Inspection on 04/02/08 for Meadow Lodge

This inspection was carried out on 4th February 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Meadow Lodge 19/03/09

Meadow Lodge 14/08/06

Meadow Lodge 13/12/05

Meadow Lodge 02/08/05

Meadow Lodge 01/12/04

Meadow Lodge 26/07/04

Meadow Lodge 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Meadow Lodge Sadlers Mead Monkton Park Chippenham Wiltshire SN15 3PE Lead Inspector Nicky Grayburn Unannounced Inspection 4th February 2008 10:00 Meadow Lodge DS0000032434.V354868.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 Lodge DS0000032434.V354868.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 Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadow Lodge Address Sadlers Mead Monkton Park Chippenham Wiltshire SN15 3PE 01249 656136 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) Wiltshire County Council Mr Mark Ashley Pearson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of care only: Care home providing personal care- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability- Code LD The maximum number of service users who can be accommodated is 4. Date of last inspection 14th August 2006 Brief Description of the Service: Meadow Lodge is situated in a quiet residential area on the outskirts of Chippenham. The home provides respite care for up to four service users who have learning disabilities, and service users continue to take part in activities and training sessions which they would when they are at home. The home is owned and managed by Wiltshire County Council. The staff team also provide care for service users in Derriads, which is part of the Chippenham Respite Service. There is 24 hour staff cover to provide support for service users. Meadow Lodge is an attractive home, with a lounge, dining room and a domestic style kitchen. It is light and airy, with comfortable furnishings. There are four single bedrooms, one with ensuite facilities. To the rear of the house is a large, secluded garden which is accessible to the service users, with attractive features and a paved patio area. There is ample parking to the front of the building. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Meadow Lodge’s key inspection and was unannounced. It was carried out over one day, into the evening. Surveys were sent out to the home to distribute to people using the service, relatives, staff, health care professionals, and General Practitioners. We received 3 surveys back from people using the service and 2 from relatives. The manager had completed the Annual Quality Assurance Assessment (AQAA). These documents and other records held at the Commission for Social Care Inspection were read prior to the inspection and form part of this report. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: What has improved since the last inspection? What they could do better: Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 6 Some of the previously made requirements have not been fully met. From this inspection, 10 requirements have been made in total (some from the previous inspection). The home’s Statement of Purpose needs to comply with the regulations to make sure that people thinking about using the service have all the information. A copy needs to be sent into the Commission. The staff team’s morale needs to be improved. Communication needs to be more fluid and effective. Care plans need to be written with the person, and need to have more information about specific health needs. Risk assessments need to have more detail in, and specific assessments regarding people’s epilepsy need to be written. All aspects of the medication process need to be reviewed and ensure that people remain safe at all times. The recording of complaints needs to show that the policy and procedure are being followed correctly. Management need to decide whether staff are work on their own or not. Then, a specific policy needs to be written for this. Staff need to do some training and do some refresher course to make sure that they can look after the people properly. These issues have been discussed with the manager. 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 Lodge DS0000032434.V354868.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 Lodge DS0000032434.V354868.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 Quality in this outcome area is adequate. People are not given all the information about the service in the Statement of Purpose. People’s needs are assessed prior to using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Meadow Lodge has a Statement of Purpose, which gives potential people information about the home. The home also has a service user guide, which is available and has a mixture text and pictures. These are well written documents giving clear information, however, the content does not fully meet with Schedule 1 of the Care Homes Regulations 2001. A requirement has been made regarding this and the revised copy must be sent to The Commission of Social Care Inspection. The Statement of Purpose explains the admission’s criteria. It says that prior to people using the service, their ‘Care Manager’ from social services “will provide Meadow Lodge with a recently completed Community Care Assessment” so that they can decide whether the service can meet their needs. From the files read, these assessments were in place. However, it was noted that these were not signed by the person who has been assessed. Meadow Lodge DS0000032434.V354868.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’s needs are not recorded effectively. People can make decisions about their lives. People are able to take risks in their lives, but information is not recorded properly to ensure that people are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection, 2 other staff members from another of the Respite homes were going through some of the care files. A requirement had been made at the previous inspection for all care plans to be completed and contain accurate, up-to-date information. Care Plans were discussed with the team leader and a member of staff. Even though, it is clear that efforts are being made to improve the care plans, the requirement has not been fully met and remains. 2 care plans were read to see what improvements have been made as we were told that work had not been started on the others, and others were spot checked for other documents. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 10 3 out of the 3 surveys returned from people who use the service stated that they ‘always’ make decisions about what they do each day. A requirement was made for all risk assessments to be kept up-to-date and changed as necessary. From the 2 care files read, it was evident that assessments have been written and people are aware of risks posed by people who use the service. However, these need to have more detail in them to fully ensure that people are safe at all times whilst staying at Meadow Lodge. One person’s care file which was read stated that they had epilepsy. There was a risk assessment about taking a shower/bath which mentioned their epilepsy. However, a specific risk assessment is needed to ensure that all areas of that person’s life is kept as safe as possible. A requirement has been made regarding this applying to all those people with epilepsy. Meadow Lodge DS0000032434.V354868.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, 16, 17 Quality in this outcome area is good. People’s preferred lifestyle and daily routines are respected and supported. People are offered a varied diet and enjoyable mealtime. People are supported to access the facilities in the local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was clear from talking with people who use the service, observations and talking with staff that daily routines and preferred lifestyles are respected and supported. Staff said that most people have been coming to the home for a while, and staff spoke of people’s likes and dislikes. People who use this service attend their local day centres; colleges, and jobs as per normal and then come ‘home’ in the evenings. Some people use this service solely at weekends and activitities are planned according to their wishes. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 12 3 out of the 3 surveys returned from people who use the service stated that they can do what they want during the day, in the evening and at the weekend. People’s daily notes showed that people are taken out and do activities which correspond with their care plans. For example, people go to play ten pin bowling; go into the local town; go a for a walk; go for a trip out in the van; go to the cinema; go to the pub. There is a van which staff can use to support people. It was observed and read that people also use local taxi companies to maintain their daily routines (going to their day centre) and to arrive at Meadow Lodge and go home. People told us that they enjoyed staying at Meadow Lodge and some people wrote on their surveys “we have fun here” and “I like everything at Meadow Lodge, I like coming here”. It was observed that people can use all the shared areas of the home and choose whether to spend time with other people or on their own. It was observed how after dinner, people treated the home as they wished and did what they normally would do (write their diary; do a jigsaw; watch television; spend time in their room). Meadow Lodge is a no-smoking house and there is a sign on the front door stating this. Staff said that people who use the service do not generally do any cleaning or chores around the home. It is the staff team who carry out such duties. The evening meal was observed and people appeared to enjoy it. Afterwards, people said that the meal was nice and tasty. A survey had an added comment stating, “The food is nice”. There was fresh fruit on the side and the fridge and freezer had a good selection of foods. It was also observed that people help to lay the table and could have helped with the preparation of dinner. Staff eat with the people who use the service creating a homely atmosphere. Meadow Lodge DS0000032434.V354868.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. Care plans for people do not include all the necessary information for staff to support people fully with their personal and healthcare needs. Medication is administered safely, however, procedures are not fully established to fully safeguard people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As people do not live at the home permanently, the majority of people do not need staff to ensure that their health needs are being met as their predominant carers take responsibility of that. However, the team leader said that staff would support people if they have an appointment during their stay at the home. As stated earlier, care plans are being reviewed and updated by external staff to ensure that people’s needs will be fully identified and therefore, people will receive the support they require in a manner they prefer. Currently, documents do not evidence that people are being supported in a way they prefer. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 14 People using the service have key workers who are designated members of staff people can go to for things. It was discussed with the team leader how key workers should be more involved in the reviewing of the files to ensure that all information is gained, and none lost. One person’s care file stated that they had diabetes, which is controlled through their diet. However, there was no care plan explaining how this is controlled or gave details as to what foods the person can and cannot eat. A requirement has already been made regarding people’s support plans and this must be included within that review. One care plan did not give any detail about the support a person needs around their epilepsy. Care plans need to include specific details about people’s epilepsy to ensure that staff are aware of, for example, the triggers; type of seizure, and the action needed to be taken. The medication procedure and cabinet was checked with a member of staff. Medication Administration Records were looked at and were appropriately signed by the member of staff who had administered the medication. If people come to the home with controlled drugs, a member staff showed us what they would do, which was good practice. There is a controlled drugs register and a lockable cabinet within the medication cupboard. Some medication for specific health matters requires staff to have training in the administration of it. Training records seen showed that the majority of staff received this training in February 2007. The manager must be mindful that this needs to be updated. The management need to consider the safety of people when they go home and are given their medication. Transfer documents need to be in place to ensure that someone is looking after the medication during transit. A requirement has been made regarding this. We were informed that the forms for administering the medication are about to change. People need to have medication profiles, for example, with their photo; what medication they are taking; the side effects; preferences about how they like to take their medication and any allergies. The team leader was aware of this and assured that these will be put into place in the near future. A requirement has not been made regarding this but will be followed up at the next inspection. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 15 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 who use the service are listened to and their views are taken seriously. Training of staff will help to ensure that people are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the home’s Statement of Purpose with timescales and in the Service User Guide. There are phone numbers and addresses for people to contact if they are not satisfied with the response from the home. The new complaints folder is currently empty but the old bound book was read. This needs to be clearer in its process. It was clear that complaints are logged but it was not clear if the procedure was followed and that outcomes had been achieved. A requirement has been made regarding this. The service must continue to use a bound book to log complaints. 3 out of the 3 surveys returned from people who use the service stated that they know who to speak to if they are not happy. 2 people ticked that they know how to make a complaint, 1 person ticked ‘sometimes’. Prior to starting work with the respite service, potential staff have an Enhanced Criminal Record Bureau (CRB) check carried out. The originals are kept centrally and the home receives a copy and a clearance letter. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 16 The reporting of abuse procedure is kept on the notice board with numbers for the relevant professionals. The Commission for Social Care Inspection’s contact details must be added to this. The policy and procedure for the Protection of Vulnerable Adults is on file but is from 2001. The home must obtain the current ‘No Secrets’ procedure. Staff training files were looked at and many of the staff are in need of receiving training in the Protection of Vulnerable Adults. This was fed back to the manager and a requirement has been made. Meadow Lodge DS0000032434.V354868.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, 26, 27, 28, 29, 30 Quality in this outcome area is good. People stay in a homely and comfortable environment. Bedrooms suit people’s needs and bathrooms provide privacy and are accessible. Shared spaces are used and are sufficient for the number of people using the service at any one time. The home was clean on the day of the visit. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Meadow Lodge is located in a residential area of Chippenham. It is in a quiet cul-de-sac. It is in keeping of the neighbourhood and is accessible for people with physical disabilities. A tour of the property was undertaken with a member of staff. On the ground floor there is a lounge with comfortable seating and a television/DVD player. There is a kitchen with an attached dining area. This area leads to the back garden. This is wheelchair accessible. There are 2 offices behind the kitchen. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 18 There is a bedroom on the ground floor with an en-suite shower room. The pipes from the shower are not protected and a requirement has been made for these to be covered to protect people from burning themselves. Upstairs, there are 3 single bedrooms and a bathroom. All the rooms have the necessary furniture for people’s stay and were clean and tidy on the day of inspection. The home provides people with bedding and towels. The bathroom has grab rails to aid people’s stability. The ceiling will be in need of attention in the near future as it is showing signs of damp, and also needs cleaning along with the rest of the room. The AQAA stated that the service ‘maintains a homely, relaxed atmosphere’, and ‘a redecoration of some of the rooms which would improve the standard to an even higher level’. It stated that all the rooms will be redecorated in the next 12 months. W were told that redecoration of some of the rooms usually takes place over the Christmas period, when there are often not many people staying. It was observed that people can access all the shared areas and use the space as they wish. It was explained that the staff do the cleaning rather than the people using the service. 3 out of the 3 surveys completed by the people using the service stated that the home is ‘always’ fresh and clean. The home was clean and tidy on the day of this inspection. Meadow Lodge DS0000032434.V354868.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, 33, 34, 35, 36 Quality in this outcome area is adequate. People are supported by a consistent and reliable staff team. Staff are not fully trained to ensure that people are safeguarded at all times. People are supported by a supervised staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff team also work at another respite home. There are regular staff meetings, and the minutes were read from the previous few meetings. These gave an insight into the morale of the team. At the moment, it is quite low. Management is aware of this and have taken action to try and rectify this. This will be followed by the Commission and people have been told that they can contact us if need be. It was recommended that the next staff meeting, staff are made aware of the whistle blowing policy, along with other relevant policies and procedures. It was clear from the rota and talking with staff and management that the service uses agency or relief staff often. The county council has a relief bank of workers, which works like an agency. The service also uses an external Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 20 agency to supply workers. We were told that 2 new members of staff were about to start that week. Staff’s induction information is on file in the office, which covers essential information about the service, as well as progressive information about their role in the home. There was not a clear lone working policy in place on the day of inspection. 2 members of staff sleep in after some people had raised their concerns with the dynamics of the home. However, during the day, it was observed that 1 member of staff is ‘allowed’ to work on their own when the house was full of people using the service. This needs to be clarified with clear risk assessments identifying whether a lone working policy needs to be in place and whether 2 members of staff need to sleep in. Due to the changing dynamics within the home, it may be necessary to assess the numbers of staff on a weekly/fortnightly basis. A requirement was made at the previous inspection for staff’s files to contain 2 references and evidence of a CRB and PoVA check. 3 staff files were checked and all contained the relevant documentation. CRBs are kept centrally at County Hall. The link inspector is meeting with the management of the respite homes to agree on permanent arrangements regarding the documents held. 4 training files were read, and 5 others were spot checked. These are being re-organised. Some mandatory training has been done recently and refresher courses have been sought. A requirement was made at the previous inspection regarding this, and despite there being some improvement, it has not been fully complied with. Some staff are in need of training and refresher courses. All staff need to have training in food hygiene, refresher courses in health and safety (inclusive of infection control), and as stated earlier, some need training in Protection of Vulnerable Adults. It is recommended that a training plan is sent in to evidence that training is booked and will take place. Supervision records were read for 3 members of staff. These were recorded well and covered areas of the person’s practice. There were notes of praise as well as issues which needed further training or discussion. The meetings were regular. Due to the temporary management arrangements in place at the home, people may not have consistent supervisors until the permanent team leaders return. This must be restored as soon as possible. From supervision records, talking with management, and reading staff meeting minutes, it was clear that there have been some problems within the staff team. This has also been discussed with the manager after the inspection. However, it was pleasing to observe and be told that these problems have not infringed into the atmosphere of the home. Meadow Lodge DS0000032434.V354868.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, 41, 42 Quality in this outcome area is adequate. The service is going through a period of change and is being adequately managed. People’s views are not being sought in order to develop the home. People are safeguarded from health and safety hazards. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr Pearson is the registered manager and has been since August 2007. He is also the registered manager for another respite service. As stated earlier, the staff team and the management of the home are going through a period of change. This clearly has impacted on the organisation of the home and the dynamics of the staff team. Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 22 Currently, there are no permanent team leaders working in the home. A temporary team leader has been employed by Wiltshire County Council to support the manager until the permanent leaders are back. The current team leader has also been employed under a specific remit to help get the home to the same standard as the other respite homes. The last inspection report is available in the staff office. The AQAA stated that the service could improve with their quality assurance system. A part of the system is for someone to visit the home on a monthly basis and check on it. This is being done. At the moment, due to the quality of the home and the concerns raised from the visit, a requirement has been made for these reports to be sent to The Commission for Social Care Inspection on the monthly basis. Throughout this change, there was no evidence to show that people’s views are being sought to develop the home. The service’s entire quality assurance system should be developed fully within the year. The fire records were read and an external contractor visited the home in October 2007 and January 2008 ensuring that people using the service are safe. Fire drills are recorded and form part of the staff’s training. However, some members of staff have not been part of an evacuation since August 2007 and some staff have had training ‘on-line’. The manager must ensure that all staff are trained to keep people safe in case of a fire. We were told that training is booked for the near future ensuring that this concern would be cleared. It was noted that Environmental Health have visited the property, but no outcome was found on file, and the health and safety checklist will be due to be reviewed in April 2008. Meadow Lodge DS0000032434.V354868.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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X 2 3 X Meadow Lodge DS0000032434.V354868.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 YA1 Regulation 4 Schedule 1 15 (2) (b) Requirement The home must have a Statement of Purpose which complies with Schedule 1. All care plans must be completed and contain accurate, up to date information. (outstanding requirement, previous timescale 14/10/06, partly met) Timescale for action 30/04/08 2. YA6 30/04/08 3. YA9 15 (2) (b) All risk assessments must be kept up to date and changed as necessary. (outstanding requirement, previous timescale 14/10/06, partly met) 30/04/08 4. YA9 13(4b,c) People with epilepsy must have a 30/04/08 specific risk assessment and care plan. Transfer documents for medication must be devised to ensure that people remain protected by the service’s procedures. 30/03/08 5. YA20 13(2) Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 25 6. YA22 22 The recording of complaints must show that the policy has been followed. Staff must receive training in the Protection of Vulnerable Adults. The pipes in the shower room must be covered to ensure that people are protected from burning themselves. Staff training updates must take place, and records kept of this. (outstanding requirement, previous timescale 14/10/06, partly met) 30/03/08 7. 8. YA23 YA24 13(6) 23(2) 30/05/08 30/03/08 9. YA35 18 (1) (c) (i) 30/04/08 10. YA39 26 The monthly visit reports to be sent to The Commission for Social Care Inspection on a monthly basis. 30/03/08 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. Refer to Standard YA23 Good Practice Recommendations The ‘No Secrets’ document must be kept in the home, read and understood by staff, and the manager. The procedures for reporting abuse according to ‘No Secrets’ must be adhered to at all times. The Commission for Social Care Inspection’s contact details are included on the procedure for reporting allegations of abuse. A training schedule is sent in to evidence that training is booked. 2. 3. YA23 YA35 Meadow Lodge DS0000032434.V354868.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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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