Inspection on 03/02/04 for Meadow View Care Centre

INSPECTION REPORTCare Home For Older People Meadow View Care Centre Wharrage Road Alcester Warwickshire B49 6QY 3rd February 2004 ESTABLISHMENT INFORMATION Name of establishment Meadow View Care Centre Address Wharrage Road, Alcester, Warwickshire, B49 6QY Email Address info@prime-life.co.uk Name of registered provider(s)/Company (if applicable) Prime Life Ltd Name of registered manager (if applicable) Sheila Denise Naisbitt Type of registration Care Home No. of places registered (if applicable) 34 Tel No: 01789 766739 Fax No: 01789 763440Category(ies) of registration, with (number of places) Dementia - over 65 years of age (17), Old age, not falling within any other category (17) Registration number E040000328 Date First registered 17th July 2003 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 17th July 2003 NO NO 16/7/03 If Yes Refer to Part CMeadow View Care CentrePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 33rd February 2004 09:30 am Stephen HumphreysID Code072649Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Sheila Nesbitt / Mel Oliver the time of inspectionMeadow View Care CentrePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementMeadow View Care CentrePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Meadow View Care Centre. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Meadow View Care CentrePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Meadow View is a purpose built care home, situated in the town of Alcester. The entrance to the home is from Wharrage road, just a few metres from the local hospital. Meadow View care home can accommodate up to 17 service users over the age of 65yrs with dementia and up to 17 service users who are in the older persons category. The service provider offers long and short - term accommodation and services associated with meeting the personal care needs of service users in the above categories. The accommodation is on one level in two wings. The complex also includes several privately owned bungalows and a Day Care centre called Poppies. All clients are offered single bedroom accommodation with en-suite facilities. Meadow View is spacious with a long wide corridor leading from the entrance to the communal and accommodation areas. The communal areas consist of a large lounge dining room with smaller sitting rooms off the main room. The gardens are landscaped and very attractive. There is a path suitable for wheelchair users leading around the gardens to the day care centre. A planned entertainment programme is in place along with regular activities. The care home is registered to provide personal care services only. The visiting district nurses treat service users needing nursing care.Meadow View Care CentrePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection took place on 3rd February 2004. Not all the standards were assessed at this inspection. The inspection found that many of the National Minimum Standards had been met or partially met and that the overall quality of care was good. Service users and relatives expressed their satisfaction with the staff and the care being delivered. The standards assessed during this inspection were mainly care standards, records and health & safety standards. Choice of Home (Standards 1- 6) The Statement of Purpose must be reviewed and updated to include a detailed description of how services are delivered and include the requirements of schedule 1 of the Care Homes Regulations 2001. Health and Personal Care (Standards 7 ­ 11) The inspector checked the service user care plan records. All the care plan records have full needs based assessments Daily Life and Social Activities (Standards 12 ­ 15) During this inspection the inspector talked to visiting relatives and community nurses. All spoke very positive about the standard of care delivered to service users. Activities were going on that offered stimulation and recreation to service users. Service users said they were happy with the home and the staff. Complaints and Protection (standards 16 ­ 18) No changes were noted from the last inspection Environment (Standards 19 ­ 26) Meadow View was built six months ago and met all the environmental standards for registration. No changes were noted at this inspection. Staffing (Standards 27 ­ 30) Training records were checked for the staff working in the home.. Care staff said they had received induction training. The service users and relatives interviewed during the inspection said the staff are very caring, and respectful at all times. Management & Administration (Standards 31 ­ 38) No changes noted from last inspection.Meadow View Care CentrePage 6 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 4 OP1 The Statement of Purpose does not describe in 31.3.04 detail how the services are delivered and other information as required by schedule 1 of the Care Homes Regulations 2001 A hand washing facility is required to be installed in the laundry for staff use. 31.3.04216OP26Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardMeadow View Care CentrePage 7 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.Meadow View Care CentrePage 8 STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 13 OP9 Eye drops and other creams must be dated from the day of use and discarded after 28 days Risk assessments must be developed for the environment and surrounding area where service users may be at risk of falls 28/2/04213OP3831/3/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 OP7 The care plan evaluation should identify the current state of the service user.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Meadow View Care CentrePage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES NO YES YES YES YES YES NO YES YES YES NO YES YES YES YES YES YES NO YES 10 5 0 YES YES YES YES 13 0 3/2/04 09:30 7Meadow View Care CentrePage 10 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Meadow View Care CentrePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) X To (£) XAny charges for extrasYESIf yes, please state what the extras are: 2 Key findings/Evidence Standard met? Extra charges are made for: Hairdressing, Chiropody, and Personal toiletries. Each service user had a copy of the Service Users Guide in their bedroom. Relatives also confirmed that they had received a copy of the Service Users Guide. The Statement of Purpose is a generic document with minimum reference to the services offered at Meadow View. Advise was given to the Registered Manager and Registered Person regarding the information that must be included in this document.Meadow View Care CentrePage 12 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The main assessment for the placement is carried out by the service users social worker. A community psychiatric nurse may also be involved as well as other members of the community mental health team. An assessment involving the professionals mentioned was filed in the service users care plan record. The Registered Manager confirmed that she also carries out an assessment of need using the Activities of Daily Living model. The registered manager is a qualified nurse and has received training in needs assessment. The care plan records checked contained needs based assessment Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Meadow View can accommodate service users who have dementia. The accommodation is on one level with large spacious rooms. Each room has a good outlook mainly to rural surroundings. Staff receive in house induction training. The inspector saw copies of the new induction and foundation training to met TOPPS standards. This is being introduced for new staff Care staff have experience and skill in delivering personal care. Collectively staff were observed to deliver a good standard of personal care. All the relatives and visiting professionals said the staff are very caring, kind and respectful to service users. The staff are commended for their customer care approach.Meadow View Care CentrePage 13 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are 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. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? The Activities of Daily Living model is used to assess the service users needs. The care plan record described clearly the personal care needs of all the service users. Evidence was found to show the involvement of the service user and their representative in the development of the care plan. The monthly review with the service user or representative should describe how the care needs are being met.Meadow View Care CentrePage 14 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)X 03 Key findings/Evidence Standard met? The service users said the carers were very kind and hard working. All the service users said they are assisted with their personal hygiene needs. The Registered Manager assesses the service user for risk of developing pressure sores, mobility problems, and for falls. All the risk assessments are filed in the service users care plan record. The district nurse carries out any nursing care needed when they visit the home. Nutritional screening is carried out at the time of assessment. Service users weight records were filed in the care plan.Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The records of receipt, administration, storage and disposal were checked. All were satisfactory. At the time of this visit only the Registered Manager and deputy manager administer the medication. Other care staff are due to receive accredited training from Boots Pharmacists. Eye drops and other creams must be dated from the day of use and discarded after 28 days. Eye drops in use are note dated.Meadow View Care CentrePage 15 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The service users interviewed said that they are looked after very well. The carers are very good and respect the individuals privacy and dignity at all times. The carers refer to the service user by the name they wish. The preferred name is recorded in the care plan record. The carers said they had received induction training that included privacy and dignity issues. The relatives spoken to confirmed that the carers were observed to be respectful and courteous at all times. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Meadow View Care CentrePage 16 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? No changes were observed to this standard from the last inspection.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? Relatives confirmed that they can visit at any reasonable time. Links with the community are being further established.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? During a tour of the home the inspector observed service users personal possessions in their rooms. Information is available to service users on how to contact the advocacy services should they wish. The Statement of Purpose makes reference to the service user accessing their personal records.Meadow View Care CentrePage 17 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The menus are based on the service user likes and dislikes. The menus are changed weekly. The service user is given a choice from the menu of the day. The inspector took lunch in the dining room with the service users. The meal was wholesome and plentiful. The choice was from two dishes for the main meal and two for the desert. Hot and cold drinks are available through out the day and service users can eat in their rooms if they wish. The cook said that she could cater for any service users with special diets, religious or cultural needs. Service users individual weight records were filed in the care plan.Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence This standard was not assessed at this inspection. 0 0 0 0 0 0 100 N/AStandard met?Meadow View Care CentrePage 18 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The care staff are aware of the abuse and whistle blowing procedure. Financial procedures, reporting procedures and other related policies were checked. The induction training included abuse trainingMeadow View Care CentrePage 19 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 4 Key findings/Evidence Standard met? The environmental standards were assessed at the time of registration. No changes were observed to the condition of the home. All fittings and furnishings are of a high quality.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Meadow View Care CentrePage 20 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Meadow View Care CentrePage 21 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not assessed at this inspection. YES NO NO 34 34 0 0 Standard met? N/A 34 00 0 0 0Meadow View Care CentrePage 22 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? A wash hand basin must be installed in the laundry, for staff use. This requirement is outstanding from he last inspection.Meadow View Care CentrePage 23 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High needs No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 0 28 5 581 No. staff hours allocated No. staff hours allocated No. staff hours allocated No. of staff hours provided 0 492.8 88 581 X X X X0 14 53 Key findings/Evidence Standard met? The minimum staffing levels were agreed with the Responsible Individual at the time of registration. The duty rotas were checked for accuracy. The staff rostered on duty were accounted for.Meadow View Care CentrePage 24 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed at this inspection. 0 0 Standard met? N/AStandard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The recruitment process was reviewed as part of the registration process. The staff files were checked and found to contain all the information required.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The induction and foundation training programmes seen by the inspector are based on the National Training Organisation training standard. The induction training is run by the organisations in-house trainers.Meadow View Care CentrePage 25 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. N/A Key findings/Evidence Standard met? The manager met all the requirements for registration. No changes were noted.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The staff said that the manager is very approachable and available to them. They are happy with her management style. The relatives confirmed that they find the manager pleasant and approachableStandard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The Responsible Individual has recently introduced a quality questionnaire, that is available to service users and relatives visiting the home. One relative said she had taken one to complete. The questionnaire is very basic and may not address the home individually.Meadow View Care CentrePage 26 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. N/A Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed at this inspection. Standard met? 0 0 0 N/AStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Policies and procedures are generic to Prime Life Plc care homes. Policies are reviewed regularly by the organisation.Meadow View Care CentrePage 27 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All statutory records were checked and found to be completed and up to date.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The home has a recent fire risk assessment report and staff had fire prevention training and drills. Moving & handling, food hygiene, and first aid training have been provided to staff. There are first aid boxes in the kitchen for the catering staff. Risk assessment must include the environment and surrounding areas used by service users.Meadow View Care CentrePage 28 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateStephen Humphreys John SawyerSignature Signature SignatureMeadow View Care CentrePage 29 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureMeadow View Care CentrePage 30 It should be noted that all NCSC inspection reports are public documents.PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleMeadow View Care CentrePage 31 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection reportYESProvider comments are available on file at the Area Office but have not YES been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Meadow View Care CentrePage 32 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Meadow View Care CentrePage 33 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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