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Inspection on 03/02/06 for Meadow Lodge Care Home

Also see our care home review for Meadow Lodge Care Home for more information

This inspection was carried out on 3rd February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The administration of residents` medication had remained good since the last inspection. The majority of the residents spoken to were happy in the home, one saying that he`d never been as happy another saying that the new owner comes and talks to them every day.

What has improved since the last inspection?

The home were setting up forms and methods of recording care given. These forms if fully completed and care given as described should ensure that good care is consistently given. The homeowners and manager were keen to ensure that systems they put in place improve practice and meet the requirements of the Commission. Regular checks on staff ability to give out medication properly were being undertaken on routine and regular basis. Prescriptions were being seen and photocopied prior to being sent to the pharmacist. Residents had a choice of food at a mealtime, the choice on inspection was the same as shown on the 4-week menu. A number of small improvements had been made on the menu to increase the calorific value of food for residents of low weight. Files looked at had inventories of residents` belongings.Residents` files had been organised so they were professional looking and each resident`s file had photograph. The homeowners had put out adverts for new staff including a qualified cook and care staff qualified to NVQ level 2. There was a commitment from the new homeowners to improve the decoration and furnishings in the home. Decoration had begun at the time of the inspection, a number of new bed bases had been bought and the intention was for linen, curtains and carpets to be changed in numerous areas of the home. A bathroom on the first floor had been changed into an assisted level access shower facility. Residents` that needed assistance to manage their finances had been referred to the social services department or were about to be. A separate accounting procedure was being set up and a separate clients account organised to manage this money.

What the care home could do better:

The home had a large number of requirements in all areas that need sustained improvement. To ensure sustained improvement the home needs to ensure that all aspects of residents` health and personal care is provided in a way that is individual to the resident. A clear assessment prior to admission would ensure that residents` difficulties could be identified. From the assessment the way that care is delivered needs to show that residents have been given choices and have involvement in the care planning. This detailed care planning needs to be recorded so as to ensure that care is consistent for each resident. The process of recruiting staff must ensure that all checks are done before staff start at the home. Staff need supervision on a regular basis to ensure the safety of residents. Staff need to be well trained in all the basic care areas as set out by Skills for Care organisation. Staff should participate in the NVQ 2 care training. In addition staff need training in areas specific to the home such as dementia care, challenging behaviour and risk assessments. The home needs to ensure that residents, relatives and resident representatives are consulted and informed about changes to the home. It is important that that the home develops ways in which they can listen to and respond to concerns and comments about the service they are providing. The home needs to develop a system of checks of weights, falls, staffing levels and dependency and so on so that the home can continue to improve. The home needed to complete a fire risk assessment and emergency plan and ensure that a routine inspection of the stair lift was done.

CARE HOMES FOR OLDER PEOPLE Meadow Lodge Care Home 445 Hagley Road Edgbaston Birmingham West Midlands B17 8BL Lead Inspector Jill Brown Unannounced Inspection 3rd February 2006 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 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 Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Meadow Lodge Care Home Address 445 Hagley Road Edgbaston Birmingham West Midlands B17 8BL 0121 420 2004 0121 434 3516 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) Coseley Systems Limited Miss Gillian Goode Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to accommodate 21 older adults who are in need of care for reasons of old age and one named person under 65 years by reason of mental disorder. The small bedroom on the first floor is increased in size by 1 June 2007. 17 April 2004 Date of last inspection Brief Description of the Service: Meadow Lodge is situated on the Hagley Road a short distance from Bearwood shopping centre. Bearwood has a variety of facilities including banks and public houses, shops and a library. Public transport into the City Centre is available directly outside of the home. The home was originally two dwellings and has been converted to provide accommodation for up to 22 older people. The home has three shared, twelve single, one shared bedroom with an en suite and two singles with en suites. The home has two lounges and two dining areas. Shower and toilet facilities are provided on the ground floor. On the first floor there are two bathrooms with bath seat lifts. There is a stair lift in the home but this does not fully access the first floor. To the rear of the home there is a large garden that residents can use. To the front of the home is a loose gravel forecourt that accommodate some car parking. The home has a ramped access available. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours on a day in February. The home had been in the hands of the new owners for just over two weeks. The home had a number of requirements with the previous owner; the Commission and the new owners are working on an improvement plan for the home. Due to the timing of the inspection the majority of the requirements remain outstanding. Eight residents were spoken to at the inspection, many areas of the homes workings were discussed with one of the homeowners and the Registered Manager. A tour of the building was undertaken and a meal taken. The Commission will be monitoring the homes progress against its improvement plan over the next inspection year. What the service does well: What has improved since the last inspection? The home were setting up forms and methods of recording care given. These forms if fully completed and care given as described should ensure that good care is consistently given. The homeowners and manager were keen to ensure that systems they put in place improve practice and meet the requirements of the Commission. Regular checks on staff ability to give out medication properly were being undertaken on routine and regular basis. Prescriptions were being seen and photocopied prior to being sent to the pharmacist. Residents had a choice of food at a mealtime, the choice on inspection was the same as shown on the 4-week menu. A number of small improvements had been made on the menu to increase the calorific value of food for residents of low weight. Files looked at had inventories of residents’ belongings. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 6 Residents’ files had been organised so they were professional looking and each resident’s file had photograph. The homeowners had put out adverts for new staff including a qualified cook and care staff qualified to NVQ level 2. There was a commitment from the new homeowners to improve the decoration and furnishings in the home. Decoration had begun at the time of the inspection, a number of new bed bases had been bought and the intention was for linen, curtains and carpets to be changed in numerous areas of the home. A bathroom on the first floor had been changed into an assisted level access shower facility. Residents’ that needed assistance to manage their finances had been referred to the social services department or were about to be. A separate accounting procedure was being set up and a separate clients account organised to manage this money. What they could do better: The home had a large number of requirements in all areas that need sustained improvement. To ensure sustained improvement the home needs to ensure that all aspects of residents’ health and personal care is provided in a way that is individual to the resident. A clear assessment prior to admission would ensure that residents’ difficulties could be identified. From the assessment the way that care is delivered needs to show that residents have been given choices and have involvement in the care planning. This detailed care planning needs to be recorded so as to ensure that care is consistent for each resident. The process of recruiting staff must ensure that all checks are done before staff start at the home. Staff need supervision on a regular basis to ensure the safety of residents. Staff need to be well trained in all the basic care areas as set out by Skills for Care organisation. Staff should participate in the NVQ 2 care training. In addition staff need training in areas specific to the home such as dementia care, challenging behaviour and risk assessments. The home needs to ensure that residents, relatives and resident representatives are consulted and informed about changes to the home. It is important that that the home develops ways in which they can listen to and respond to concerns and comments about the service they are providing. The home needs to develop a system of checks of weights, falls, staffing levels and dependency and so on so that the home can continue to improve. The home needed to complete a fire risk assessment and emergency plan and ensure that a routine inspection of the stair lift was done. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 7 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 Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed. The home had developed new ways for recording pre admission assessment information, risk assessments and personal care that residents have been given. These new recording methods were to improve the standard of information kept and monitoring of residents’ care. However no new assessments had taken place since the new owners have taken over and it was not possible to assess whether these forms had improved the information collected and these requirements were brought forward. The home is renewing its assessments of existing residents. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 10 The homeowners were developing systems in care planning that if followed and completed well should assist in the consistent care of residents. The management of medication remained good. EVIDENCE: The registered manager was reviewing the care plans of the residents. One of these care plans looked at, was an improvement on previous care plans but still needed more specific detail on how help with personal hygiene was to be given to residents. The homeowners and registered manager were receptive to suggested changes to the care plans to make information easier for the care staff to read quickly. Previous requirements on the monitoring of residents’ weights, falls and behaviour were not looked at on this occasion and these requirements were brought forward. The medication administration records (MAR) looked at showed that the home had maintained improvements required from previous inspections. The home were ensuring that they had a photocopy of the prescription next to the relevant MAR sheet so it could be checked, medication audits were being Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 11 undertaken, there were no gaps in recording on the MAR sampled. Requirements on medication procedures being available, risk assessments for residents that self-administer medication, and GP medication reviews were not inspected and these requirements were brought forward as not assessed. The homeowners were auditing all staff training including safe medication administration training and training was to be arranged for any gaps identified. Staff appeared to treat residents appropriately and calmly. Residents seemed on the whole to be happy with the care they were receiving. One resident said ‘I am as happy as I have ever been’. One resident said that one of the new owners came to talk to them every time he was in the building, another thought it was too early days to see if there was any improvement. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The arrangements for residents to have choices, visitors and food were adequate. It was not possible to fully assess the access to activities due to the change of ownership. EVIDENCE: It was difficult to judge the planning of activities in the home because of the turmoil of new ownership and decoration and refurbishment in the building. Residents were seen to be in either their own room watching television or in the lounges watching television. It was clear where residents wanted and were able they could go out to the local shops and pubs. Residents were asked about activities but a number were not able to express what they would like to do. Residents were able to get up or stay in bed, as they wanted. There was no undue restriction to freedoms in the home. Relatives were able to visit the home, as they wanted. The home has two dining areas, two lounges where residents can talk to their visitors and residents are also able to have visitors in their rooms. On the day of the inspection residents had a choice of fish and chips, or egg and chips with either mushy peas or salad and mash potatoes were also available. The inspector received a copy of the home’s menus over 4 weeks Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 13 these seemed to be adequate nutritionally. The home had increased the use of cream etc. in response to residents that are of low weight. The homeowners expressed their intention to employ a qualified cook capable of organising ordering and menu planning as part of their improvements to the home. The home will have to demonstrate that resident’s needs and comments about food influence the menu provided. The egg and chips meal tried by the inspector was well cooked. There was adequate food in the home on the day of the inspection. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home had numerous complaints since the last inspection and the homeowners must develop robust methods of improving resident, relatives and staff satisfaction with the service. The home has recently shown that it can act appropriately where the safety of a resident is in question. EVIDENCE: The home had a number of complaints since the last inspection that resulted in visits from the inspector and the making of requirements. Legal action was being considered prior to the home changing hands. The complaints were about the poor care planning, delivery of personal care to residents, staff training, food provided and money management. The records of the home did not show clearly how these matters were managed and these complaints were substantially upheld. The new owners are aware that these are key areas of improvement that they must work on. The homeowners have developed a comment, complaint and compliment form but will need to involve residents, relatives, representatives and staff to pick up comments quickly to ensure improvements. Since taking over the new owners and the registered manager have demonstrated that such concerns, complaints and allegations are taken seriously, action taken and appropriate consultations taken with Social Care and Health, the Commission and the police if necessary. The home has started developing their policies and procedures but these were not looked at the Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 15 inspection. Inventories on residents’ belongings and clear records of residents finances were being put in place. A number of residents had been referred to Social Care and Health to ensure a safer arrangement for the management of residents’ money. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 16 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): 19, 26 Arrangements for improving the environment of the home had started but residents must be consulted to ensure the feeling of home is maintained. EVIDENCE: At the time of the inspection the home was being decorated. The intention was to decorate the home in neutral colours and have more patterns and colour in the furnishings. The disruption that this was causing to residents was an issue with a number of residents finding this disruption difficult, others said that it would be better when it is finished. The home must involve residents in choosing the soft furnishings pictures and so on in the communal areas of the home as well as residents’ rooms so that a sense of home can be maintained. An assisted bathroom had been upgraded prior to the sale of the home as required. Several of the previous requirements had yet to be acted upon about the garden being safe, making the lighting more domestic in character and ensuring residents have all the furniture required and these were brought forward. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 17 Others such as monitoring the hot water temperatures were not inspected. It was difficult to monitor the odour control in the home because of the painting. However the home had started to replace some bed bases which can harbour offensive odours. The home was planning to replace carpets in a number of the areas of the home but until these works are completed the requirements will remain. Liquid hand wash was not available in all communal toilets. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 18 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): 28 Further improvements are needed to ensure that the staffing standards are met and protect residents. EVIDENCE: The homeowners have recently set out with the staff their expectations for training. All care staff are expected to undertake NVQ 2 in care training and all vacant posts have been advertised as requiring NVQ 2 certificate. However the standard of 50 staff trained had not been met. The home also intended to employ a cook that can both order food and set up menus. The post of a cook was put out to advert at the time of the inspection and several applications had been received. The new homeowners were undertaking remedial work with staff files and were aware of the requirements of the process of recruitment and documents needed for newly recruited staff. All the previous requirements for these standards remain until the home is able to evidence that they are fully met. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 19 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, 33, 35, 36, 38 Arrangements for the management, staff supervision, and management of residents’ involvement and money needed further improvement. EVIDENCE: The new homeowners have had a staff meeting since taking over and determined the levels of and lines of accountability for the registered manager, the staff and homeowners, this should ensure that there is a consistent management of the home. The registered manager has the required qualifications and experience for the post and this clear management structure should assist in improvements in the home. The home did not have a quality assurance system in place. The home must ensure that audits of key areas such as falls, weights of residents, accidents, residents and relatives views, complaints, record keeping and so on are undertaken to maintain a good service. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 20 The homeowners were setting up systems to ensure that residents’ finances were more easily dealt with, responded to residents needs and ensured that they could be audited appropriately. This included residents’ personal allowance and setting up clear system of payment for cigarettes and alcohol that was fair to all. A number of residents had to be referred to Social Care and Health for these systems to be put in place. Previous requirements will stay in place until this system is finally settled. Staff one to one supervisions had not taken priority. Supervision of staff is one way of finding out staff concerns, measuring staff ability and therefore improving resident’s safety. Regular supervision must be a priority for the future. Records in the home were slowly improving residents records were now in individual files all residents had a photograph on file and this was an improvement. The homeowners were aware of all the maintenance and inspections needed for all their service such as gas, electric and lifting equipment needed in the home. An insurers inspection of the stair lift needs to be organised. A fire risk assessment needed to be completed. The home had records of routine fire checks undertaken. Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 21 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 X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 1 X 2 Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(b) (d)(2) Requirement The registered person must ensure a full assessment is carried out on all prospective service users. This must include detailed risk assessments that lead to specific actions to minimise risk before admission. (This standard was not assessed and this requirement had been outstanding since 30/08/04) Service users that are being considered for bed rails must have risk assessment. (This standard was not assessed and this requirement had been outstanding since 31/01/05) All service users must have care plans that clearly detail how staff will meet their individual identified needs. (This requirement remained outstanding since 24/04/05) Care plans must be reviewed monthly. (This aspect of the standard was not assessed and this requirement had been Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 23 Timescale for action 28/02/06 2 OP3 14(1)(d) 15/03/06 3 OP7 15 31/03/06 4 OP8 12(1a) 17(2) S4 12a,b 16 outstanding since 28/08/02) Service users weights must be regularly scrutinised and remedial action taken where required. (This standard was not assessed and had been outstanding since 30/11/04) All falls must be scrutinised and action be taken to minimise recurrence. (This standard was not assessed and had been outstanding since 19/04/05) Incidents of aggression and agitation must be recorded in detail and actions determined to minimise recurrence. (This standard was not assessed and had been outstanding since 17/05/05) The home must devise a procedure to ensure that staff know that service users are out of the home. (This standard was not assessed and had been outstanding since 24/05/05) The registered person must 15/03/06 ensure that the medication policy is current and reflects practice and that staff adhere to the policies for medicine management. All service users must be suitably risk assessed as able to self-administer their own medication using a selfadministration risk assessment form and compliance checks performed on a regular basis. New staff must be enrolled in an 31/03/06 5 OP9 13(2) Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 24 accredited training course safe handling of medicines. Medication reviews must be sought on a regular business in line with the National Service Framework for older people. (The above parts of the standard were not assessed on this occasion and these requirements are brought forward.) A quality control measure must be put in place for customer satisfaction of meals. (This remained outstanding since 30/11/04) The home must put systems in place to gain comments about the home and to ensure that complaints are responded to appropriately. A risk assessment must be completed for the garden and external sheds must be kept secured The home must ensure that discarded items and equipment does not pose risks to service users and staff. (This standard was not assessed and had been outstanding since 30/06/04) The registered person must ensure that lighting in the dining rooms is changed to be more domestic in character. (Outstanding since the inspection 28/08/02) The registered manager must ensure that all bedrooms have the furniture and fittings as detailed in the National Minimum Standards. Any bedroom without these must be shown to in the service user’s best interest and reasons must be detailed in the service user’s care plan. DS0000065927.V282717.R01.S.doc 6 OP15 (16)(2)(i) 30/04/06 7 OP16 22 30/04/06 8 OP19 13(6) 16(2)(o) 31/03/06 8 OP20 23(2)(d) (p) 30/06/06 9 OP24 16(2)(c) 30/06/06 Meadow Lodge Care Home Version 5.1 Page 25 10 OP25 13(6) 11 OP26 13(3) (This standard was not assessed and had been outstanding since 20/06/05) The home must evidence weekly testing on a sample basis of the hot water outlets to ensure the efficiency of the thermostats. Remedial action must be taken to ensure water temperatures are restricted as near to 43 degrees centigrade as possible. (This standard was not assessed and had been outstanding since 24/04/05.) The home must eradicate offensive odours evident in some parts of the home. Carpets must be audited for cleanliness and replacement. (These part of the standards were not assessed and were brought forward) Liquid hand wash and disposable towels must always be available in the kitchen, staff and communal toilets. (This part of the standard remained outstanding 19/04/05) Staff must have adequate training to the roles they are to perform. (This remained outstanding 20/05/05) The registered manager must ensure that all new staff have the appropriate checks as detailed in schedule 2 of the Care Homes Regulations 2001. (This standard was not assessed and had been outstanding since 02/07/03) The home must demonstrate robust recruitment practices including investigation of gaps in employment and records of 31/03/06 31/03/06 12 OP27 8 18(1c)(i) 30/06/05 13 OP29 19 Sch 2 15/03/06 Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 26 interview (This standard was not assessed and had been outstanding since 18/05/05) Staff that do not have a CRB police check must apply for one. (This standard was not assessed and had been outstanding since 20/04/06) 14 OP30 18(1)(c) (i) All care staff must have the induction and foundation levels of basic training recommended by Skills for Care. (This standard was not assessed and had been outstanding since 28/08/02) A proposed plan of future training including dates and staff attending must be sent to the Commission by 15/03/06. 31/08/06 15 OP33 24(1)(a) (b) 16 OP35 17(2) Sch4(9) 13(6) The home must have a system 30/04/06 for the home to maintain and improve the standards of all areas of the homes performance. (This requirement remained outstanding since 20/02/04) The registered provider must investigate more appropriate systems for the management of service users money. The registered provider must ensure that adequate records of service users being given their personal allowance. This should include two signatures of any transactions preferably one, if able, from the service user. (These requirements remain 31/03/06 Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 27 outstanding until systems are sufficiently settled) 17 OP36 18(2) Formal recorded supervision must take place no less than six times a year. (This standard was not assessed and had been outstanding since 28/08/02) A rota of staff supervision must be formulated to achieve the required target and a copy of this rota of staff names and dates must be sent to the Commission by 31/03/06. An independent inspection of the passenger stair lift must be undertaken routinely. A copy of the inspection certificate must be sent to the Commission by 31/03/06. A fire risk assessment must be completed for the property and a emergency plan devised from that risk assessment 31/08/06 18 OP38 13(4c) 23(2b)(4) 15/03/06 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 OP8 Good Practice Recommendations It is recommended that the registered manager arrange dietetic advice. (Not assessed on this occasion.) Meadow Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Lodge Care Home DS0000065927.V282717.R01.S.doc Version 5.1 Page 29 - 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. 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