S.doc Version 5.0 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 J Biggin Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 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 of character 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, including a large patio area and seating, 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 has the support opf a team of nursing, care and hotel services staff and there is a full time support from an activities co-ordinator. Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection, which is the second inspection of this service for the inspection year 1 April 2005- 31 March 2005, was on the staffing and managements arrangements for the home. However, compliance with previous requirements made during the inspection carried out on 06 July 2005 was also assessed. This included aspects of records and record keeping in relation to care planning and also the management and administration of medicines in the home. What the service does well: What has improved since the last inspection? A review of the arrangements for the management and administration of service users medicines has been undertaken and the requirements made at the previous inspection in relation to these had been achieved. A review of the format of record keeping for service users care planning documentation and associated records had been undertaken and changes (identified and planned) were identified in respect of these, which are in accordance with recognised practise. A review of storage facilities in the home has been undertaken and action identified. Meadow Grange DS0000002063.V263723.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 Grange DS0000002063.V263723.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 Grange DS0000002063.V263723.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): 2 & 3. Service users whose admissions are organised via care management arrangements and funding did not have individual written terms in accordance with requirements. Service users who were privately funded did have individual written contracts, however, these did not detail all information as is required. EVIDENCE: At the previous inspection for this service carried out on 06 July 2005 a requirement was made that individual written terms and conditions must be provided between the home and each service user (or contract where care is privately funded), which details information in accordance with that detailed under Regulation 4 (amended 2003) of the Care Homes Regulations 2001. Such terms and conditions had not been provided as stated. Service users who are privately funded do have written contracts, however, these still did not contain all information as required. This was discussed with the manager. Meadow Grange DS0000002063.V263723.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): The standards in this section were not fully assessed on this occasion. Approaches to records and record keeping in respect of service users needs assessment and care planning documentation had been reviewed, with development plans put into place in accordance with recognised good practise. There were satisfactory systems and arrangements in place in relation to the management and administration of service users medicines. EVIDENCE: Although the standards in this section were not fully assessed on this occasion, the Inspector reviewed progress with requirements made at the previous inspection regarding aspects of records and record keeping in relation to service users individual risk assessment and care planning information. A review of the format and arrangements for the keeping of these records was underway and previously identified requirements had been achieved. Aspects of the homes systems and arrangements for the management and administration of service users medicines were also examined in accordance Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 10 with requirements made at the previous inspection for this service carried out in July 2005 and were found to be satisfactory. Meadow Grange DS0000002063.V263723.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): The standards in this section were not assessed on this occasion. EVIDENCE: Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 12 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 There were satisfactory systems and arrangements in place to enable service users (or their representatives) to raise concerns and to complain and also to promote the protection of service users from abuse. EVIDENCE: Discussions were held with the manager and staff regarding the arrangements in the home to assist service users and their representatives to raise concerns and to complain, which were satisfactory. Records were also examined. There had been no complaints since the previous inspection. At the previous inspection of the home (July 2005) service users had said that they knew how to complain if necessary, although all stated that any concerns or matters raised were always dealt with promptly and satisfactorily, generally without the need to make a formal complaint. However, during that inspection service users said that they had not seen the complaints procedure as displayed in the reception area of the home, which was felt possibly to be due to the fact that it was in very small print. This had been replaced by a larger print version as observed during this inspection. Discussions were also held with the manager and staff regarding the home’s policy and procedures and staff training and instruction in relation to the prevention of abuse and action to take in the event of any suspicion or witnessing of the abuse of any service user, which were again satisfactory. Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 13 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): The standards in this section were not assessed on this occasion. EVIDENCE: At the previous inspection a requirement was made to review storage capacity and facilities in the home. This had been undertaken with further action identified. Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 14 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 home is properly staffed. There are suitable arrangements in place to ensure that staff are recruited, inducted, trained and supervised in accordance with recognised guidance in order to meet service users needs. EVIDENCE: The manager provided details of staff employed, together with staff duty rotas and the arrangements for staff cover in the home and also details of staff turnover over the previous 12 months. These were satisfactory. The arrangements for staff recruitment, induction, training and supervision were also inspected. This included discussions with the manager and staff and examination of relevant records, which were properly maintained. Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 15 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, 32, 33, 34, 35, 36, 37 & 38. The home is effectively and competently managed. There are effective staffing and management systems and arrangements in place to promote service users best interests in relation to their health, safety and welfare. EVIDENCE: Discussions were held with the manager regarding training and development undertaken by her in the previous 12 months and also planned. Records were examined in relation to this. Discussions with staff indicated that there were clear lines of accountability both within the home and with external management arrangements. Formal systems of communication and monitoring were established and recorded. These included staff meetings and handovers, reviews and monthly visits by the registered provider. Quality monitoring systems were discussed and Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 16 records examined. These included periodic formal consultation with service users and their representatives by way of a satisfaction questionnaire, recently undertaken. Outcomes and any action taken as a result of this were also well documented A number of records, which must be kept in the home, were examined. These included staff recruitment, induction, training and supervision records, records of service users monies, duty rotas, complaints records, fire and maintenance records and accident and incident records. These were properly maintained. A number of the home’s policies and procedures were also examined in relation to the staffing and management of the home. Discussions with staff indicated that they were conversant with key policies and procedures as discussed with them in relation to the above. Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 17 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 X 1 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 18 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 Requirement Each service user must be provided with individual written terms and conditions, which are between the home and individual, which 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. Original timescale 31.08.05 Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Derbyshire Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Meadow Grange DS0000002063.V263723.R01.S.doc Version 5.0 Page 20 - 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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