Inspection on 23/02/06 for Meadowcroft

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Meadowcroft 06/03/07

Meadowcroft 21/06/05

Meadowcroft 15/11/04

Meadowcroft 22/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

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 Meadowcroft 289 Rooley Lane Bradford BD5 8LG Lead Inspector Pamela Cunningham Unannounced Inspection 10:30 23 February 2006 rd 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 Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 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. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Meadowcroft Address 289 Rooley Lane Bradford BD5 8LG 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) 01274 733561 01274 725574 City of Bradford Metropolitan District Council Department of Social Services Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st June 2005 Brief Description of the Service: Meadowcroft is a large purpose built care home operated by Bradford Metropolitan District Council. It is situated approximately three miles from the City centre and is located close to a Social Services area office. There are no amenities nearby, and although there is a bus service along the main road, it is a good walk down to the home. There is limited parking is available for visitors at the front of the building. The accommodation is provided on the ground floor level in single rooms. Access to other areas of the home is available by shaft lift, and equipment for the disabled is provided as required. The home provides care for three long stay residents Intermediate care is provided. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 21 June 2005. This was an unannounced inspection carried out by one inspector who was at the home from 10.30 until 16.30. The main purpose of this inspection was to make sure that the home provides a good standard of care for the residents, and to assess progress on meeting any requirements or recommendations made at the last visit. The methods used at this inspection included looking around the building, looking at care records; observing working practices and talking to staff, residents, relatives and to the manager. In addition to conducting the inspection, time was also spent on preparation. What the service does well: What has improved since the last inspection? The majority of the home has been redecorated. On one wing, all rooms have been completely refurbished, and all corridors are awaiting the fitting of new carpets. Staffing is to be increased following the placing of adverts. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 6 The new manager attends the Intermediate care management meetings, and hopes to improve services for ethnic minority groups, and a representative from the ethnic minority group is to visit the home the week following the current inspection. 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. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 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 the following standard(s): 3 and 6 Residents are assessed before admission. The manager also undertakes pre admission assessments, as on occasions the information provided by the social worker does not provide sufficient information for the home to ensure they can meet their needs. Many different services are being provided in the home, which is still causing dissatisfaction with some service users. Intermediate care is provided. EVIDENCE: The manager who is very new in post told me that on occasions she has needed to contact social workers for more in formation about prospective residents before she has undertaken her own assessment. The home offers a range of services including respite, short stay, assessment, interim, rehabilitation, and emergency admissions. Five day care places for people from the community are also provided. The home no longer admits long stay admissions although three long stay residents continue to live there. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 9 There are different admission’s processes depending on the type of stay. Some admissions are linked to health care; others are done in conjunction with social workers. I focussed on all types of admissions at this inspection. The manager said social work assessments are always received before residents move into the home, although there had been one occasion when she had needed to speak to the social worker involved, as the information provided was not sufficient. She also said that historically there is no pre admission assessment done before residents are admitted for rehabilitation, and interim care. (A requirement has been made) Residents are encouraged to visit the home, and many do, although there has been one occasion when this was not possible. The have also been occasions when the homes staff have visited residents in their own homes. At the last inspection, some of the residents expressed concerns about the many different people coming to live at the home, however at this inspection, things seem to have settled down somewhat. Residents spoke to during the visit passed favourable comments about the home. One long stay resident told me that he had made friends with two of the people attending for day care, that the staff were excellent, and “wouldn’t hear a wrong word said against them.” Two other lady residents said the place was fine and the food is very good, “sometimes there is too much of it.” One other lady who had only been at the home for two days said that the place seemed ok, and the food was quite good. I spoke to one gentleman visitor who was visiting his grandmother who lived in Wiltshire, who said his concerns were always addressed immediately. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 10 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 and 10 The health care needs of residents are met and care plans provide clear and detailed instructions for staff to follow. Residents are treated with respect and their privacy is upheld. EVIDENCE: I looked at and case tracked the care documentation of 2 long stay residents, 2 assessment residents, 2 emergency admissions, one short stay, and one interim stay resident. Although care plan documentation seen was informative, and there was evidence of relative involvement, there were four concerns raised; these being, Correction fluid was seen in the care plan documentation. Manual handling assessments were being done by a person who had not been trained to do them. (A requirement has been made) One resident had been admitted out of the category of care the home was registered to provide. The person identified has a history of recent alcohol Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 11 dependence, and there was no evidence of a pre admission assessment having taken place. Nutritional risk assessments were present however pressure sore risk assessments were still not being carried out. (Requirements and recommendations have been made.) Health care needs of long stay service users are met. Regular health checks are arranged, and health care professionals are consulted at appropriate times. The manager and previous temporary manager said all staff who are involved in dispensing medication have received appropriate training. I was also told that there are 6 residents who administer their own medication, records show that risk assessments have been undertaken. Residents spoken to said the staff always respect their privacy, and staff were seen to knock on doors before entering. I observed medication being given out, it was handled appropriately. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 12 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 and 14 A good activities programme is provided. Independence is encouraged within the range of the resident’s capabilities. Family and friends are encouraged to visit and made to feel very welcome. EVIDENCE: The home employs an activities coordinator who works 25 hours each week. She was on annual leave at the time of the visit, and therefore there were no activities taking place, however residents spoken to said they enjoy the different activities that are provided, and would like activities organised when the activity organiser was on holiday. One resident told how he had become friends with a day care resident; residents receiving respite care spoke of friendships and said they looked forward to their stays at the home. The bar, which was appreciated by the residents, has now closed; residents said how disappointed they were. At the last inspection certain residents spoke of being expected to perform certain household tasks such as serving meals and clearing away tables, this is currently being investigated by the new manager. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 13 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, 17 and 18 Complaints are dealt with appropriately. Overall, service users are protected from abuse with the majority of staff aware of adult protection. Residents are protected and feel safe living in the home. Residents are aware of the complaints procedure and how to use it. EVIDENCE: There has been one complaint received by the home since the last inspection. Documentation reviewed identified it had been appropriately dealt with and responded to in writing. The home has an adequate complaint procedure, which contains the timescales for the completion of the process. The manager told me that voting papers are not sent to the home for respite and short stay residents, and that the three long stay residents are taken to the polling station to vote. Adult Protection training is incorporated into the NVQ training, and the manager said that training was available for all staff. The manager was clearly aware of POVA and the procedure for reporting suspected abuse to the appropriate authorities. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 14 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): All standards. The home is clean, tidy and pleasantly decorated. All service users are given keys to their room. There were no Health and Safety issues identified. EVIDENCE: The majority of the home has been redecorated since the last visit, and one wing had been completely refurbished. The home is now awaiting the fitting of new carpets to corridors. Appropriate laundry facilities are provided and control of infection systems are in place. All residents are given the option of having keys to their room. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 15 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): All standards were reviewed. The numbers and skill mix of staff were sufficient to meet the needs of the service users. There are good recruitment procedures in place to protect service users. The staffing rota now provides an accurate picture of when all staff have worked at the home. EVIDENCE: From looking at staff rotas and from talking to the manager it was identified that there was a shortfall in care provision of 120 hours per week, this included shortfalls in provision of care, domestic cook and administrative personnel. It was identified that a person who has not been provided with adequate training is doing manual handling assessments of residents. (A requirement has been made) At the last inspection it was identified that 75 of the care staff had achieved an NVQ qualification. Since then, three more care staff are due to commence level 2 on the 3rd March 2006. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 16 Recruitment documentation reviewed identified CRB and POVA checks had been undertaken and references had been received prior to the carer commencing work, however, there was neither copy of birth certificate, passport nor marriage licence present in the documentation. Unexplained gaps in employment were also present, and there was no documentation present from the interviewing process. (A requirement has been made) Staff have attended training courses which cover health and safety areas and good care practice; these include medication, slips, trips & falls, person centred care, first aid and fire training. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 17 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, 35, 37 and 38 The home has been well managed by a temporary manager who has stayed on as deputy manager since the recent appointment of a permanent manager. Resident’s personal allowances are now managed appropriately. EVIDENCE: There is now a permanent manager in place in the home who has been in place for two weeks. She must make an application to the Commission, and return the completed application with a check for the correct amount, which is £518 if received before 1st April 2006, or £596 if received on 1st April 2006, or after. She must also obtain a new CRB check. Considering the new manager has only been in post since 13th February 2006, I was impressed by how much information she was able to provide on request for the purpose of the inspection. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 18 The manager told me that she is undertaking a Management in Health and Social Care certificate. She also told me she had three days shadowing during her induction. Residents’ finances are now appropriately handled in separate financial accounts, which are interest bearing. Records seen confirmed this. Health and Safety checks are being carried out at the home and are all up to date with the exception of the checking of the water system for Legionella (Last date seen 7.2.03, and the checking of hot water discharge from wash hand basins which should be done monthly and documented. (Last recorded check 22.1.06) (Requirements have been made) All staff with the exception of the three recently employed staff have received Fire Safety training. Staff are appropriately supervised, and records kept. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 3 3 3 Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 20 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 OP4 Regulation 12 Requirement The registered provider must review service provision to ensure the home has the capacity to meet the assessed needs of service users admitted to the home, and ensure all prospective residents have tgeir needs assesed prior to admission to the home. (Prevoius timescale of September 2005 unmet) The registered provider must ensure service users admitted meet the homes registration category. (Previous timesacle of 31/7/05 unmet) The registered provider must ensure that residents are not placed at risk, and that manual handling risk assessments are done by an appropriately trained person. The registered manager must ensure tissue viability assessments are carried out. (Previous timescale of 31/8/05 unmet) DS0000033608.V280929.R01.S.doc Timescale for action 01/05/06 2 OP3 14 01/05/06 3 OP7 13 (4)(c) 01/05/06 4 OP8 14 01/05/06 Meadowcroft Version 5.1 Page 21 5 OP29 19 6 OP31 9 7 OP38 13 8 OP38 13 The registered provider must ensure that all information required under this regulation, and which can be found in Schedule 2 Care Standards Act is present in all recruitment documentation for the purpose of inspection, and ensure all unexplained gaps in application forms are accounted for. The registered provider must ensure the proposed manager makes an application to the Commission to become the registered manager. The registered provider must ensure that annual checks are undertaken of the water system to rule out the presence of Legionella. The registered provider must ensure that documented checks of all hot water outlets are made regularly to ensure residents are not at risks from scalding. 01/05/06 01/05/06 01/05/06 01/05/06 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 Refer to Standard OP7 OP12 Good Practice Recommendations The use of correction fluid in care documentation should be discouraged. Recreational activities to be provided in the absence of activities coordinator. Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Meadowcroft DS0000033608.V280929.R01.S.doc Version 5.1 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!