Inspection on 12/01/09 for Meadow View Care Centre

This inspection was carried out on 12th January 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Meadow View Care Centre 29/06/09

Meadow View Care Centre 09/05/07

Meadow View Care Centre 13/09/06

Meadow View Care Centre 20/01/06

Meadow View Care Centre 27/07/05

Similar services:

Ashlea Mews Residential Home

Harwood House

South Chowdene Care Home

Farmborough Court

St Albans Place (14)

Bisley Drive (18)

Carrdale

Ransdale House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Meadow View Care Centre Kibblesworth Gateshead Tyne and Wear NE11 0YJ Lead Inspector Ms Glynis Gaffney Key Unannounced Inspection 12 and 14 January 2009 14:30 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 View Care Centre DS0000063769.V357116.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 View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadow View Care Centre Address Kibblesworth Gateshead Tyne and Wear NE11 0YJ 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) 0191 4103488 0191 4109908 mveuropeancare@aol.com www.europeancare.co.uk European Care (England) Ltd David Bell Care Home 22 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Sensory Impairment over 65 years of age (3) Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Meadow View is a large, older building, which has been converted for use as a residential care home. There is an extension to the rear of the building. The home is registered to provide up to 21 places for older people with dementia that require assistance with personal care needs. It is also registered to provide care to older people who may have a sensory impairment or mental health needs. Nursing care is not provided. Single bedroom accommodation is provided. Six bedrooms have en-suite facilities. There are three lounge areas all of which include dining facilities. The home has a large landscaped garden area to the front of the building. The home has level access to the rear and there are local shops, a public house and a bus route within walking distance. The weekly fees are £400 to £430:00 per week depending upon care needs. Additional charges are made for chiropody, hairdressing and personal items such as toiletries and newspapers. Copies of the home’s inspection reports are available on request. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. How the inspection was carried out: Before the visit: We looked at: • • • • Information we have received since the last key inspection visit on the 07 May 2007; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The temporary manager’s view of how well they care for people. The views of relatives and staff. No surveys were returned by people using the service. The Visit: An unannounced visit was made on the 12 January 2009. During the inspection we: • • • • • • Talked with the temporary manager; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff have the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit. We told the provider and temporary manager what we found. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Update the home’s service user guide. This will help to ensure that people interested in using the service have access to information that will tell them what to expect when they move in. Carry out pre-admission assessments and obtain copies of social services assessments and care plans. This will help to ensure that suitable placements are offered. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 7 Devise care plans that set out how the home will meet people’s need for support with the management of their medication and finances. This will help to ensure that staff are clear about how to meet people’s needs in these areas. Arrange for people who have dementia care needs to undergo a Mental Capacity Act assessment. Obtain better quality information about the choices and decisions that each person with dementia is able to make. This will help to ensure that people with dementia are supported to be as independent as possible. Ensure Ensure ensure quality that people have regular access to chiropody and sight care checks. that nutritional risk assessments are fully completed. This will help to that people are able to live healthy lifestyles, which improves the of their life at Meadow View. Ensure that an accurate record of medicines received into the home is kept. This will help to ensure that people’s health and welfare is promoted and protected. Ensure that the premises related concerns identified in this report are addressed. This will help to ensure that people are able to benefit from living in a home which is well maintained and where their health and safety is taken seriously. Take steps to eliminate the offensive odours that are present within the building. This will help to ensure that people are able to benefit from living in a home, which is free from unpleasant odours. Ensure that all staff are aware of their responsibilities and duties in relation to keeping people safe in line with the home’s safeguarding policy and the local authority’s safeguarding procedures. Ensure that all safeguarding concerns are reported to the Commission within 24 hours. This will help to ensure that people using the service are properly protected. 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 View Care Centre DS0000063769.V357116.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 View Care Centre DS0000063769.V357116.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): 1 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for making sure that people’s needs are assessed before they are admitted into the home are not fully satisfactory. This might lead to staff being unclear about how to meet the needs of people admitted into Meadow View. EVIDENCE: The home’s service user guide provides people interested in using the service with information about what they can expect once they move into Meadow View. The guide contains all of the required information with the exception of service users’ views of the home and the sizes of individual bedrooms. Some of the factual information contained within the guide is out of date. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 10 The home’s service user guide states that wherever possible the home will assess people’s needs to enable a ‘smooth transition into the service to take place.’ However, some people’s care records do not contain evidence confirming that the home carried out its own pre-admission assessment. Carrying out a pre-admission assessment will help the home to reach a decision as to whether they can offer a suitable placement that will meet an individual’s needs. A copy of the social services assessment was not available in some people’s care records. Failure to obtain this documentation could lead to staff being unclear about how to meet people’s needs following their admission into the home. Meadow View Care Centre DS0000063769.V357116.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 adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting people’s health and personal care needs are not fully satisfactory. This means that people using the service cannot be confident that their assessed needs will be well met. EVIDENCE: The care records of three people were looked at. This showed that: • • A suitable assessment is carried out following a person’s admission into the home. This provides staff with a pen-picture against which they can judge whether people’s health and welfare has improved or deteriorated; Care plans have been devised for each person. Care plans address people’s needs in a range of areas such as mobility, nutrition and personal care. These provide staff with good information and guidance DS0000063769.V357116.R01.S.doc Version 5.2 Page 12 Meadow View Care Centre • • about how to meet people’s needs. People’s care plans are generally reviewed each month; Staff have completed social histories for each person. This helps staff to appreciate the life experiences that each person had before they moved into the home; The home obtains people’s agreement to, and satisfaction with, the content of their care plans. However, there are also some concerns: • • Care plans covering the management of some people’s finances and medication have not been devised; People’s care records contain limited information about their personal preferences regarding how they want to be cared for. Having detailed information about people’s personal preferences will help to ensure that they are able to live their chosen lifestyles. Arrangements are in place to meet people’s healthcare needs. For example, staff arrange for people to be visited by their GP when needed. Each person has received dental care in the last 12 months. Community nursing intervention is arranged as and when required. People’s weight is generally checked each month. People interviewed said that they felt confident that staff would be able to meet their health care needs. However, the written records kept by staff show that some people last received chiropody care in July 2008. Also, there is no evidence that some people have received an eye care test during the last two years. A range of preventative health care risk assessments is completed for each person. For example, in the care records checked, nutritional, skin care and falls prevention risk assessments have been carried out for each person. However, some of the nutritional risk assessments looked at have not been satisfactorily completed. Failure to fully complete nutritional risk assessments could lead to gaps in staff’s knowledge about how to keep people healthy. The provider has devised a medication policy to ensure the safe handling of medicines at Meadow View. A pre dispensed monitored dosage system is used. This helps to reduce the possibility of mistakes occurring thereby helping to keep people safe. A sample of medication records was checked. This showed that medication records are generally well maintained. However, the receipt of people’s medication into the home is not always recorded on their medication administration record. There have been no incidents involving the misadministration of medication since the last inspection. The medication trolley and treatment room are kept in a clean and hygienic condition. Staff administered medication in a safe and competent manner. Observations of personal care show that staff try to involve people using the service in day-to-day decision-making. For example, staff consult people about Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 13 their meal choices on a daily basis. People said that staff always ask them about what they want to eat and drink. However, people’s care records contain limited information about the decisions and choices that they are able to make. There is no evidence that Mental Capacity Act assessments have been carried out for individuals who have difficulties making decisions and choices. Meadow View Care Centre DS0000063769.V357116.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for providing service users with a lifestyle that satisfies their social and recreational interests and needs, and nutritional requirements, are good. This means that people are able to benefit from living in a home where the staff know how to meet their social care needs. EVIDENCE: The home obtains information about people’s social interests and hobbies before, and after, their admission into Meadow View. People’s care records contain social histories. This helps staff to understand people’s life experiences before they moved into the home. A social needs care plan is then devised for each person. This helps to ensure that staff are clear about how people’s social needs are to be met. However, person centred activity plans have not been devised for people with dementia care needs. This would show that the home is committed to following best practice guidance in relation to further developing its dementia care services. People’s social care plans are reviewed each month. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 15 There is a social activities programme, which is posted throughout the home. People said that they are invited to participate in activities but are able to decline if they are not interested. People’s care records show that they are provided with opportunities to join in a range of social activities. For example, one person’s records showed that they had joined in 1 to 1 pamper sessions, exercise and musical movement sessions during the previous week. During the inspection, staff were observed providing a variety of activities such as playing cards with a small group of service users and encouraging people to join in a musical session. People seemed to respond well to the efforts made by staff to engage them in the day’s activities. People told the inspector that they are happy with the range of activities offered by the home. Arrangements have been made for a local minister to give Holy Communion each month. A service took place during the inspection and all service users were invited to attend. However, care plans have not been devised which set out how staff should meet people’s religious care needs. A hairdresser visits weekly. Visitors are made welcome and there are no restrictions on visiting times. People are able to meet with their visitors either in the home’s communal areas or in the privacy of their own bedrooms. A visitor spoke very highly of the care provided by the home to their relative. The home has a rotating four-week menu that includes photographs of the food to be served at each mealtime. Breakfast is from 8a.m. onwards and tea from 4pm. Hot and cold food choices are available at all main meal times. People said that the food served at the home is very good. Alternatives are always available and people can change their minds if they wish. The inspector observed people taking their lunchtime meal. There was a friendly and unhurried atmosphere in the dining areas. The meal served looked tasty and nutritious. It was nicely presented with good portion sizes. Staff provided people with the support they needed to eat their meal in a dignified manner. People said that they are asked the night before what they would like to choose from the menu for the next day. Small dining areas have been created to enable people to experience a more domestic atmosphere. Although the dining areas are pleasant, the dining tables are not attractively dressed. Some of the table clothes did not look as though they had been ironed and condiments had not been placed on the tables. Meadow View Care Centre DS0000063769.V357116.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 adequate. This judgement has been made using available evidence including a visit to this service. There are satisfactory arrangements for ensuring that complaints are properly handled. This means that people can be confident that their complaints will be listened to, taken seriously and acted upon. However, the arrangements for keeping people safe are not fully satisfactory. This means that people cannot be confident that staff will know how to keep them safe. EVIDENCE: The provider’s complaints procedure is displayed throughout the home so that people using the service, and their families, know who to complain to and how to make a complaint. The procedure is included in the service user guide. The temporary manager said that no complaints have been received during the previous 12 months. Of the seven staff that returned surveys all said that they are clear about how to handle complaints. People using the service said that they would feel comfortable about making a complaint. They also said that they felt they would be listened to and taken seriously. Although all staff have attended safeguarding training, a recent safeguarding incident showed that staff are not clear about their reporting responsibilities. As a consequence, an assault committed by one service user against another went unreported to both the Commission and the local authority safeguarding Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 17 team. The temporary manager dealt with this shortfall in practice immediately and following the inspection has arranged for all staff to undergo refresher training. Previous safeguarding incidents have been satisfactorily handled by the service. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 18 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. The standard of accommodation is generally satisfactory and meets the needs of the people using the service. This means that people are able to benefit from living in a service, which is generally well maintained. EVIDENCE: The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable and there are plans to carry out further renovations to the rear of the building following which the remainder of the home will be refurbished. The rear of the building is in a poor state. However, at present, people do not have access to this area. The provider confirmed that the requirement set in the last fire officer’s inspection report has been met. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 19 The home has tried to make the home more suitable for people with dementia care needs. For example, photographic door labels have been fitted to help people identify their bedroom. ‘Way-finding’ signs have been provided to identify the purpose of each room. Bedroom doors are colour coded to help people distinguish between bedroom doors and walls. On entering the building, visitors are faced with an unpleasant odour. Staff said that this is connected to people’s incontinence. They also said that steps have been taken to address this problem. For example, laminate flooring has been fitted in corridor areas. People with continence care needs are supported to use the toilet on a regular basis. Air fresheners have been installed. Each person has access to their own bedroom but only some have private ensuite facilities. People can personalise their bedrooms if this is their preferred wish. People said that the home is clean, warm and well lit. Toilets are appropriately located within the home, are easily accessible and in sufficient numbers. People have access to a range of aids and adaptations such as a variable height bath and hoisting equipment. Aids and adaptations have been fitted in some toilets. Staff knew how to work the aids they are expected to use. The premises were checked as part of the inspection. The following concerns were identified: • • • • There is an unguarded radiator in one of the bedrooms; Bedroom 11: there are no aids in the en-suite facility and the walls are in a poor condition. There is no lockable facility; A radiator guard has come away from a corridor wall. The temporary manager agreed to address this matter immediately following the inspection; The laundry floor does not allow for easy cleaning. However, the laundry is due to be refurbished as part of the forthcoming re-development. A number of requirements were made by the local environmental health officer following their last inspection of the kitchen. The provider confirmed that all matters raised have been addressed. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 20 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 arrangements for ensuring that people using the service are in safe hands at all times are not fully satisfactory. This means that people cannot be confident that they will be cared for by staff who are suitable to work at the home and who are competent to do their jobs. EVIDENCE: There is a rota that shows, which staff are on duty and at what times. However, they do not include all of the information needed by the Commission to ensure that staffing levels are adequate such as: staff’s full names; the year to which the rota refers; the hours worked by catering staff; confirmation of who is the shift senior; the hours being worked by the temporary manager. In addition, the rotas are not being updated to reflect changes in the shifts worked by staff. The rotas show that there are always a minimum of three staff on duty between 8am and 10pm for up to 21 people. Two staff cover the nighttime period. Domestic and catering staffing levels are satisfactory. No concerns about the appropriateness of staffing levels were identified during the Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 21 inspection. Of the seven staff that returned surveys, the majority said that there are sufficient staff on duty to meet people’s needs. A range of pre-employment checks is carried out. For example, personnel files contain confirmation that staff’s identities have been checked. Criminal Records Bureau disclosure checks have been carried out. However, a member of staff employed after the provider purchased the home had not completed the provider’s application form in full. Also, a full employment history had not been provided. Failing to carry out all of the required pre-employment checks could result in unsuitable staff working at the home. Over 50 of the staff team have obtained a recognised qualification in care. Other staff are in the process of doing so. Staff are provided with in-house induction training. This helps to familiarise new staff with the home’s environment and safety precautions. However, there is no evidence that some staff have completed a ‘Skills for Care’ induction. At present, staff induction training records are electronically based. However, the temporary manager was unable to access the home’s electronic training records. Staff are provided with opportunities to complete statutory training. There is a detailed training matrix in the office, which identifies what training each member of staff has completed. A sample of three staff records was looked at. This showed that all staff have completed training in moving and handling, infection control, food hygiene and health and safety. However, one member of staff had not updated their moving and handling training during the previous 12 months. Although two staff did not have an update first aid certificate, arrangements had been made for these staff to update their training. Some staff have completed extra training to help them meet the special needs of people with dementia. For example, some staff have completed physical intervention training. Two staff have completed training in managing aggressive behaviour. All staff have completed ‘Yesterday, Today, Tomorrow’ training. This helps staff to understand how people are affected by dementia and how they can provide person centred care. Of the seven staff that returned surveys, all said that: their employer had carried out pre-employment checks before they started work at the home; their induction had covered what they needed to know to do the job; the training they are given is relevant to their role, helps them to understand the needs of the people they care for and keeps them up to date with new ways of working. The majority of staff said that they have the right support, experience and knowledge to meet the different needs of people using the service. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 22 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. The arrangements for ensuring that the home is properly managed and administered are not fully satisfactory. This means that people are not able to benefit from living in a home that is being run in their best interests. EVIDENCE: In the absence of the registered manager, temporary management arrangements have been put in place. This involves the registered manager from another home covering two days a week at Meadow View. The reduction of management oversight over an extended period of time could have a detrimental impact upon the running of the home and the quality of care Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 23 received by people living at Meadow View. Following the inspection, the temporary manager has been appointed to a permanent position. The provider carries out regular monthly monitoring checks to ensure that the home is operating in accordance with the company’s policies and procedures. However, people using the service and their families, staff and professionals visiting Meadow View, have not been asked to complete satisfaction surveys. The provider has not prepared a report setting out its findings about how well the home has performed against the National Minimum Standards and legal regulations during 2008. Although the provider is planning to improve the service, an annual development plan is not available within the home. Staff have not received formal supervision at the frequency stipulated in the National Minimum Standards, which states that each member of staff should receive supervision at least six times a year. For example, two staff did not receive any formal supervision during the previous 12 months. Another member of staff had only received two supervision sessions in 2008. However, staff that returned surveys said that they met with their manager regularly to discuss their work and felt well supported. A tour of the premises revealed no health and safety concerns. A selection of health and safety records was checked. These showed that: • • • • Fire prevention safety checks are carried out on a regular basis; Personal emergency evacuation plans have been devised for each person; The home has an up to date fire risk assessment; The home has current gas and electrical safety certificates. However, the following concerns were also identified: • • The majority or workplace risk assessments have not been revised during the previous 12 months; Some staff have not received fire instruction, or participated in fire drills, at the recommended frequency. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 24 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 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 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X 2 X 2 Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 Timescale for action Where relevant, obtain copies of 01/04/09 each person’s social services assessment before they move into the home. This will help to ensure that staff have access to the information they need to provide people with safe care. 2. OP7 15 Devise care plans that address 01/05/09 people’s need for support with the management of their medication and finances. This will help people to feel confident that staff are clear about the actions that must be taken to meet their needs in these areas. 3. OP9 13(2) Ensure that an accurate record 12/01/09 of medicines received into the home is kept. This will help to ensure that people’s health and welfare is promoted and protected. Requirement Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 26 4. OP18 13(6) Ensure that all staff are aware of 12/01/09 their responsibilities and duties in relation to keeping people safe. This will help to ensure that people using the service are properly protected. 5. OP18 13(6) 37 Ensure that all safeguarding 12/01/09 concerns are reported to the Commission within 24 hours. This will help to ensure that people using the service are properly protected. 6. OP19 23(2) Ensure that: • • All radiators are guarded or low surface temperature radiators fitted; All radiator guards are secure. 01/04/09 This will help to ensure that people are able to benefit from living in a home which is well maintained and where their health and safety is taken seriously. 7. OP26 16(2) Take steps to eliminate the 01/04/09 offensive odours that are present within the building. This will help to ensure that people are able to benefit from living in a home, which is free from unpleasant odours. 8. OP29 Schedule 2 Ensure that all staff provide full 01/04/09 employment histories. This will help to ensure that staff are suitable to work with vulnerable adults. Ensure that staff have an up to 01/07/09 DS0000063769.V357116.R01.S.doc Version 5.2 Page 27 9. OP30 18 Meadow View Care Centre OP38 date first aid certificate. This will help to ensure that staff have the first aid skills needed to keep people living at the home safe. 9 24 Submit an application to register a manager for the home. Establish and maintain a system for• • Reviewing at appropriate intervals; and Improving, 01/05/09 01/08/09 10. 11. OP31 OP33 the quality of care provided at the home. Complete a written report setting out the findings of any review completed. The review carried out should take account of service users’ views and those of their representatives. This will help to ensure that the home is being run in the best interests of the people living at Meadow View. 12. OP36 18 Ensure that staff receive formal 01/08/09 supervision at least six times a year. A written record should be kept. This will help to ensure that people using the service are able to benefit from being cared for by staff that are properly supported and supervised. 13. OP38 23 Ensure that staff receive fire 01/08/09 instruction every six months and participate in at least two fire drills a year. This will help to ensure that people are able to benefit from living in a home where staff are Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 28 clear about how to keep them safe in the event of a fire. 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 OP1 Good Practice Recommendations Ensure that the home’s service user guide is revised to include: • • Service users’ views of the home; Details of bedroom sizes. The guide should be updated to ensure that it is factually correct. 2. OP8 Ensure that: • • • 3. OP10 People receive chiropody care on a regular basis. An accurate record of any chiropody care provided should be kept; Each person is given the opportunity to have an eye test every two years. Any refusal should be recorded in the person’s care record; People’s nutritional risk assessments are fully completed. Obtain information about the decisions and choices that each person is able to make. Request Mental Capacity Act assessments for those people with dementia care needs. 4. OP10 Purchase a copy of the Mental Capacity Act Code of Practice. Ensure that all staff are aware of the above Code and how it affects their day-to-day work. Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 29 Update your assessment and care planning policy to include guidance on how your service will consider people’s capacity to take decisions and make choices. Devise documentation, which will enable you to record how you have reached a ‘best interest’ decision or choice on someone’s behalf. In respect of each ‘best interest’ decision you need to make, you should include the following trigger points in your documentation: • • • • • 5. OP12 Have you considered the two stage test of capacity and recorded the outcome; Can the person understand information relevant to the decision that needs to be made; Can the person remember that information long enough to make the decision; Can the person weigh up information relevant to the decision; Can the person communicate their decision by talking, using sign language, or by any other means. Where relevant, ensure that care plans describing how staff should meet people’s religious care needs are put in place. Develop a person centred activity plan for each person with dementia care needs. Create more attractive table settings. Make condiments available at each table. Ensure that tablecloths are suitably ironed. 6. 7. OP12 OP15 8. OP18 Update the home’s safeguarding policy to ensure that it fits with the Mental Capacity Act and the latest developments within the field of adult safeguarding. Ensure that: • • • All toilets are fitted with appropriate aids to help people be more independent; All bedrooms have a lockable space; The laundry floor covering can be easily cleaned. 9. OP19 10. OP27 Ensure that the home’s rotas contain the following information: DS0000063769.V357116.R01.S.doc Version 5.2 Page 30 Meadow View Care Centre • • • • • Staff’s full names; The year to which the rota refers; The hours worked by catering staff; Confirmation of which member of staff is acting as the shift senior; The hours being worked by the temporary manager. In addition, the rotas should be updated to reflect changes in the shifts worked by staff. 11. 12. OP29 OP30 Ensure that all application forms are fully completed and referee details provided. Ensure that newly employed staff complete the ‘Skills for Care’ induction. A certificate of completion verified by the manager should be available within the home. Ensure that staff update their moving and handling training every 12 months where they carry out such tasks on a regular basis. Ensure that people using the service and their families, staff and professionals who have contact with Meadow View, are invited to complete satisfaction surveys. Devise an annual development plan which takes account of the following: requirements and recommendations arising out of Commission reports; any actions arising out of the home’s annual quality assurance audit; comments made in satisfaction surveys. Ensure that workplace risk assessments are reviewed yearly. 13. OP30 14. OP33 15. OP33 16. OP38 Meadow View Care Centre DS0000063769.V357116.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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