Inspection on 24/11/06 for Meadowcroft

This inspection was carried out on 24th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Meadowcroft 09/01/06

Meadowcroft 07/06/05

Meadowcroft 21/10/04

Meadowcroft 23/04/04

Meadowcroft 25/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Meadowcroft Meadowcroft 197-199 Bushbury Lane Bushbury Wolverhampton West Midlands WV10 9TY Lead Inspector Pat Scott Key Unannounced Inspection 24th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Meadowcroft DS0000020895.V297491.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. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadowcroft Address Meadowcroft 197-199 Bushbury Lane Bushbury Wolverhampton West Midlands WV10 9TY 01902 307170 01902 307170 info@sclcare.co.uk www.meadowcroftcare.co.uk SCL Care Limited 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) Pamjit Kaur Badhan Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Females over 60 years and males over 65 years. Date of last inspection 9th January 2006 Brief Description of the Service: The Home is a two-storey, purpose-built care home for older people overlooking Low Hill recreation ground. There is easy access to local amenities, which includes the recreation ground, a church, a library and shops. There are seventeen single bedrooms, sixteen of which have en suite facilities. All the bedrooms are fitted with a staff alarm call system, fire alarm system, secondary lighting telephone points and television aerial points. There are two lounges on the ground floor. On the first floor is an additional lounge with dining area. The Home has a vertical lift in addition to the two internal staircases. There are adequate car parking facilities and the garden is easily accessible and well maintained. Meadowcroft makes its services known to prospective service users in: The Statement of Purpose, service user guide and Company Brochure. The inspection report is available upon request. Fees are reviewed annually and service users are notified one month in advance. The additional charges to service users are clearly laid out in the admission agreement. Fees for Meadowcroft as of 24/11/06 are: £336-356 per person per week. All service users pay monthly in advance by standing order or BACS. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, staff records kept in the home, medication records, discussion with people who use the service, discussions with the staff team, discussion with the manager, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? What they could do better: The manager fully acknowledged the need to amend the service user guide and service user contract to meet the amended Regulations 2006. It must include the current fee levels and state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole, or part, by someone other than the service user. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 6 The statement of terms and conditions also needs to include the fee when a third party is paying in whole or part. Service user facilities must not be used to clean or store items. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 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 DS0000020895.V297491.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Key Standards 1.2.3.4 Prospective residents and their representatives have most of the information required to choose a home which will meet their needs They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: Prospective service users are given the opportunity to spend time in the home. Records show that the staff team are qualified and experienced to work with the needs of the service user. Documentation and training logs show that specialist areas of work have been explored and that staff have access to detailed guidance and training materials. The home provides a statement of purpose that clearly sets out the objectives and philosophy of the service supported by a service user guide that Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 9 summarises the SOP and provides good clear information about the home. The guide gives a good detailed account of the quality of the accommodation, qualifications and experience of staff, how to make a complaint. It does not, however, contain recent CSCI inspection findings or comments and experiences of residents living at the home. But these were found within the outcomes of the quality assurance surveys. Neither does it comply with the changes in the Care Home Regulations as amended in September 2006. Each resident is provided with a statement of terms and conditions prior to moving to the home an example of which was seen. This sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident. It does not include the fee when a third party is paying in whole or part. Admissions are not made to the home until a full needs assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a care management assessment the assessment is always undertaken by a skilled and experienced member of staff. Evidence seen in care files confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the service user. A service user spoken with stated that she was satisfied with the information she and her family had received. She knew how much was to be paid and when it was due. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 7.8.9.10 The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Each service user has a plan that has been agreed with them. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes a risk assessment. Staff have skills and ability to support and encourage service users to be involved in the ongoing development of their plan. The home ensures that each service user’s plan is reviewed regularly and involves the service user and where agreed their family. The plan is updated and the necessary action taken to respond to any changes. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 11 Service users were satisfied with their care and thought the staff knew what they were doing. Service users have right of access to health and remedial services and the home’s policies, procedures and practice guidance strongly support this. The health care needs of those service users too frail to leave the home are managed by visits from local health care services e.g. the district nurse was visiting a service user on the day of inspection. She confirmed that there is good liaison with the home and that staff are knowledgeable about the service users in their care. Service users’ personal aids are well maintained and the home provides the necessary aids and equipment to support both staff and service users in daily living. Service users have individual health care plans that give a comprehensive overview of their general health and acts as an indicator to changing health needs. Residents have the choice to shower or bath when they wish, and are supported and facilitated to be independent in their personal hygiene. The aims and objectives of the home reinforce the importance of treating residents with respect and dignity and these values were seen and heard. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 12.13.14.15 Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: Rotas showed that sufficient staff resources are provided to allow time for activities and stimulation. The home has developed a system for displaying information and bringing attention to community events and activities. The manager stated that although the provision of leisure activities is working well it is an area they are keen to develop. Service users stated that family and friends are made welcome and know they can visit the home at any time. Staff were seen to make time to talk to service users as they were going about their work. The design of the home Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 13 provides seating areas within the communal areas of the home where service users can entertain their visitors, in addition to the privacy of their own room. A care plan seen demonstrated how staff were sensitive to the religious observance of a service user that included his family. The home is able to offer service users information and telephone numbers for contacting independent people who will act as advocates on the service users’ behalf where the service user prefers the help of an independent person. Service users have the choice to bring a limited amount of small goods with them on admission to the home and were seen to keep personal items which are important to them in their own room. Food and mealtimes are something to be looked forward to, as stated by service users. A cook is responsible for providing quality nutritional meals that meet the dietary needs of the service users. Tables were set attractively for lunch with the necessary cutlery and aids to help individuals during their meal. Service users stated they enjoy the food and said they could eat in their own room if they wished. Regular drinks are available and service users commented that staff are willing to make a cup of tea at any time when asked. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 16.18 Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. Service users, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff in charge. The complaints log showed that none had been received so far this year. The policies and procedures regarding protection of residents are in place. Training of staff in the area of protection is regularly arranged by the home. Service users stated that they are very satisfied with the service provision, feel very safe and well supported by staff that have their protection and safety as a priority. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 19.26 The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. They have the choice to bring small personal items of furniture into the home as was seen in those rooms entered. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 16 There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. The ground floor bath contained the fly screens from the kitchen for cleaning by the cook. This is unhygienic and a hazard for service users. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. Staff were seen to wear gloves and aprons at appropriate times. Regular reviews of the premises take place as seen in the reports of the provider’s unannounced visits to the home. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 27.28.29.30 Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. EVIDENCE: Services users commented that they have confidence in the staff that care for them. Management encourage staff members to undertake relevant qualifications and recognise the benefits of a skilled, trained workforce. The service clearly defines the roles and responsibilities of staff through accurate job descriptions. The service ensures that all staff receive relevant training that is focussed on improving outcomes for residents e.g. infection control, dementia awareness, first aid and fire. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. An example of an induction file and training portfolio of a member of staff was seen. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. Three staff recruitment files were seen. NVQ training is high priority with 16 out of 19 staff having level 2. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Key Standards 31.33.35.38 The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by the provider. EVIDENCE: The manager has the required qualifications and experience to run the home. She works to continuously improve services and provide an increased quality of life for service users. The manager is service user focused and leads and supports a strong staff team who have been recruited and trained to a high standard. Service users knew her by name and also the other staff on duty. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 19 Systems are in place to monitor staff adherence to policies and procedures during their practice, e.g. day to day supervision. Management processes ensure that they receive feedback on their work through formal supervision and appraisals. The provider has a good record of meeting relevant health and safety requirements and legislation and conducts its own audit to ensure compliance with policies. Records are of a good standard and are routinely completed. The registered manager together with support from her deputy and the provider has the skills and ability to deliver business planning and provides a quality assurance and monitoring process through service users satisfaction questionnaires and service user three monthly meetings. ‘Stakeholder’ surveys are also conducted to ascertain views of other parties e.g. district nurses, GPs. If they wish and are able to, residents are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. The arrangements are regularly audited by management. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X 3 X X 3 Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(A) Requirement To amend the service user guide to provide the detail required by the amendment Regulations 2006. To include the fee level in the terms and conditions where a service user’s care is funded in whole or in part by someone other than a service user. Timescale for action 24/12/06 2 OP2 5(1)(b) 24/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Meadowcroft DS0000020895.V297491.R01.S.doc Version 5.2 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. 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