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Inspection on 09/01/07 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 9th January 2007.

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

A warm and welcoming atmosphere is evident on entering the home. Staff were helpful and polite and there was evidence of a good rapport between staff and service users. Service users spoken with said that they were happy with life within the home and that staff were very kind, they felt listened to and their needs were met. Staff spoken with showed compassion and empathy and were able to discuss service users needs. Although improvements in the plans of care are required information already gained is extremely personalised and reflects service users choices and preferences. Service users were seen to be free to walk about the home as able and undertake their own interests. Meals are at a good standard and service users spoken with expressed that these were plentiful and choices were available. Fifty percent of staff have now attained the National Vocational Qualification (a nationally recognised work and practice based qualification) thus ensuring that service users are in safe hands.

What has improved since the last inspection?

The manager has purchased a new quality assurance programme; she has begun to implement areas of this and intends to continue to make further developments in the near future. Evidence was avaible to show that service users and relevant others had been involved in the plan of care, however further evidence is required to fully confirm this. The manager ensures that two references are obtained for all new members of staff. The practice of the secondary administration of medicines has ceased, working towards further protecting service users.;

What the care home could do better:

The responsible person is required to obtain consent for the use of bedrails to ensure that service users rights are promoted. The responsible person is required to ensure that plans of care are in place for all identified needs and these demonstrate how service users will be supported in meeting these needs, thus ensuring needs are fully met. The registered person must ensure that a written plan of care is created after consultation with residents or representative. The registered person must ensure that evidence is provided to support this standard. This has been partly met; however further evidence is still required to fully demonstrate that service users and relevant others had had the opportunity to partake in their plan of care. The responsible person is required to ensure that appropriate risk assessments and management plans are in place for all highlighted risks to ensure service users are fully protected To ensure that necessary equipment is available for the safe use of bedrails to ensure service users are fully protected The responsible person is required to ensure that evidence is available to demonstrate that staff who administer medication are trained appropriately for the work they are to perform. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in to the home to ensure that service users are fully protected. The registered person shall not employ staff without a POVA 1st in place. Once this is obtained staff are to work under a supervisory practice programme untila satisfactory Criminal Record Bureau check is received, thus ensuring service users are fully protected. A staff training matrix is available to demonstrate that staff undergo an induction and are trained in all mandatory areas to demonstrate that they are fully trained and competent to do their jobs. Ensure surface temperatures on radiators are kept at a safe temperature; ensure risk assessments are in place with regards to this to demonstrate that service users are safe. Monitor water temperature delivery and provide a risk assessment to ensure service users are fully protected. Eleven good practice recommendations were also made, further information is available within the full body of the report.

CARE HOMES FOR OLDER PEOPLE Meadow Lodge Care Home 21-23 Meadow Road Beeston Rylands Nottingham NG9 1JP Lead Inspector Karmon Hawley Unannounced Inspection 9th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Meadow Lodge Care Home DS0000008717.V326211.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 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 DS0000008717.V326211.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadow Lodge Care Home Address 21-23 Meadow Road Beeston Rylands Nottingham NG9 1JP 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) 0115 922 8406 0115 922 8406 Mr David Teece Mrs Margaret Ann Teece ** Post Vacant *** Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Meadow Lodge is situated on a main bus route, close to a railway station and one mile from Beeston Town Centre. The home is registered to care for 25 older people, including those with Dementia, in two linked adjacent houses. Accommodation is in single and double rooms and is provided on two floors with two passenger lifts. There is a large dining room and four separate lounges. The patio and gardens are pleasant and well maintained. The current weekly fees for the home are between £288 and £326, these fee do not include hairdressing, chiropody and toiletries of choice. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in six and a half hours and was performed by two inspectors. The main method of inspection was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users were spoken with during the inspection so as to give the inspector an insight into the conditions and standards within the home. All were satisfied with the care received and the standards within the home. Two members of staff were spoken with and they were able to discuss core values and principles of care and their job role in meeting service users needs. What the service does well: A warm and welcoming atmosphere is evident on entering the home. Staff were helpful and polite and there was evidence of a good rapport between staff and service users. Service users spoken with said that they were happy with life within the home and that staff were very kind, they felt listened to and their needs were met. Staff spoken with showed compassion and empathy and were able to discuss service users needs. Although improvements in the plans of care are required information already gained is extremely personalised and reflects service users choices and preferences. Service users were seen to be free to walk about the home as able and undertake their own interests. Meals are at a good standard and service users spoken with expressed that these were plentiful and choices were available. Fifty percent of staff have now attained the National Vocational Qualification (a nationally recognised work and practice based qualification) thus ensuring that service users are in safe hands. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The responsible person is required to obtain consent for the use of bedrails to ensure that service users rights are promoted. The responsible person is required to ensure that plans of care are in place for all identified needs and these demonstrate how service users will be supported in meeting these needs, thus ensuring needs are fully met. The registered person must ensure that a written plan of care is created after consultation with residents or representative. The registered person must ensure that evidence is provided to support this standard. This has been partly met; however further evidence is still required to fully demonstrate that service users and relevant others had had the opportunity to partake in their plan of care. The responsible person is required to ensure that appropriate risk assessments and management plans are in place for all highlighted risks to ensure service users are fully protected To ensure that necessary equipment is available for the safe use of bedrails to ensure service users are fully protected The responsible person is required to ensure that evidence is available to demonstrate that staff who administer medication are trained appropriately for the work they are to perform. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in to the home to ensure that service users are fully protected. The registered person shall not employ staff without a POVA 1st in place. Once this is obtained staff are to work under a supervisory practice programme until Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 7 a satisfactory Criminal Record Bureau check is received, thus ensuring service users are fully protected. A staff training matrix is available to demonstrate that staff undergo an induction and are trained in all mandatory areas to demonstrate that they are fully trained and competent to do their jobs. Ensure surface temperatures on radiators are kept at a safe temperature; ensure risk assessments are in place with regards to this to demonstrate that service users are safe. Monitor water temperature delivery and provide a risk assessment to ensure service users are fully protected. Eleven good practice recommendations were also made, further information is available within the full body of the report. 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 Care Home DS0000008717.V326211.R01.S.doc Version 5.2 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 DS0000008717.V326211.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although assessments take place the assessment does not fully cover the standard, therefore service users needs may not be fully assessed prior to admission. The home does not provide intermediate care. EVIDENCE: The manager does not generally visit prospective service users within community, however relatives and the prospective service user may visit the home and spend time there prior to making a decision whether to move in. The manager assesses assessments provided by the prospective service users social worker and liaises with relevant others. Information is transferred onto an assessment sheet, however this does not cover the requirements of the Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 10 standard. There were three completed basic assessments forms within service users case files to demonstrate that this had taken place. The home does not provide intermediate care services. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in a plan of care however further development is required in regards to care planning for complex needs and risk assessments to ensure service users are protected and their needs are fully met. Service users health care needs are fully met. Service users may not be fully protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Four service users plans of care were seen. Service users undergo various assessments such as manual handling, mental health, physical health, pressure area care and nutritional needs. Assessments were at a good standard, contained sufficient information in regards to service users needs were personalised and reflected individual needs and preferences. Plans of care Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 12 were based upon the identified needs, however all identified needs were contained in one plan, were brief and did not cover complex needs such as diabetes and dementia care needs in full. Risks had been highlighted for a number of concerns, however the management plans were brief and did not contain all the action that the manager said that takes place to protect the service user. Risk assessments in regards to the risk of entrapment and the use of bed rails were not in place. There was no evidence of written consent being obtained for the use of these or the use of a cocoon that one service user had in place. The manager and staff both stated that the relatives had given verbal consent for the use of these. Due to the level of information gained in the assessments it would be deemed that service users or relatives had been involved in the process, however there were no signatures available to confirm this. Running records were maintained when significant events occurred, however there were large periods where no entries had been made in these records. Monthly reviews were seen to take place and significant changes monitored. Service users spoken with said that their needs were met. Staff spoken with were able to discuss service users needs and how they are supported in meeting these. Service users are enabled to access the multidisciplinary team and specialist services as required. There was evidence of these services being accessed within service users plans of care case tracked. Staff spoken with discussed how these services were accessed. Two service users spoken with said that they may see the doctor at any time and one said that they had seen the optician recently. There was evidence of relevant equipment available throughout the home, such as specialist mattresses and manual handling equipment, however bedrails seen did not have bumpers in place, staff spoken with said that they use pillows to protect service users. The manager has now implemented a new system for the administration of medication and secondary dispensing no longer occurs. Four service users medication administration records were seen. These were checked against the prescription. Hand written entries were not signed by two members of staff to show that these had been checked as correct. One entry on the medication chart did not correspond with the prescription and the medication had been administered by not signed for. There was three gaps in signing for medication, there was no reason given for why this had not been administered on the chart. Medication is not checked into or out if the building, the manager said that the pharmacist makes a list of what he has collected. Fridge temperatures were available, however room temperatures were not. One senior member of staff has undertaken training in the administration of medicines via The Peoples College, the remainder of staff who administer medicines have carried out in house training, there were no records available to substantiate this, however the manager showed the training booklet to the inspector and stated that she ensured that staff were fully competent to administer medication prior to taking on this responsibility. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 13 The manager said that staff are instructed in maintaining service users privacy and dignity at all times. Staff were observed to knock on service users doors prior to entering, screening was available in shared rooms. Service users spoken with said that staff were respectful at all times and they felt that their privacy was upheld. Staff spoken with were able to discuss how they ensure that they maintain privacy and dignity whist assisting service users to meet their needs. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle experienced in the home matches their expectations and satisfied their needs, however evidence of a structured programme for those service users with dementia needs would prove beneficial. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome, appealing and balanced diet in pleasing surroundings. EVIDENCE: The manager said that the routine of the home was flexible and service users may choose where and how they spend the day depending upon their mental health needs. Service users spoken with confirmed this. Service users were seen to be able to move freely around the home and make choices about what they were doing. The manager said that staff and outside entertainers provide activities to service users, which include bingo, sing a longs, quizzes, reminiscence, dominoes and keep fit. Staff spoken with confirmed this. Service users spoken with said that they were satisfied with the level of activities Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 15 provided, however they were unable to discuss activities that take place with the exception of keep fit and watching television. Several service users were seen to enjoy looking at the memorabilia that was on display within the home. There were no records available to show what activities service users had participated in. A Catholic priest visits the home on a weekly basis and offers Holy Communion. The manager said that if any religious services were required these would be facilitated. There are no restrictions on visiting and visitors may be received in private. There are a number of seating areas that visitors may be received in should it be required. One service user was seen to take their relatives to their room during the visit. Service users spoken with confirmed that visitors were always made welcome and they could visit at any time. Several service users spoken with spoke of how they enjoyed trips outside the home with their families. Staff were able to discuss how they ensure that service users are treated as individuals and that their rights were upheld. Within plans of care seen all had personal profiles in place and personal information, which reflected upon that person’s personality, which gave an insight in to the lives they had led. Also within plans of care reference was made to ensuring that service users choices are upheld, preferences and likes and dislikes were noted. Service users spoken with said that staff were very kind and they could ask for what they wanted, they felt that they were treated as individuals. The manager said that advocates were used as needed, there was booklet seen in the managers’ office about this service. A wholesome, varied and appealing menu was seen to be on offer. Choices are offered at all meals with the exception of the main lunchtime meal, however alternatives are available should this be required. Specialist diets are also catered for. One service user spoken with discussed how their special diet is maintained. Service users spoken with said that food was at a good standard and plentiful. The kitchen was clean and tidy and there was evidence of stock control. Fridge, freezer and food temperatures were seen. Although there was a cleaning programme in place staff do not sign to show this has been completed. The manager has received the safer food better business documentation and is in the process of implementing this. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relevant others may be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Appropriate policies and procedures were in place for dealing with complaints should they be received. There have been no complaints received since the last inspection. Staff spoken with were able to discuss how they would deal with a complaint should it be received. Service users spoken with were happy with the care received and life within the home. All staff members with the exception of one had current Criminal Record Bureau checks in place. (This will be further discussed in standard 29.) The manager said that staff had received training in regards to adult protection via the National Vocational Qualification (a nationally recognised work and performance based qualification). One member of staff spoken with was able to confirm this. Both staff members spoken with were able to discuss relevant issues in regards to adult protection to a good standard. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and generally well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: A tour of the home was undertaken, during this time a trip hazard was noted on the stairs, this was repaired on the day of the inspection and the manager said that plans are in place to replace the carpet. Windows have restrictors in place, one was noted to be broken again this was repaired on the day of the inspection. The manager said that a programme of routine maintenance takes place and a significant area of the home has been redecorated, records of this were available. Furniture in service users rooms see was ‘tired’ looking and was in need of re-varnishing. Some radiators had covers in place, whereas others did not. Radiators in two communal areas were very hot; there was no evidence in place of a risk assessment being undertaken for these. The Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 18 Environmental Health Officer visited the home in June 2006, no requirements were made during this visit, however the safer food better business documentation was recommended. The home offered a comfortable and homely feel and all rooms were individualised and personalised. The laundry room was clean and tidy and organised. Relevant hand washing equipment was in place. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff meets service users needs. Service users are in safe hands, however it is recommended that further guidance is sought in regards to the induction package. Service users are not fully protected and supported by the homes recruitment policies and practices. Staff are working towards ensuring they are trained and competent to do their job, it is recommended that a training matrix is devised to aid tracking of training undertaken. EVIDENCE: The duty rotas seen showed that sufficient staff were on duty throughout the day. The manager said that skill mix was considered when planning this. Staff spoken with confirmed that sufficient staff were available. Service users spoken with said staff were available when needed. Fifty percent of staff have attained the National Vocational Qualification level 2 or above. Staff spoken with confirmed that they had undertaken this training. Although there have been no new staff for some time an induction programme is in place should the need arise. This was discussed with the manager who said she would consult with the Skills for Care Counsel to ensure it was still up to date. One member of staff spoken with said that they had undergone an induction programme and staff had been very supportive during this time. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 20 There were no records of an induction programme completed in this staff members file. Four staff files were seen. Due to the majority of staff being employed for a number of years there were no references available within three files. The manager said that she would complete character references for these members of staff. All other required documentation was in place with the exception of one member of staff’s Criminal Record Bureau check that had been completed by another company. The manager said that she would apply for another one as soon as possible. Within staff training files there was evidence of training certificates, however it was difficult to ascertain exactly the amount of training all staff had achieved. There was no evidence available to show that staff had received training in health and safety. However the manager said that this had taken place, staff spoken with said that they had received training in infection control and the Control of Substances Hazardous to Health. Staff spoken with said that training was at a good standard. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home which is run and managed by a person who is fit to be in charge and of good character, however it is recommended that a qualification in management is obtained. The home is run in the best interests of service users, however further documentary evidence is required to fully substantiate this. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff is not fully promoted and protected. EVIDENCE: The manager has been in place for 25 years and is registered with the commission for social care inspection. She has previous nursing experience. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 22 Although she does not intend to complete the Registered Managers Award she ensures she remains up to date with mandatory training. Staff spoken with said that the manager was approachable and very kind and understanding. Service users spoken with also felt that the manager was very kind. Several questionnaires are due to be sent out in the near future to gain feedback from service users, relatives, staff and professionals. The manager said that on the return of these she would then consolidate the responses. The manager said that there is an ongoing plan of maintenance, records of maintenance undertaken was seen. Policies and procedures are updated when needed and the manager said that she tries to keep abreast of new developments. The manager has intentions to implement a new quality assurance process in the near future. The manager said she is not responsible for any service users money and no service users money is kept on the premises. Should a cost be incurred relatives are invoiced for this amount. Maintenance and servicing certificates were seen such as the portable appliance testing for electrical items, the lift and fire equipment. The electrical system has not been tested since 1986, the manager was not aware of how frequently this is required to be tested. The fire logbook seen showed that 9 members of staff had undertaken fire safety training, which included fire drills. Fire alarms are tested on a weekly basis. The emergency lights were last tested in November of last year. Water temperatures are not recoded, however the manager said that all outlets except the kitchen and laundry had thermostatic controls. Fire risk assessments were in place for all service users. Two radiators in communal areas were extremely hot; there were no risk assessments in place for this. Meadow Lodge Care Home DS0000008717.V326211.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 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 12(2) Requirement Timescale for action 12/02/07 2 OP7 14 (1) 3 OP7 15 4 OP7 13(4,c) The responsible person is required to obtain consent for the use of bedrails to ensure that service users rights are promoted. The responsible person is 12/03/07 required to ensure that plans of care are in place for all identified needs and these demonstrate how service users will be supported in meeting these needs. The registered person must 12/03/07 ensure that a written plan of care is created after consultation with residents or representative. The registered person must ensure that evidence is provided to support this standard. This has been partly met; however further evidence is still required. The responsible person is 12/03/07 required to ensure that appropriate risk assessments and management plans are in place for all highlighted risks to ensure service users are fully protected. DS0000008717.V326211.R01.S.doc Version 5.2 Meadow Lodge Care Home Page 25 5 OP8 13(4,c) 6 OP9 18(1,i) 7 OP9 13(2) 8 OP29 19(1) 9 OP30 18(1,i) 10 OP38 13(4,c) 11 OP38 13(4,c) To ensure that necessary equipment is available for the safe use of bedrails to ensure service users are fully protected. The responsible person is required to ensure that evidence is available to demonstrate that staff who administer medication are trained appropriately for the work they are to perform. Med Act 1968 Misuse of Drugs Act 1971 The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in to the home. The registered person shall not employ staff without a POVA 1st in place. Once this is obtained staff are to work under a supervisory practice programme until a satisfactory Criminal Record Bureau check is received A staff training matrix is available to demonstrate that staff undergo an induction and are trained in all mandatory areas. Ensure surface temperatures on radiators are kept at a safe temperature; ensure risk assessments are in place with regards to this. Monitor water temperature delivery and provide a risk assessment to ensure service users are fully protected. 20/02/07 20/02/07 20/02/07 09/01/07 09/04/07 20/02/07 20/02/07 Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 26 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 6 7 8 9 10 11 12 Refer to Standard OP3 OP7 OP9 OP9 OP12 OP15 OP28 OP31 OP33 OP38 OP38 OP38 Good Practice Recommendations To review the preadmission documentation to cover the information as set out in standard 3. Entries are made into the service users case notes at least weekly to show service users current care and condition. All handwritten entries on the medication chart are to be signed by two members of staff to ensure that these have been checked as correct. Record room temperatures of the room in which medication is stored. Provide evidence of a structured activity programme suitable for those service users with dementia care needs. Staff sign to demonstrate that cleaning has taken place in the kitchen. Obtain advice in regards to the induction programme that is in use to ensure that this is up to date and at the required standard. The manager obtains an appropriate management qualification. Continue to develop the quality assurance systems and provide further evidence of this. The mains electrical system is tested 5yearly. Emergency lights are tested on a monthly basis. Replace the identified stair carpet to avoid future trips hazards. Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI Meadow Lodge Care Home DS0000008717.V326211.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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