Inspection on 07/09/05 for Meadowbrook Manor

This inspection was carried out on 7th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Meadowbrook Manor 14/02/07

Meadowbrook Manor 02/03/06

Meadowbrook Manor 02/12/04

Meadowbrook Manor 12/05/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Meadowbrook Manor 147/149 Wakefield Road Garforth Leeds LS25 1NE Lead Inspector Mary Bentley Unannounced 7 September 2005, 11.45am th 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 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. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Meadowbrook Manor Address 147/149 Wakefield Road Garforth Leeds LS25 1NE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2320054 0113 2320054 Mrs Beverley Mc Hale Mrs Beverly McHale Care Home Only 23 Category(ies) of Old Age (23) registration, with number of places Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 02/12/04 Brief Description of the Service: Meadowbrook Manor is a purpose built home set in a half acre of landscaped gardens, which are accessible to wheelchair users. The home is just outside the village of Garforth with a parade of shops and a pub within a short walking distance. The home offers care to a total of 23 older people, male and female with low to medium dependency needs. The home does not provide nursing care. The home has three floors, there are 19 single and 2 double rooms with en-suite facilities provided in 19 rooms. The home has a large dining room and three lounge/day areas. There is a ramp at the front door for wheelchair access and inside a passenger lift provides access to all floors. Car parking is provided at the front of the home. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was announced and took place in December 2004. There have been no further visits until this unannounced inspection. This inspection was carried out during the afternoon of September 7th 2005 by one inspector. The people who live in the home prefer the term resident; therefore this will be the term used throughout this report. The methods used during the inspection included looking at records, talking to residents and staff and observing care staff carrying out their work. The Registered Manager was not in the home during the inspection and it was not possible to follow up the requirements from the last inspection, therefore these have been carried forward and will be checked during the next visit to the home. Comment cards/questionnaires for residents and visitors were left at the home. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection. Comments received in this way are shared with the provider without revealing the identity of those completing them. None had been returned to the CSCI at the time of writing this report. What the service does well: What has improved since the last inspection? Supper is served at approximately 8.00pm, since the last inspection the menu has been changed and residents are now offered sandwiches, staff said many of the residents like jam sandwiches at this time. The garden area at the back of the home has been made secure so that residents are able to use this area without staff supervision. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 6 What they could do better: 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. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 8 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 standard(s) 3 & 5. Standard 6 does not apply to this service. The needs of prospective residents are assessed before they are admitted to the home. Prospective residents and/or their representatives are encouraged to visit the home before making a decision about admission. EVIDENCE: A copy of the pre-admission assessment done by the home was seen in the care records of a resident recently admitted, a copy of the assessment done by Social Services was also available. During the visit relatives of a prospective resident were shown around the home and given information about the services and facilities offered. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7, 8 & 10. Residents’ personal and health care needs are met in a way that respects their privacy and dignity despite the fact that this is not always supported by the care records. The lack of detailed information in the care records creates the opportunity for needs to be overlooked. EVIDENCE: The care records of three residents were looked at. There were care plans in place setting out how personal, health and social care needs would be met and the records showed that residents and/or their representatives were involved in planning care. In some cases the care plans did not show how all the identified needs would be met, for example, one resident’s assessment said there was a history of alcohol abuse but there was no care plan about this, another resident was demonstrating challenging behaviour and there was no care plan to guide staff on how to manage this. The care plans were reviewed monthly but these reviews did not always reflect changes in circumstances, for example the reviews of some care plans about eating and drinking said there was “no change” although weight records showed that residents were losing weight. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 10 The home uses a pre printed format for care records and there were several gaps in the personal care records, in some cases no personal care had been recorded since July. The residents seen looked clean and well cared for. During the inspection four residents were identified as having problems with nutrition and were showing signs of weight loss, from discussions with staff it was clear that the home was making every effort to deal with this problem but this was not reflected in the records. Residents have access to other health and social care professionals including GPs, District Nurses and Community Psychiatric Nurses. In their interactions with residents staff were seen to be kind and caring and when necessary calm and patient. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13 & 14 The rights of residents who are able to make choices are respected and residents are supported in keeping in contact with family and friends. More attention should be given to the less able residents to help them occupy their time meaningfully. EVIDENCE: Many residents spend their time in their own rooms following their own interests and only join other residents for meals. Residents can see their visitors in private and some go out regularly with family and/or friends. The hairdresser was in the home on the day of this visit and for some residents this was the main activity of the day. The home has an activities organiser who visits on Monday and Friday afternoons and provides entertainment in the form of games, exercises and reminiscence sessions. On other days staff said they organise activities such as games, videos or manicures. There are a number of residents in the home who are unable, due to their illnesses, to occupy their time meaningfully without guidance and support and on the day of the inspection staff had very little time to spend with them, as a result these residents spent most of the afternoon either watching television or wandering up and down the corridor and in some cases becoming increasingly restless. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 12 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 standard(s) These standards were not inspected. EVIDENCE: Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 22, 24 & 25. Residents live in clean, comfortable and homely environment. EVIDENCE: The home was clean and free of unpleasant smells. In the bedrooms seen residents had their own belongings around them. Most of the bedrooms are decorated to a good standard but in some the carpets are showing signs of wear and tear. A number of bedrooms did not have a lead attached to the call bell system. Many of the bedroom doors look unsightly where photographs have been removed and the sticky tape has been left on the door. Thermostatic valves have been fitted to control hot water temperature and to reduce the risk of scalding, however it is still necessary to check hot water temperatures to make sure that the valves are working properly, the records showed that this had not been done since November 2004. The fire officer has been asked for advice on the locks in use on the fire exit doors. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The home does not always have enough staff on duty to meet residents’ needs. EVIDENCE: From 3.30pm to 6.00pm, on the day of the inspection there were only two staff on duty. The evening meal is served at 5.00pm and the staff on duty are responsible for preparing and serving this meal as well as attending to residents care needs. Some residents were seen to become increasingly restless during the afternoon and one in particular became very agitated, it was evident that it was a struggle for staff to give residents the time and attention they needed. The duty rosters showed that there are regularly only two staff on duty during the late afternoon with a third member of staff not coming on duty until 6.00pm. The duty roster also showed there are times when the home only has two staff on duty on all the shifts over the weekend. This information was confirmed by discussions with staff. Following the inspection this was discussed with the registered manager who said there are plans in place to change the staffing levels so that there are always at least three staff on duty. Staff files were not looked at because in the absence of the manager no one in the home had access to the records. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 38 Overall the health, safety and welfare of residents and staff are protected. EVIDENCE: The maintenance records showed that the required checks and maintenance of the fire safety systems and the passenger lift were carried out. The call bell system was due to be serviced in May 2005; it was not clear if this had been done. One resident said she had fallen in her bathroom last week; an accident form had not been done. Some records were not available for inspection because the manager was not in the home. Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x 2 x 3 3 x STAFFING Standard No Score 27 1 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x 2 2 Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 17 Yes Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 Requirement The care plans must set out in detail how all the needs identified during assessment will be met and must be kept up to date to reflect changing needs. Call systems with an accessible alarm facility must be provided in all rooms used by residents. The registered persons must ensure that there are enough staff on duty at all times to meet residents needs. All the required checks must be completed before new staff commence work in the home. Carried forward from the last inspection. The records required by regulation must be available for inspection at all times. A risk assessment must be recorded for the portable heater identified during the inspection. Timescale for action 31 December 2005 31 December 2005 Immediate and ongoing 5 October 2005 2. 3. 22 28 16(2)(c ) 18 4. 29 19 5. 6. 37 38 17 13(4) 31 December 2005 5 October 2005 7. 38 17(1)(a) Schedule 3. 3(j) Carried forward from the last inspection. Detailed accident reports must 5 October be completed for all accidents 2005 and incidents involving residents. Version 1.40 Page 18 Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 12 24 25 28 Good Practice Recommendations The home should make sure that suitable activities are provided for less able residents. A review of the furnishings provided in each bedroom should be carried out to make sure that all rooms are equipped to the specification of this standard. Hot water temperatures should be checked at least once a month and records of these checks should be maintained. The duty rosters should show clearly the designation of staff. The managers hours of work should be shown on the duty roster. Interview notes should be kept in individual staff files. Carried forward from the last inspection. An audible alarm should be fitted to fire exit doors so that staff are alerted when these doors are opened. Carried forward from the last inspection. All staff should sign in and out when entering and leaving the building. 5. 6. 29 38 7. 38 Meadowbrook Manor J52 J03 S1481 Meadowbrook Manor V236279 150705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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