Inspection on 04/12/06 for Meadowcroft

This inspection was carried out on 4th December 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 23/01/06

Meadowcroft 05/09/05

Meadowcroft 04/01/05

Meadowcroft 31/08/04

Meadowcroft 11/03/04

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

CARE HOMES FOR OLDER PEOPLE Meadowcroft 304 Spital Road Bromborough Wirral CH62 2DE Lead Inspector Inger Moynihan Key Unannounced Inspection 4th December 2006 09:00 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 DS0000035960.V307761.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 DS0000035960.V307761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadowcroft Address 304 Spital Road Bromborough Wirral CH62 2DE 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) 0151 334 6325 Metropolitan Borough of Wirral Miss Sheila Hardie Care Home 23 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (17) of places Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 23rd January 2006 Date of last inspection Brief Description of the Service: Meadowcroft is a registered care home providing 24-hour personal care and accommodation for younger and older people who suffer from dementia. The home is owned and managed by Wirral Social Services which is a part of Wirral Borough Council. The home is located close to Bromborough town centre which has a selection of shops, pubs, a post office and other town amenities. There are public transport links close to the home which give access to Birkenhead and other parts of the Wirral. Meadowcroft is a single storey purpose built home. All bedrooms are single occupancy with en-suite facilities. The rooms are bright and spacious with emergency call points fitted. Specialist bathing facilities are provided in spacious bathrooms. There are two lounges as well as a separate lounge for service users who wish to smoke. There is also a large conservatory overlooking an inner courtyard. The home is well furnished throughout. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information about Meadowcroft care home was obtained through a preinspection questionnaire and discussion with the Registered Manager and members of the staff team. Policies, procedures and supporting documentation were looked at along with a selection of service users’ case files. Service users carers were spoken to during the visit for the purpose of obtaining their views on the standard of the service . A part of the inspection process includes sending questionnaires to service users carers and health care professionals in order to obtain their views on the standard of the service provided. Comments made in these questionnaires are included in the report and contribute to the basis of any judgments made. The CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘Experts by Experience’ are an important part of the inspection team and help Inspectors get a picture of what it is like to live in or use a social care service. The term ‘Experts by Experience’ used in this report describes people who have been appointed by Help the Aged, under the direction of the Commission for Social Care Inspection, to take part in the inspection of services for older people. Charges for the service provided at Meadowcroft - £342.65 p/w What the service does well: Service users only move into the home after their needs have been assessed and they have been assured these needs will be met. The Expert by Experience reported that she found the standard of service provision to be very high commenting I noticed staff being attentive towards the service users and offering reassurance where appropriate. Nine questionnaires were returned to the CSCI from service users carers. All of the questionnaires indicated the care staff welcome them into the home at all times and they are kept informed and consulted on important matters affecting their relative. One of the comments made in a questionnaire said the staff are lovely people and give excellent care to my wife. I could not wish for better care. Staff take responsibility for service users medication to ensure their safety and welfare. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 6 The Expert by Experience observed the lunch being served and commented at the time how well the staff attend to service users needs. The carers spoken to during the visit commented on the kind and caring nature of the staff team. One relative commented the staff are excellent, they are always very patient and very kind. None of the carers had any concerns to raise about the way their relatives were being looked after. Service users friends and relatives can visit the home at any time to ensure they can maintain friendships and family contact. Service users are encouraged and helped to make decisions for themselves to maintain their independence. A complaint procedure is in place to ensure service users and carers views and opinions are listened to and acted upon appropriately. Systems are in place to ensure service users are safeguarded from abuse. The standard of the environment remains very high and provides service users with a comfortable place to live. The Expert by Experience reported I found the environment very relaxed and friendly, clean and orderly with staff going about their business in a professional way. Service users needs are met by appropriate staffing levels. The staff recruitment procedure ensures suitably qualified and competent staff are employed. Service users live in a home which is run for their best interests. safety and welfare of service users and staff are promoted. The health, Staff spoken to during the visit confirmed they enjoyed their work and felt well supported in their role Five questionnaires were returned to the CSCI from health care professionals. All of the questionnaires indicated the home works in partnership with them and staff demonstrate a clear understanding of service users care needs. All of the questionnaires indicated they had never received any complaints about the standard of service provision. What has improved since the last inspection? Improvements have been made to the assessment and medication administration procedures and further training has been provided to staff. This further improves service provision. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 7 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 DS0000035960.V307761.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users only move into the home after their needs are assessed and they have been assured these needs will be met. EVIDENCE: Service users care needs are assessed before they move into the home. The Registered Manager identified in the pre inspection questionnaire that improvements had been made to the initial assessment process to ensure service users care needs are continually met. Service users carers and relevant health care professionals contribute to the assessment process to ensure the staff team have the necessary information on how to look after the service user in accordance with their particular requirements. Issues of equality and diversity are addressed during the assessment process. The staff spoken to during the visit confirmed they had access to this information to support them within their role. Three of the service users carers were spoken Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 10 to during the visit. They all commented on the kind and caring nature of the staff team and stated their relatives were well cared for. Intermediate care is not provided at Meadowcroft care home. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although service users health care needs are set out in an individual plan of care, some improvements need to be made to the supporting documentation to ensure staff have the necessary information on how to look after the service users properly. Staff take responsibility for service users medication to ensure their safety and welfare. EVIDENCE: Service users health care needs are documented into a plan of care which covers a range of appropriate issues. Staff monitor and record details of service users general welfare and visits made by health care professionals. Issues of equality and diversity are addressed during the care planning process. Risk assessments have been completed in relation to specific aspects of care provision to ensure service users safety and welfare. Guidance is in place to support the staff in this aspect of care provision. Minimal information had been collated during the review process and in some instances the information recorded by staff in the daily diary sheets did not Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 12 correspond to that identified in the care plan. Some risk assessments relating to service users health care needs such as behaviours and pain levels etc had not been recorded in sufficient detail to allow staff to provide the appropriate level of care. The issue of poor record keeping in relation to the care plans has been raised at the last four inspections and while it is acknowledged that improvements have been made, the Registered Manager must ensure the staff are more vigilant in the recording of information about the service users care needs. It is only by doing this can the staff team ensure the service users receive the care they need and important aspects of their care needs are not missed which may leave them vulnerable to the risk of harm. Documentation was in place to demonstrate the staff had acted appropriately in the event of an accident or a service user becoming unwell. Staff take responsibility for the administration of service users medication to ensure their safety and welfare. The records inspected were accurately maintained and appropriate storage facilities were in place. Only senior trained staff are allowed to administer medication. Nine questionnaires were returned to the CSCI from service users carers. All of the questionnaires indicated the care staff welcome them into the home at any time and they are always kept informed and consulted on important matters affecting their relative. They noted there were always sufficient staff on duty and they had no reason to make a complaint. All questionnaires indicated the carers were satisfied with the overall care provided. One carer had recorded in their questionnaire I am very pleased with the home and treatment of our mother by staff. Restaurant/dining room excellent. Manager always available for advice and help. Another carer stated the staff are lovely people and give excellent care to my wife. I could not wish for better care. One query was raised in relation to whether a health care issue could be managed by the staff team. The Registered Manager agreed to address this issue. The Expert by Experience reported that she found the standard of service provision to be very high commenting I noticed staff being attentive towards the service users and offering reassurance where appropriate. It would certainly appear from the comments made above that staff treat service users with respect in all aspects of care provision. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Improvements need to be made to the social activities provided to ensure service users have a stimulating environment in which to live. Service users friends and relatives can visit the home at any time to ensure they can maintain friendships and family contact. Service users are encouraged and helped to make decisions for themselves to ensure they can maintain their independence. EVIDENCE: A range of social activities are provided which include beauty therapy, listening to music and gentle exercises etc. The Registered Manager had already identified in the pre inspection questionnaire that improvements need to be made to this aspect of care provision to ensure a more stimulating environment is provided and to prevent service users from becoming bored. The Registered Manager particularly identified the need for more outings and entertainments outside of the home. The Expert by Experience gave the Registered Manager useful information about this aspect of care provision and highlighted the need for specialist training to be undertaken to ensure the activities are appropriate to people with dementia and Alzheimers disease. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 14 Preparations were being made for the Christmas festivities which will include carol singers and a Christmas party which will involve service users carers. Service users relatives confirmed they could visit the home at any time and were always made welcome by the staff team. This ensures service users friendships and family relationships can be maintained. Although staff help service users make decisions, they also encourage them to maintain as much independence and control within their own lives. Lunchtime was observed during the visit. The mealtime was relaxed and staff were attentive to service users needs. A choice of meal and drinks was offered to service users. The cook is informed of service users dietary needs and regular drinks are provided throughout the day. The Expert by Experience observed the lunch being served and commented at the time how attentive staff were to service users needs. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 15 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 and 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A complaints procedure is in place to ensure service users and their carers views and opinions are listened to and acted upon appropriately. Systems are in place to ensure service users are safeguarded from abuse. EVIDENCE: Service users and carers can voice their concerns and complaints through the homes complaint procedure. A number of carers were spoken to during the visit. They said they were very happy with the standard of care their relative received and they had no complaints to make. The staff spoken to during the visit confirmed they knew what action to take in the event of them receiving a complaint. The CSCI has not received any complaints about the service provided at Meadowcroft. Systems are in place to ensure service users are safeguarded from abuse and neglect. A copy of the Wirral adult protection procedure is in place along with supporting documentation which staff can refer to when necessary. A rolling programme of staff training in place in relation to this issue. Most of the staff have completed this training and arrangements have been made for the ancillary and newly appointed staff to complete this training within the near future. This aspect of care provision is included in the in-house induction training programme. The staff spoken to during the visit demonstrated a basic understanding of this issue and were clear on the action they should take in the event of them suspecting a knowing an incident of abuse had occurred. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 16 Service users carers commented on the kind and caring nature of the staff team. One relative commented the staff are excellent, they are always very patient and very kind. None of the carers had any concerns to raise about the way their relatives were being looked after. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The standard of the environment remains very high and provides service users with a comfortable place to live. EVIDENCE: The standard of the decoration in Meadowcroft remains very high and provides the service users with a very comfortable and attractive environment. The communal areas had been decorated for Christmas and the home looked particularly festive. All bedrooms are single occupancy with en suite facilities which ensures service users privacy. A range of equipment is provided to assist service users with their bathing and mobility. All parts of the home are kept clean and tidy. The bathrooms are functional but rather clinical in appearance. They lack homely touches such as curtains, additional furniture and other decoration. As Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 18 Meadowcroft now serves as service users own home, steps should be taken to make these areas more homely. This will enable staff to create a more relaxing atmosphere for service users when they are having a bath. In order that service users can wander around the inside of the home, all doors had been left open with the exception of two. These doors were very difficult to open and may prevent a service user from wandering freely. The Registered Manager agreed to address this issue. An efficient laundry system is in place which means service users clothes are taken care of and not mixed up with other peoples clothes. To ensure service user safety, the laundry/sluice room must be kept locked at all times and toiletries must always be kept locked away. The Expert by Experience reported I found the environment very relaxed and friendly, clean and orderly with staff going about their business in a professional way. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users needs are met by appropriate staffing levels. The staff recruitment procedure ensures suitable qualified and competent staff are employed. EVIDENCE: There are currently 23 service users living at Meadowcroft. The staffing levels are appropriate for this number with additional staff being provided at busy times of the day. Sufficient ancillary staff are provided to ensure the building is kept clean and tidy and nutritious meals are provided. The Wirral Social Services is proactive in providing staff with appropriate training to ensure they know how to care for the service uses properly. A training programme specific to the home has not been drawn up, rather the staff tap into the training provided by the training department. In the light of Meadowcroft being a specialist care unit, the Registered Manager must identify the staff training needs and request in advance the training that is necessary for the care of the service users who have complex needs. All staff have completed training in relation to dementia care earlier this year. It was agreed with the Responsible Individual that this training would become mandatory rather than it having to be requested as was the case in the past. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 20 Training in relation to equality and diversity is currently being planned for the whole staff team. The staff recruitment procedures are thorough and all staff spoken to during the visit confirmed they had completed a Criminal Record Bureau check to ensure they are suitable to work with vulnerable adults. The recruitment procedures are based on equal opportunities and issues of equality and diversity are explicitly addressed. Most of the information relating to staff was held at the Social Services head office. Staff spoken to during the visit confirmed they enjoyed their work and felt well supported in their role. They confirmed they met with a senior member of staff regularly to discuss their training needs and their personal development within their role. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 37 and 38 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users live in a home which is run for their best interests. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted. EVIDENCE: The Registered Manager is qualified, competent and experienced to run the home for its stated purpose. She has undertaken training for her own personal development and the improvement of the service. There are clear lines of accountability within the home. Meadowcroft is run for service users best interests. Quality assurance systems are in place to ensure the ongoing efficient and effective running of the home. This includes monitoring staff, reviewing administrative systems Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 22 and ensuring the protection and welfare of the service users. The Responsible Individual will also carry out a monthly check to ensure the home is running smoothly and the service users are being cared for properly. The pre inspection questionnaire identified that improvements need to be made to the quality assurance system by reviewing the homes existing carers questionnaire for the purpose of improving communication with service users families. The Registered Manager is also planning a series of events to establish contact with families and friends of service users. The Registered Manager does not routinely take responsibility for service users finances as this is handled by their carers. However with carers agreement she does take on this responsibility for a couple of service users. A selection of financial records were looked at and found to be accurately maintained. It was recommended that a more regular check is carried out on all financial transactions to ensure service users receive the money they are entitled to. Five questionnaires were returned to the CSCI from health care professionals. All of the questionnaires indicated the home works in partnership with them and staff demonstrate a clear understanding of service users care needs. All of the questionnaires indicated they had not received any complaints about the standard of service provision. The staff at Meadowcroft have set up an amenity fund which is used to buy additional luxury items for the service users. A record of all transactions had been kept with the records being audited annually by an external private accountant. The management of the amenity fund was primarily taken on by the Deputy Manager with the Registered Manager having little input into any financial dealings. Staff spoken to the during the visit confirmed they had access a range of policies and procedures to support them within their role. The policy on equality and diversity was looked at during the visit. This policy outlined how the Wirral Social Services was committed to promoting equality and diversity in all areas of work and outlined staffs responsibilities with regard to addressing this issue. A serious concern arose however in relation to the information given about Sexual Orientation. This read Sexual orientation includes orientation towards the same sex, the opposite sex or both sexes. The Regulations do not extend to sexual preferences such as paedophilia or sado masochism. The link between sexual orientation and paedophilia is offensive, factually incorrect and unacceptable. This information therefore goes against the ethos of the organisation. The Registered Person must ensure this policy is changed to reflect the ethos of the organisation and the Care Homes Regulations 2001 which states the home must be run in a way that respects the dignity of the service users. Systems are in place to ensure service users health, safety and welfare are promoted through staff training and supporting policies and procedures. Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 23 Regular health and safety checks are carried out to ensure staff and service users safety. All accidents are monitored with a risk assessment being completed after each incident to prevent further risk of harm Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 24 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x 3 3 Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Person is required to ensure the care plans are an accurate reflection of service users care needs. Detailed information must be recorded during the review process (previous timescale of 01/03/06 not met) The Registered Person is required to ensure a management plan is included as part of the care plan for any service user who presents with complex or challenging behaviours (previous timescale of 01/03/06 not met) The Registered Person is required to ensure staff are provided with training on record keeping and care planning. In this instance the Registered Person must write to the CSCI and inform the Inspector of when this issue will be addressed. The Registered Person is DS0000035960.V307761.R01.S.doc Timescale for action 04/01/07 2. OP7 15 04/01/07 3. OP7 18 04/01/07 4. OP12 16 04/01/07 Version 5.2 Page 26 Meadowcroft required to ensure more varied social activities are provided to service users to ensure a stimulating environment is provided and to prevent service users from becoming bored. 5. OP19 13 The Registered Person is required to promote service users safety and welfare by ensuring the laundry/sluice room door is kept locked at all times. The Registered Person is required to identify the staffs training needs and compile a training programme to reflect the complex nature of the service user group. The Registered Person is required to ensure service users financial records are checked more regularly. The Registered Person is required to ensure the policy on equality and diversity is changed to reflect accurately the ethos of the organisation and good practice. 04/12/06 6. OP30 18 04/01/07 7. OP33 15 04/12/06 8. OP33 18 04/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Meadowcroft DS0000035960.V307761.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 DS0000035960.V307761.R01.S.doc Version 5.2 Page 28 - 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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