Inspection on 04/06/08 for Meadow House Nursing Home

This inspection was carried out on 4th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Meadow House Nursing Home Norwich Road Swaffham Norfolk PE37 8DD Lead Inspector Kim Patience Unannounced Inspection 4th June 2008 10:00 Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 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 House Nursing Home DS0000071004.V366680.R01.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 Adults 18-65. 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 House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadow House Nursing Home Address Norwich Road Swaffham Norfolk PE37 8DD 01760 725146 01760 720597 ray@rayludford.wanadoo.co.uk 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) Healthcare Homes Limited Raymond Ludford Care Home 29 Category(ies) of Physical disability (29), Physical disability over registration, with number 65 years of age (29) of places Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission are within the following category: Physical disability - code PD and code PD(E). The maximum number of service users who can be accommodated is 29. N/A 2. Date of last inspection Brief Description of the Service: Meadow House offers care to people with physical disability, specialising in care for people with multiple sclerosis. The premises is single story purpose built and offers a range of single rooms, large lounges, dining room and a separate activities centre. Meadow House is situated on the outskirts of Swaffham, near to a range of shops and other amenities. The fees for the service range from £760.60 £1200.00 Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection has been completed by looking at the last inspection report, using information given to us about the service since the last inspection and a site visit. The site visit was held over two days and took approximately 9.5 hours to complete. During the site visit we conducted a tour of the premises, we spoke with people who live and work in the home and people visiting the home. We also looked at records relating to people accommodated and staff. In December 2007, the home changed ownership and is now owned by Healthcare Homes Ltd. What the service does well: What has improved since the last inspection? Since the last inspection the home has changed ownership and the new larger organisation has introduced many updated policies and procedures. The manager is supported by an operations manager who now completes monthly regulation 26 visits as a way of monitoring the service. Staff have worked hard to make improvements to their medication practices and they are now adequate, with only minor improvements still to make. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4. Quality in this outcome area is good. People come to live in the home knowing that their needs have been assessed and can be met and that the service and facilities meet their expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has policies and procedures in place for admitting new people to the home. Each prospective resident is issued with a welcome pack, which contains information about the services and facilities and a service users guide which sets out the terms and conditions of residence. People are invited to view the accommodation before making a decision to live in the home and their needs are assessed to ensure that the home has the capacity to meet them. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. People living in the home are satisfied that their needs are being met, but the home cannot always demonstrate this through their record keeping practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the records relating to three residents. The home are in the process of introducing new care plans and risk assessments. Once these are in place, completed fully and kept up to date then the care plans will be much improved. The records looked at contained lots of information, primarily about medical needs and action taken in response to health issues. The records showed that appropriate action was taken in response to health issues. For instance, contact with the GP. Relatives spoken with also said that the home responded well to health issues that arose and kept them informed of any changes. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 10 There was a record of activities of daily living and this provided a summary of people’s abilities. However, this information was not transferred into a meaningful plan of care, with a focus on people’s strengths and abilities and how they can be supported to live an independent life. For instance, how people can manage their own personal care and what support is needed or how people can manage their own finances and how they should be supported with this. Whilst the home has assessments in place for health needs such as the incidence of pressure sores and nutritional needs, there were no assessments in place for other risks associated with daily living. For instance, in the records relating to one person there were incidents of behaviours that placed the resident and others at risk yet there was no plan as to what steps should be taken to prevent harm. There are systems in place to consult with people about life in the home and any changes they want to see. For instance, there are regular meetings with residents and the activities staff hold group discussions when the need arises. One relative spoken with said that the care provided was good and there were no concerns. A resident said he was very pleased with the care provided and had all his needs met in the way that he wanted. Residents spoken with said that staff showed them respect and kindness. People felt they were able to choose how they wanted to spend their day. For instance, one resident said he had days when he wanted to stay in bed and staff supported him with this. One visitor was spending time with their relative in a quiet room and their privacy was respected. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. People living in the home do not necessarily have a plan of care for their social needs, but are supported to live life in the home as they choose to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records relating to people living in the home were inspected to look for plans in relation to meeting people’s social needs. The home employs two activities staff in the afternoon that work 30 hrs each week. People were observed to participate in exercise classes in the morning and other activities in the afternoon. We found that records did not show that the home had discussed people’s interests and aspirations for the future. This is an area that needs to be improved upon and in doing so the service will demonstrate that they have Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 12 actively engaged people in pursuing their interests and hobbies and achieving longer-term goals. However, we observed people moving freely about the home and venturing outside on their way to the activities centre. We also spoke with residents who had been engaged in activities that they enjoyed very much. A number of people spoken with talked of having very supportive families who they regularly went out with either going to the pub for a meal or going back home for the day. Some residents have been out on various excursions with staff from the home and there was a board in the dining room advertising these events. People who live in the home are supported to maintain good relationships with family and friends. However, it is not clear how the home supports people to meet others to form new relationships. For instance, if people wish to find a new partner. Lunchtime was observed and the meal looked appetising and well presented. Residents spoken with said they enjoyed the food. The cook was spoken with and discussed the menu planning. The cook meets with people and they are asked what they would like to see on the menu. Any special requests or dietary needs are taken into consideration. People have a choice of two meals on the menu but can have an alternative if they prefer. Records of people’s choices and dietary intake are maintained. A resident was heard thanking the kitchen staff for the meal he was given saying it was very good. One relative said the food appeared to be good. Lunch is split into two sittings so that people who need more time to dine can do so without feeling under pressure. The dining room was crowded for the first sitting and this may be due to the number of people using equipment to aid mobility. There were also several people who needed assistance to dine. Staff were observed to support people in a sensitive and discrete manner showing patience and kindness. People living in the home would benefit from more space in the dining area but not to the extent that it looks institutional. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. People say that they receive support in the way they want it, but this cannot be demonstrated by the home’s record keeping. People can be assured their medicines will be managed safely but improvements are still needed to safeguard people’s health and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some people spoken with told us that they were given good support from the staff at the home and their needs were being met in this respect. However, some people are not able to communicate how their needs are met and this is not demonstrated in the assessments and records kept at the home. For instance, in the service user files inspected, care plans did not set out what people were able to do for themselves and how they would like to be assisted to achieve their daily goals. Additionally, for the same reasons it was not clear how the home supports people’s emotional needs. For instance, one person was displaying behaviours associated with emotional disturbances, but there was no plan setting how staff should support the person with this need. One member of staff became so Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 14 concerned about the lack of guidance in order to protect this individual and others that they took the step of reporting the concerns to the Commission. The home’s medication arrangements were inspected by observations of medicines being administered and looking at the records relating to both medicines and people living in the home. We found that since the last inspection the home has worked hard to improve overall medication practice in the home. They have introduced regular audits and have systems in place for recording medicines in and out of the home. Medicines are stored securely in the nurse’s office. Only people authorised and trained to handle medicines have access to the room. The room contains lockable cabinets for the storage of medicines, a lockable trolley for transporting medicines around the home, a fridge for the storage of medicines at low temperatures and a cabinet for the storage of controlled drugs. The medication administration charts were examined and found to be in good order. There were no gaps in the records and good practice was seen in relation to identifying photographs of residents, highlighting dose instructions and which containers medicines are stored in. There were clear audit trails for medicines coming into the home, those administered and those being disposed of. When medicines were checked against the charts they were found to be correct. This includes controlled drugs. When looking at the medicines for administration on a ‘when required’ basis good practice was seen in respect of care plan guidance, which provided staff with information about what steps they should take before administering medicines prescribed in this way. There were assessments in place for people who are not able to communicate verbally. For instance, pain assessments that look for non-verbal signs of distress. In addition, there were clear records justifying the administration of these medicines. Healthcare Homes has introduced a new document with the intention of setting out clearer instructions for the administration of some medicines. This was located alongside medication charts for some people. But this is potentially misleading, as dosage ranges stated did not always apply to actual doses prescribed for people. When looking at ophthalmic medicines that have limited periods of expiry (28 days), we found a number of open bottles containing eye drops that had not been dated when opened. Therefore we were unable to determine if the drops had exceeded their use by date. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 15 We observed a member of staff administering medicines at lunchtime. Good practice was seen in relation to following instructions, record keeping and handling medicines. However, on at least two occasions during the medicines round the trolley was left open whilst the member of staff took medicines to the resident placing people at risk of harm by allowing unauthorised access to medicines. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. People living in the home said they would feel confident they could raise concerns and they would be dealt with. However, issues around safeguarding are not always dealt with appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure that is publicised in the service users guide and on display in the dining area. The home could place a copy of the procedure in the reception area to publicise it more widely. However, the manager says he has an open door policy and people are able to come to him at any time to raise concerns. One relative spoken with said that they would feel confident that any concerns would be taken seriously and acted upon. Residents spoken with also said they could talk to staff or the manager if they had a problem. Staff spoken with and those surveyed indicated that they would support people in making complaints if needed. The home has not received any formal complaints since the last inspection. However, the commission has received one complaint that was referred to the safeguarding adults team. The complainant raised the issues with the home and was not satisfied that it was dealt with. This matter is under investigation and some of the issues have been covered in this report. The manager must recognise what safeguarding issues are and how action must be taken to protect people. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 29, 30 Quality in this outcome area is good. People living in the home have a comfortable, safe, clean environment that offers a range of communal spaces. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was completed. We found that on the whole the premises were clean and tidy. People’s rooms were homely and personalised with lots of their own belongings. Some areas are in need of redecoration and are looking a little tired. However, when people are using equipment to mobilise freely about the building certain areas are soon exposed to damage. People spoken with were happy with the standard of accommodation and said it was kept clean. One resident said he would like a full-length window so he could fully benefit from the view across the fields nevertheless he was happy with his room. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 18 The home looked clean and tidy on the day of inspection and domestic staff are employed to ensure it is kept in good order. Some of the communal facilities could be made more inviting and homely. In some bathrooms there were unnamed toiletries and the manager said this was because staff had not returned them to people’s rooms after providing assistance with bathing. However, this could seem that people are not given the choice to use products of their choosing. One sluice room entered contained hazardous substances and if this is usual practice the room should be locked to ensure that people are protected from harm. Looking around the home there was evidence of specialist equipment to meet individual needs. For instance, various ways to call for assistance if unable to use a conventional call bell facility. The laundry procedures were in good order and the home employs designated laundry staff. We spoke with staff and they said they had received training in infection control and good hygiene practice. The floor in the laundry room may need some attention to ensure good infection control procedures are maintained. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. People living in the home benefit from having their needs met by an adequate number and skill mix of staff to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a good skill mix of staff, with some cultural diversity. There are nurses and care assistants trained to a good standard. Staff spoken with and those surveyed said they were provided with adequate training to do their job. However, some said they did not feel entirely confident about issues relating to diversity. The amount of training has increased since the new owners took over and all staff are provided with mandatory training. This was supported by training certificates seen in staff files. In addition, staff benefit from having an in-house trainer who can give advice and support on training needs. Files relating to new staff were checked and found to be in good order. Files contained all the necessary pre-employment checks and new staff are not able to start work until they have a POVA check and two written references. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 20 On the day of the visit there were 27 people living in the home and two people visiting for respite. The manager said the staffing levels, which are determined according to need, were 10 staff in the mornings, 4 staff in the afternoon and 4 at night. This includes at least one registered nurse per shift. The home also employs two activities staff who work in the afternoons. The number of staff on duty in the afternoons appears to be low and this raises questions about how staff manage at peak times and support people to make choices. For instance the time they want to go to bed. The staff rotas showed that at times the staffing levels have fluctuated due to sickness falling below the homes own targets. However, agency staff have been used when needed. The manager said he hoped the staffing issues had been resolved now and the home has appointed some more staff to ensure they have a bank of staff available in the future. Staff surveys indicated that people would benefit from having more staff on duty. Residents and relatives spoken with did not raise any concerns about the lack of staff to attend to peoples needs. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 Quality in this outcome area is adequate. People living in the home can be assured the home is well managed, but improvements are needed in quality monitoring and health & safety so that people’s health and welfare is safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a registered manager who has worked there for approximately 20 years. He is experienced and has a good relationship with staff and residents, many of whom have lived and worked in the home for several years. We asked about the home’s quality assurance procedures and the manager said they did not have a policy and procedure on quality assurance. However, there were many quality assurance processes in place such as, residents meetings, medication audits and regulation 26 visits. This could be improved Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 22 by developing quality assurance in its wider sense and producing the results of how the service is performing and how it intends to improve based on the findings. We looked at the way in which the home supports people with their finances. Very few people living in the home manage their own finances and are happy for the home to keep their money secured in the safe. There are accounting systems in place for each resident ensuring that a record of money coming in and spent is maintained. We checked some of the records and the amount of money held matched the accounts of those checked. We discussed how money is paid into people’s accounts when they receive cheques and were informed that people are asked to make cheques out to Healthcare Homes who then deposit the cheque in an account created by them and issue a cheque back to the home for cash. A member of staff then goes to the bank and cash’s the cheque then pays the money into the individuals account at the home. People living in the home must be supported to handle their own money as far as possible and cheques must be paid into the individual’s own bank account. We looked at health and safety and found there were some issues around individual risk assessments, medication and potentially hazardous products that need to be addressed. We looked at premises risk assessment and these were being completed. In addition, a fire safety risk assessment has been completed. Fire safety checks are being carried out in accordance with the regulations and all staff have been provided with training in fire safety procedures. A recent visit from the fire officer highlighted the need to replace some of the doors with those that comply with fire safety regulations. This work has not been completed as yet and the home must address this as a matter of priority. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 3 X 2 1 X 2 x Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 24 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. Standard YA6 Regulation 15.1 Requirement Timescale for action 01/09/08 2. YA9 3. YA15 4. YA20 People’s holistic needs must be assessed and written into a plan of care so that staff know how people wish to be supported to live their lives. 13.4 (a)(b) People must have risks to their safety and wellbeing assessed and written into a plan so that staff know how to support people in minimising risks to their safety and well being. 16.2(m)(n) People living in the home must be supported to form new relationships with people and fulfil their emotional need for meaningful social contact. 13.2 People living in the home must have their medicines safely handled and secured at all times so that their health and welfare is safeguarded. This relates to ophthalmic medicines and the medicine trolley during drug rounds. 13.6 People must be protected from harm and the safeguarding procedures must be followed so that people’s health and wellbeing is safeguarded. DS0000071004.V366680.R01.S.doc 01/09/08 01/09/08 01/09/08 5. YA23 01/09/08 Meadow House Nursing Home Version 5.2 Page 25 6. YA39 24.1 & 2 7. YA40 20.1(a)(b) 8 YA42 23.4(a) People living in the home must have the services provided to them quality monitored so that their health and wellbeing is be promoted. People living in the home must have their money paid into a bank account in their own name and be supported to manage their own finances. People living in the home must have precautions taken against the risk of fire. The home must comply with the requirements of the fire department so that people’s safety and welfare is safeguarded. 01/09/08 01/09/08 01/09/08 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. Refer to Standard YA22 YA24 YA25 YA26 YA32 Good Practice Recommendations The home should publicise the complaints procedure more widely so that visitors to the home also know how to make a complaint. The home should develop a plan of maintenance and renewal and take action to improve the environment. The home should consider locking the sluice room door to safely contain hazardous products and improve infection control. The home should consider replacing/renewing the laundry room floor to ensure good infection control is maintained. The home should review the staffing levels to ensure that peoples needs and choices are met. Meadow House Nursing Home DS0000071004.V366680.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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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