Inspection on 13/09/06 for Meadow View Care Centre

This inspection was carried out on 13th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Meadow View Care Centre 29/06/09

Meadow View Care Centre 12/01/09

Meadow View Care Centre 09/05/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Meadow View Care Centre Kibblesworth Gateshead Tyne and Wear NE11 0YJ Lead Inspector Mrs Irene Bowater Key Unannounced Inspection 13th September 2006 09:15 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.V309208.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.V309208.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 4109088 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.V309208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 Brief Description of the Service: Meadow View is a large, grand older building, which has been converted for use as a care home with an extension to the rear. It is sited in the pretty rural village of Kibblesworth. It provides 21 places for older people who require assistance with personal care needs. It does not provide nursing care. At this time most of the people who live there have dementia care needs. All the bedrooms are single and well decorated and 6 of the bedrooms have en-suite facilities. The home also provides a good choice of sitting areas for the people who live there, and it enjoys extensive mature gardens and an indoor patio area with fishpond. There are local shops, public house and a bus route a short walk from the home. The fee rates range from £365 to £430. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced Inspection took place over seven hours. The inspector spent time with the Registered Manager, staff, residents and visitors. The inspector looked around and talked to residents and staff, and saw the contact between them. Time was also spent checking the cleanliness, maintenance and decoration of the home. A number of documents were looked at including, training, maintenance, catering, medication, financial, recruitment, health and safety, and complaint records. What the service does well: The staff have all the necessary information before any resident moves into the home to ensure they can meet their needs. There is communication with other professionals to ensure residents health care needs are met. Comments from relatives included: “The care and support given is of a high standard”, “the staff have a good understanding of what my relative is trying to communicate,” “I rarely have to complain”,“ he staff are very caring and supportive”, “the residents are well cared for and treated well”, “the staff make us welcome”. The residents said “they are good girls” and “they are always nice to me”. The meals are nutritious, nicely presented and choices are available. Residents agreed with this by saying, “the meals are nice”; “there’s plenty to eat”. Visitors are made welcome and there are good links with the local community. The staff have created a friendly homely atmosphere in the home and have formed good relationships with residents and their representatives. The recruitment policies are followed. Staff and residents are kept informed about any changes in the home. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? The staff are working hard to improve the care plans. The menus are now in a picture style so that residents can easily choose what they want to eat for each meal. The arrangements for meal times have changed making these times an unhurried, pleasant occasion. There is now a registered manager who is improving the service and quality of life for the people who live there. The home has a business and financial plan for the year which shows how the home is going to be developed. There is better communication with the staff and relatives. Relatives are now encouraged to have their say about the home and help improve it. Staff now have supervision to help them do their job better. Staff said they now felt supported and settled since the home changed owners. What they could do better: Although there have been improvements made to the care plans, work is still needed to ensure they are clear and detailed about the care provided. Improvements are needed to the medicine charts. The home needs to improve the activities for residents, which develops individual choices, independence and meets assessed needs. A plan is needed to show how the home is going to be refurbished and redecorated. The staff must follow infection control procedures to make sure all areas of the home are clean. A planned programme of staff training needs to be developed to make sure staff have the continual skills to care for the residents. The health and safety issues that have been highlighted must be addressed within timescales. The home must inform the Commission of any event that affects the well being of any resident in the home. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 7 All of the requirements must be completed with the given timescales. 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 View Care Centre DS0000063769.V309208.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.V309208.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Standard 6 is not applicable. The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The homes Statement of Purpose and Service User Guide provides prospective residents and their representatives with the information they need before deciding to move into the home. The pre-admission assessments ensure the residents care needs will be met. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which sets out what the home provides. Clear information is available about all aspects of the service and includes some pictures that will help those who have difficulty understanding the wording. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 10 Since the last inspection the Company have introduced new documents, which include preadmission, assessment tools and care planning records. The five care plans inspected showed that information was available from Care Managers and the Home Manager. This information forms the basis of the care plan for when the resident is admitted or readmitted to the home. All of the preadmission and admission assessment tools are held in a file and the actual working care plan is held in a separate file. Meadow View Care Centre DS0000063769.V309208.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements are needed to the care plans to make sure that the staff have detailed information to meet all of the residents assessed needs. The health needs of residents are currently being met. There is interagency working. The lack of detail on Medicine Administration Records has the potential to place residents at risk. Personal support is currently promoting residents right to privacy and dignity. EVIDENCE: Since the last inspection new documentation has been introduced regarding care planning. It is acknowledged that improvements are being made to the record keeping in the home. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 12 The registered manager and the staff are currently working through all of the care plans to bring them up to date and make sure that staff know how to care for each residents individual needs. Five care plans were inspected and showed that `a pen picture of the resident had been written. Assessment tools were completed for dependency, nutrition, moving and handling, falls risk, pressure sore prevention and continence care. Social care assessments had been completed with the family members. There was limited information about how staff assessed and monitored the mental health status of the residents given they all have a degree of mental health illness. Three care plans have not been updated or reviewed since May 2006 and one has not been updated since August 2006. One resident who was admitted in July 2006 had all of the assessments completed but a care plan has not been written. The care plans need more detailed information about all aspects of the residents individual needs especially how their psychological health is monitored. The care plans must detail how staff are going to care for residents who display challenging or difficult behaviours. Personal care and social care is recorded in the daily records. There is evidence that the residents relatives are now encouraged to help with the care plans by providing information about previous lifestyles, likes and dislikes. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including dentists, opticians and chiropody services. The district nursing services visits the residents who have any nursing needs. There is a record of general health care treatment and intervention including monthly weight recording. The home has medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. None of the residents are administering their own medication. The handwritten directions on the Medicine Administration Records (M.A.R.) was not always signed and witnessed by another staff member. Medicines requiring cold storage are held in a domestic refrigerator. The daily temperatures of the fridge are recorded. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 13 There is a register of staff who are authorised to administer medication. The treatment room is small and very untidy with an activities trolley and out of date policies and papers. The medicine trolley was locked in the dining room for most of the morning. The staff leave the trolley until all the residents have had breakfast at approximately 10:30 am. This was discussed with the manager for review. There was a good rapport between staff, residents and relatives, which was friendly and professional. Care was delivered in private and staff were caring and kind and made sure that the residents rights to dignity and privacy was respected at all times. Residents are able to maintain contact with their relatives and friends as they wish. Meadow View Care Centre DS0000063769.V309208.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Social activities do not provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are supported to make choices and take control over their lives whenever possible. Dietary needs of residents are catered for with a balance of food available that meets residents’ needs. EVIDENCE: An activities organiser has been recruited but was not on duty on the day of inspection. Residents mainly sat in the lounges watching television or listening to music. A couple of the residents wandered around the home and although it was a nice day none went into the large pleasant garden. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 15 There were visitors to the home and staff confirmed that some residents regularly go out with their families. There is no planned activity programme in the home. The staff tried to have some meaningful activity in the afternoon by using reminiscence cards and talking to the residents about them. Staff said they always try to spend time with the residents but confirmed that this was not always recorded in the care plan. There have been improvements to the social care since the last inspection. Relatives are asked to become involved in helping to gain information about residents’ previous lifestyles and their likes and dislikes and this information is generally available in the care records. Staff are recording when events take place in the home and there is evidence that residents have been to the theatre and have had in house entertainment. The registered manager confirmed that the residents now had membership to Beamish Museum and the home had links with the local church and community centre. Several of the residents attend church on a regular basis. The home now has a mini bus to take residents out and about. Many of the good practices and generally daily events are not accurately recorded in the care plans. The planned changes to the records, introducing a “Person Centred Approach” to care and further training in Dementia Care will hopefully create activities and enable residents to lead meaningful lives within and outside of the home. Relatives and friends are made to feel welcome and know that they can visit at any time. There were visitors on the day of inspection and the staff took time to welcome them and discuss events with them. Residents have been encouraged to bring small items of furniture and other belongings with them, making their rooms highly individualised and reflective of their lifestyles. There are two dining rooms in the home. Both were being used on the day of inspection. The tables were appropriately set with tablecloths, cutlery and napkins. The home has a two-week menu, which offers choices for each meal. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 16 Residents in the home have difficulty reading the menu and the registered manager has produced the menus in a picture format so residents can choose what they wish to eat for each meal. The choices for lunch were steak casserole or pasta bake with mashed potatoes, Yorkshire pudding, cauliflower and swede. None of the residents choose to have the pasta bake. Dessert was ice cream. The inspector observed the lunchtime meal being served in both dining rooms. The meals were served from a hot trolley by kitchen staff or the team leader. The food was of ample portion size, hot, nicely cooked and presented. Residents were asked what they wanted on their plates and preferences given. The staff had a good understanding of individual likes and dislikes and were able to discuss what they did when meals were refused. They were also able to discuss how residents with low weight and poor appetites were encouraged to eat by offering fortified drinks, extra sandwiches and finger foods. None of these good practices are documented in the care plans. The meal tome was a pleasant unhurried time with staff assisting in a discreet manner. Hot and cold drinks were readily available throughout the day. Residents said “the food is nice”, “the meals are lovely” and “there is sometimes to much on my plate”. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The complaints procedures are clear. Residents and relatives are confident that their views are listened to and acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: There are detailed complaints procedures available in the home, which detail how to make a complaint. Records showed that all complaints are taken seriously and are investigated within 28-day time scales. A relative said there was no cause for complaint but would go to the unit manager or registered manager if they were unhappy. There have been two recorded complaints in March 2006. These have been appropriately investigated with outcomes recorded. There are policies and procedures in place for the Protection Of Vulnerable Adults. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 18 Staff have completed POVA training with Gateshead Council and the council’s policies and procedures are in place for staff to refer to should they suspect a case of abuse. POVA guidelines and contacts have been made available to all staff employed in the home. There have been no allegations of abuse. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 19 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): 19,20,21,24,26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home is comfortable, homely and meets the needs of the people who live there. Refurbishment and redecoration is not planned ahead to deal with the natural wear and tear. There are several infection control issues that have the potential to place residents at risk. EVIDENCE: The location of the home is suitable for the people who live there. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 20 A tour of the home found that all areas are being maintained, however there is no planned redecoration and refurbishment programme available to set out when furnishings and fittings are going to be replaced within timescales. There are two lounges, two dining rooms and two conservatories on the ground floor. One of the conservatories is used as dining area and access to large landscaped gardens is via the other. All of these areas are furnished and decorated to a satisfactory standard although carpets are showing some signs of wear. The colour and patterns of the carpets are confusing to the residents how have dementia. Staff agreed that residents been down to “pick” items up when in fact it is the pattern they are confused about. The families have been involved in auditing the communal areas and several repairs are needed. Comments from relatives include, “they keep it nice but it’s looking tired”, “the carpet have been down for years” and “it would be nice to have some new things”. There are bathrooms and toilets close to the communal areas. The shower room opposite room 8 is not used as residents would have to step into it and it is not suitable for those with any disability. Another bath is domestic in style and again is not suitable for those with any disability. The paint was flaking off the window ledge in another shower room and there was evidence of bar soap and communal toiletries being used. All of the call and light cords were grimy and could not be cleaned on a daily basis. All of the rooms are being used for single occupancy. The bedrooms inspected are appropriately furnished and decorated. Many of the residents have brought items of furniture and other personal effects into the home making the rooms individual and reflecting their preferences and lifestyles. Some of the furniture and carpets are showing signs of wear although there is evidence that some bedroom furniture has been replaced. Two identified rooms had very small windows making the rooms dark without artificial lighting. On the day of inspection the home was clean and odour free. The laundry is very small and staff have to wash soiled linen and clothes and iron freshly washed items in this small space. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 21 Given the restrictions the area was generally organised and clean. There was no liquid soap or anti bacterial gel to let staff wash their hands. The sluice is separate from resident areas and a sluice disinfector is available. All of this area was disorganised, full of different equipment, clinical waste bags and a clean laundry trolley. The hand washbasin was being used to store commodes, which were being soaked in unidentified liquid, and the top of the disinfector was being used to store soiled commode pots. The open sluice hopper has not been cleaned for some time and the bowl and rim was filthy with old contaminated faecal debris. This area has not been cleaned for some considerable time. The floor was dusty and dirty. There was no liquid soap, paper towels or anti bacterial gel available in this area. The responsibility of who cleans this area had not been identified on the cleaning schedule therefore no one did it. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The current staffing levels ensures the residents care needs are met. The arrangements recruitment and selection of staff protected. ensure that residents are Further training will ensure that the staff have the skill to do their work. EVIDENCE: The home has three staff on during the day one of which is a team leader or senior carer. Overnight there are two waking staff with a member of staff on call. The off duty shows that on some days the staffing is increased according to the needs of the residents or because audits have to be completed. There is also evidence that on some afternoons up to five staff can be on duty. The home also employs domestic staff, cooks, kitchen assistants, administrator and maintenance staff. An activities organiser has recently been employed. The registered manager is supernumerary. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 23 The home has over 50 of care staff with NVQ level 2 or equivalent. Four staff files with their training and development records were inspected. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, two written references, proof of identity, induction, job description and terms and conditions of employment. There is evidence that staff have received mandatory training last year. The registered manager is aware that further training is now due to ensure the staff can continue to care for the residents assessed needs. Training this year for some staff has included first aid, infection control and COSSH. Senior staff are receiving training in Dementia Care. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 24 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): 31,33,34,35,36,38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home has an experienced manager who provides clear leadership. The systems for consultation and quality monitoring have improved with evidence that views of residents are sought and acted upon. Residents personal accounts are managed to ensure their best interests are protected. Staff receive the support and supervision they need to carry out their jobs. There are some health and safety issues, which have the potential to place residents at risk. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager is a qualified social worker who has a diploma in business management and holds a training certificate. He has vast experience of working with older people. He is currently completing the Registered Managers Award. He is working hard with residents, relatives, other professionals and the staff team to improve the quality of care and service provision in the home. The home has changed hands and he is aware of the many issues that need to be put right. A business plan has been completed which gives a clear picture of where the service is and how it is going to be developed over the next year. The relatives now have regular meetings and they are encouraged to be part of the developments in the home. Regular staff meetings are held with minutes recorded. The company have produced a home audit, which the managers have to complete. This audit tool covers all of the minimum standards. The regional manager visits the home on a monthly basis and also completes an audit with any action needed. There is a business and development plan and the registered manager has a yearly budget, which makes sure financial controls are in place. Resident’s personal financial records were inspected. A record is maintained for each person’s transactions. Entries were clear with signatures available. The paper records can be cross-referenced to the computer held records. The registered manager carries out regular audits. Staff now have regular supervision with the manager with records kept. The staff have had training in safe working practices. The registered manager is aware that some of this training is due to be updated and is currently sourcing suitable accredited training. Staff have received fire training at the required intervals. The date, full name and staff signature should be written in the fire logbook. A fire risk assessment is available and up to date and residents also have an emergency evacuation plan. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 26 The homes accident book is completed fully and is compliant with the Data Protection Act. The home also has produced a weekly accident analysis that documents the number of accidents that happen and any that are reported to RIDDOR and details the outcomes. The completed document gives trends so that accidents can be minimised following a risk assessment. A recent incident in the home was not reported to the Commission. registered manager is to forward a full report following the inspection. In house maintenance checks are carried out weekly and recorded. Contract maintenance records were available and up to date. The lift report identifies some defects that need to be addressed and the further investigation is needed regarding the recent rewiring assessment. Risk assessments are available, however a risk assessment for the internal fish pond and surrounding area was not available. The registered manager completed this on the day of inspection. The Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 27 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 3 3 X 2 Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 28 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 15 Requirement The registered persons must ensure that the care plans set out in detail the action which needs to be taken by staff to ensure all aspects of the health, personal and social care needs of residents are met. The care plans must be reviewed by care staff at least once a month and updated to reflect changing needs for health and personal care. Timescale of 01/04/06 not met. The registered person must ensure that all handwritten directions on the Medicine Administration Record (M.A.R.) have two signatures. The registered persons must ensure that a meaningful activity programme is implemented which suits individual needs, preferences and capacities. Up to date information must be circulated about activities in formats that residents can understand. The registered persons must DS0000063769.V309208.R01.S.doc Timescale for action 01/12/06 2. OP9 12,13, 30/09/06 3. OP12 16 01/12/06 4. OP19 13,23 01/12/06 Page 29 Meadow View Care Centre Version 5.2 5. OP21 23 6. OP24 16,23 7. OP26 13,23 ensure that a planned programme of renewal and redecoration of the premises is produced and implemented with records kept. The registered persons must ensure that there are sufficient usable bathrooms and shower facilities available at all times to meet the needs of the residents. The bathrooms and toilets must be upgraded as part of the refurbishment programme. The registered persons must ensure that the bedrooms are refurbished as part of the planned programme. The registered persons must ensure that hand washing facilities are readily available where infected material or clinical waste is being handled. All emergency call cords and light cords must be changed and be easily cleanable. 31/03/07 31/03/07 30/09/06 8. 9. OP31 OP38 9 13 10. OP38 37 The sluice must be deep cleaned and then kept clean in accordance with professional guidance. The registered person must 31/03/07 progress with the completion of the Registered Managers Award. The registered persons must 01/12/06 ensure that the electrical systems and electrical equipment is checked and any defects rectified. The registered persons must 01/10/06 ensure that all accident ,injuries and incidents which affect residents are notified to the Commission orally and then in writing. Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Meadow View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 View Care Centre DS0000063769.V309208.R01.S.doc Version 5.2 Page 32 - 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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