Inspection on 06/03/07 for Meadowcroft

This inspection was carried out on 6th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 23/02/06

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 6th March 2007 10:00 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 DS0000033608.V323652.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 DS0000033608.V323652.R01.S.doc Version 5.2 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 Badar Khan Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (2) of places Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23rd February 2006 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 two long stay residents Intermediate care is provided. Care is provided in four wings, each with their own wing manager. Prospective residents and their families can find out all about the home by asking to see the Statement of Purpose and function and service user guide, and by a visit to the home. On the day of the inspection fees charged for personal care provided were between £96:53 and £435:68 per week. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A visit was made on 6th March 2007. The home did not know that the visit was going to happen. Feedback was given to the manager during and at the end of the visit. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents, and to see if any improvements had been made regarding the legal requirements made at the last inspection of which there were 8. Two recommendations were also made Before visiting the home the inspector asked for information from the manager (the pre inspection questionnaire – PIQ) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and other safety checks were carried out and by who, menus used, staff details and training provided. However the PIQ had to be returned because there was not enough detailed information recorded. When the PIQ was returned the second time it was complete with all information asked for. Comment cards were sent to the home to be given to residents, their relatives and other visitors to find out what their views of the home were. At the time of writing this report one relative’s response had been returned. The person returning the comment card indicated they were very pleased with all aspects of care, and said the staff were very kind. In order to find out how well staff knew residents, care plans were looked at during the visit and residents, visitors and staff were spoken to. Other records in the home were looked at such as accident records, health and safety documentation, recruitment documentation and complaints received. At the time of the inspection all requirements and recommendations from the last inspection had been resolved. On the day of the visit a social worker undertaking a degree was on the premises as her placement. What the service does well: The interaction between staff and residents’ was good with a balanced cultural mix within the staff team, which benefits them. The manager has a good knowledge of each resident and uses her professional experience to relate to the people in her care in a relaxed and friendly manner. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 6 Residents’ are treated as individuals and encouraged to maintain their interests and skills for as long as possible. The home provides a secure environment with minimum restriction of movement around the building and garden area. The staff are good at responding properly to residents questions and behaviours. The home provides a good standard of care to residents in a comfortable and well-maintained home. It is decorated and furnished to a good standard. Residents’ said that the home was always clean tidy and did not smell. They said that the food was good. Visitors said that they could visit the home at any time, and that they were made welcome, and were offered refreshments by staff. This makes it a pleasant, comfortable and homely place to live. Relationships between staff and residents’ were warm and friendly. Residents’ said that they were happy with the care provided and that the staff were kind and caring. They said that they could choose how and where to spend to their time and whether or not they want to join in with the planned social activities. The home has an activities organiser and a good range of activities is provided. The activity organiser also spends one to one time with residents talking about their past lives and finding out what they would like to do. Information about the services provided by the home is available in the foyer of the home, and lets residents’ and their relatives decide if the home will be suitable for them. Senior staff visit prospective residents to assess their needs to make sure that the home and staff team will be able to meet them. The manager is very keen on making sure there are no residents admitted to the home with needs the home cannot meet. What has improved since the last inspection? What they could do better: The manager needs to make sure the current practice of hand sluicing soiled laundry stops. This is unsafe practice, creates an aerosol effect and goes against Control of Infection practices. All medication brought into the home by residents be they for respite, rotational or intermediate care must be accounted for and amounts entered Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 7 onto the MAR chart. A new MAR chart should also be started for each separate admission period. The main kitchen needs to be upgraded, and all areas of concern highlighted in the main body of the report needs to have appropriate action taken to ensure the kitchen is a safe place to work and fit for purpose. 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 DS0000033608.V323652.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 DS0000033608.V323652.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6. Quality in these outcomes is excellent. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have enough information about the home to decide if it will meet their needs. EVIDENCE: The Statement of Purpose and function was complete with all information new residents need to help them to decide if they want to come and live at Meadowcroft. Information for residents and visitors is also available in the reception areas and can be posted out on request. Contained in the information was the March newsletter for the home from the new Director of Social Services. She gave very complimentary information about the manager and her deputy who between them have a wealth of experience backed by certificated management training. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 10 Only permanent residents, of whom there are only two, have contracts of residence. The manager said it was not suitable for short stay; respite care and intermediate care residents to have contracts arranged, because they do not stay long enough at the home for contractual arrangement to be agreed. All residents, be they short term, rehabilitation, intermediate or respite care have their care needs fully assessed by the manager before being admitted. The manager also gets information from other professionals such as Social workers, physiotherapists and the primary care trusts. These assessments were seen in care documentation chosen for case tracking and review. Residents spoken to during the visit also said the manager had visited them at home. Trial visits are not implemented, as there are only two permanent residents living in the home. It is thought that for the short term the home will only provide respite, rotational, and short stay care. In the long term it is thought the home will provide only intermediate care, with 5-day care places. All intermediate care residents have their care provided by a team of physiotherapists, and occupational therapists. There is a gymnasium fully equipped for their use so that their recovery is helped. There are no unsuitable admissions made to the home. This was evidenced by the manager providing me with copies of pre admission assessments she and the senior members of staff had done as proof that inappropriate admissions are not made to the home. This is evidence of good practice. Meadowcroft DS0000033608.V323652.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in these outcomes is good. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are met and their privacy is respected. EVIDENCE: I looked at and case tracked three sets of care documentation. The health care needs of the residents’ are met and care plans provide clear and detailed instructions for the staff to follow. The care files were consistent in layout making it easy to find information, and with all risk assessment dated and signed. The home has effective systems in place to make sure the care plans are reviewed and updated monthly. Additional reviews are arranged when necessary. The manager also arranges for annual reviews of the residents care to be done. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 12 Each set of care documentation was complete with a pen picture, which gave good insight into what the resident was like before they needed to come into care, and what important events had happened in their lifetime. This provides the staff with information of what to talk about to the residents when they spend one to one leisure time with them. This important information is obtained from the resident if possible, but if not, from the relatives. This makes the residents feel secure in the fact that they are being cared for by staff who have taken the time to get to know them. This is evidence of good practice. All necessary risk assessment were in place where a risk had been identified and the care plans ran alongside them. Residents’ healthcare needs are fully met, and this was evidenced by proof of dental, optical and chiropody care in the care file. I reviewed the medication system. The home has a drug room especially for the safe storage of all the medication. There are no controlled medications in use, although the home has a controlled drug cupboard for safe storage should the need arise. Because of the type of care provided for in the home, the current systems in use(of which there are five) are what each individual brings into the home on the day of admission. These are, the Lloyds heat-sealed blister pack system. The Nomad cassette system (which is tamper evident.) The Boots Manrex heat-sealed blister pack system. The advantage heat-sealed blister pack system, and the bottle to resident system. I reviewed the medication system. The home has a drug room especially for the safe storage of all the medication. There are no controlled medications in use, although the home has a controlled drug cupboard for safe storage should the need arise. Because of the type of care provided for in the home, the current systems in use (of which there are five) are what each individual brings into the home on the day of admission. These are, the Lloyds heat-sealed blister pack system. The Nomad cassette system (which is tamper evident.) The Boots Manrex heat-sealed blister pack system. The advantage heat-sealed blister pack system, and the bottle to resident system. These are all pre packed and prepared for each individual by their own chemist. Considering the complexities of the five systems in use, safe practices are in place. The manager said there are usually five residents at any one time who handle their own medication. These residents have risk assessments done to make sure they are capable of handling their own drugs, and the risk assessments are signed in agreement by the resident. The home has a self-medication policy. The manager said there are usually five residents at any one time who handle their own medication. These residents have risk assessments done to make sure they are capable of handling their own drugs, and the risk assessments are signed in agreement by the resident. There was only one occasion when amounts of two medications were not recorded on admission. New MAR charts Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 13 are also not started for each admission, and this is recommended. Otherwise the system is safe with all staff involved in the dispensing of medicines having had training in the safe handling of medicines On speaking to the residents during the tour of the building, it was clear that the staff treat them with respect and respect their privacy. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14, and 15. Quality in these outcomes is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a good range of social activities; they are helped to exercise choice and control over their daily lives and to maintain contact with family and friends. EVIDENCE: A good level of interaction was seen throughout the day between residents and staff. Overall, the group of people in the home is quite mobile and individuals were seen to move freely about the home. Some people were in their rooms and several residents were in the dining room next to the kitchen talking, and in the lounges watching TV. The home enjoys the services of an activity organiser, and there were care plans for social and recreational activities for each person. On the day of the visit the residents were playing bingo in the dining room near to the kitchen. If individuals are not joining in with group sessions she will see them in their rooms and find out what they want to do. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 15 She keeps a record of what activities individuals have joined in with. She has also photographed all the staff and displayed them for all the residents to see at the entrance to each wing. This helps the resident to get to know who is who. Relatives were visiting the home at the time of the visit and said they are always made welcome by the staff and could visit at any reasonable time. Residents spoken to during the tour of the building said they could get up and go to bed when they wanted, and that they could please themselves what they did during the day, although one gentleman receiving respite care said “there’s not much amusement and I get bored” but he also said he hadn’t any grumbles, that the home was pretty good, that the staff were too good, that he couldn’t grumble about the food as it was like home cooking, and that he feels much better than when he arrived at Meadowcroft. One lady resident who was receiving respite care told me she has her spells of respite care every 2 months for one or two weeks. She said,” this place is second to none it’s the tops. I didn’t think I would enjoy it but I look forward to coming now. The staff are very involved. The food is beautiful, plenty of choice. I give the home top marks.” I looked at the menus when I visited the kitchen. Meals are all home cooked with a good variety of choice. Residents said there was always something you could have if you didn’t fancy what was the main choice of the day. There was also evidence that fresh vegetables are used, and fresh fruit is provided. Meals are taken in the dining areas of the home, but residents can also eat in the privacy of their own rooms if they want. Meals are discussed at residents meetings and residents can make suggestions for different meal ideas. Special diets can be catered for such as for people who are diabetics. The cook, who is qualifies to NVQ Level 2 in catering said he was aware of ways of enriching food and meals for people who had lost or were at risk of losing weight. The kitchen was very clean, tidy and well organised, however there are problems with the environment. There are door fronts missing near the waste disposal unit. The wood of the unit itself has rotted and smells. The waste disposal unit has no guard over the mechanism, and the door to the motor for the unit is missing. This is a hazard, as water and electricity do not mix. I was told, when the cooker hood metal doors are open the kitchen is open to the elements, the sky is clearly visible, and it rains in onto the cooker. To the left of the main kitchen doors when you enter the kitchen is a wooden cupboard that contains emergency cut off valves. There is a hole in the concrete floor. I was told that when it is very windy outside, dust constantly blows into the kitchen. This represents a health hazard as vermin could enter the kitchen. Immediate attempts must be made to rectify it. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 16 These concerns were told to the manager at the end of the inspection. She said that money had been set-aside in the capital expenditure for this year, and she is waiting for a start date for work to begin that will rectify all concerns. She said she was aware of the problem with the waste disposal sink; but that she was not aware of the other problems identified and said she would see they were dealt with. The cook showed me all the records he keeps, and these were all in order. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 17 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel safe and can be confident any complaints will be taken seriously. EVIDENCE: The complaints procedure is displayed in the front entrance to the home. It is clear and easy to follow. Information from residents and their visitors was that they knew who to speak to if they had any concerns. Information in the Pre Inspection Questionnaire said that there have been two complaints since the last inspection, one of which was partially substantiated, and one, which is as yet unresolved. . Records seen showed that these had been thoroughly investigated, and that the complainant was satisfied with the written response they received. There have been no Adult Protection issues about the home. Adult Protection policies and procedures are in place at the home, and the home had the Local Authority Multi Agency policy document “No Secrets”. The majority of staff has had training on Abuse Awareness. Staff spoken to said they knew how to recognise abuse and would report back to the person in charge if they needed to. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 18 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): All standards were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is clean, tidy, well maintained and suitable for their needs. EVIDENCE: Meadowcroft is purpose built. The home is divided into four wings, each with its own wing manager, and care is provided on the ground floor. It provides care in 30 single and two double rooms. None of the rooms have ensuite facilities. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 19 Parkview – Is a seven-bed unit and caters for the two long stay residents and five residents who are receiving short stay care. There is a lounge with television and music centre. There is an assisted bathroom and disabled WC. The seated weigh scales which have had a risk assessment done on them are kept in this bathroom There is also an activity kitchen on this wing. This is provided so that residents who are receiving intermediate care can have kitchen assessments done, and can be assessed as being safe to undertake simple household tasks, such as making a sandwich, or cup of tea, or being competent at washing up, before they go home. Glenview – Is an 8-bed unit providing care for respite and short stay residents. It has a dining room that seats 8. A lounge with television video and music centre and a conservatory with a patio and rural outlook where the residents can sit during nice weather. Bathing facilities and a WC are also provided. Highview – Is an 8-bed unit with 2 interim care beds, 2 assessment beds and four respite care beds. It also has a lounge with TV video and music centre. Bathing facilities and a disabled WC. This wing is also the designated smoking area for the home. Woodview – Is a nine-bed unit specifically for rehabilitation purposes. It has a dining room that seats twelve people. A TV lounge with video and music centre, and a fully equipped gymnasium to enhance recovery. All bedrooms in the home have washing facilities and televisions. Information in the PIQ stated all the kitchens have been refurbished and fully decorated, and the home as a unit has been redecorated. The home is kept clean by a team of domestic staff. All areas of the home were very clean, tidy and fresh smelling with no unpleasant odours. Many of the rooms were bright and airy. Many areas of the home were seen, and it was evident that those residents who are cared for permanently, have made their rooms look very homely, with small items of furniture, wall pictures and family ‘photos. Some of the other rooms were however quite bare. There is no dedicated laundry person. All the care staff tend to do the laundering of bed linen and personal laundry of the residents. The laundry area was clean and tidy. The carer in the laundry was wearing protective clothing and gloves, and red dispersible bags are used for the soiled laundry, however she told me that hand sluicing of soiled linen is carried out. This is unsafe practice as it creates an aerosol effect, creating the potential for cross infection to occur, and negates infection control policies and procedures. Four ceiling tiles need replacing in this area, however the manager said she was already aware of this and was waiting for the work to be done. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 20 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): All standards were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the homes recruitment policy and practices EVIDENCE: Two sets of recruitment documentation were looked at. The procedure is good and protects the residents, and included a full induction training record. Duty rotes for two weeks were sent with the Pre Inspection Questionnaire. These showed there was enough staff on duty to adequately provide for the needs and any special needs of the residents. This was true on the day of the visit. There are still some staff vacancies mainly on night duty, however these shifts are filled by the homes own care staff and agency. There is a cultural mix of staff employed so that the cultural needs of the residents can be met. The manager also continues to attend the Intermediate care management meetings. Training is a high priority within the organisation with all the care staff with the exception of two being qualified to N VQ Level 2., and all staff have the Basic Food Hygiene Certificate. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 21 Information in the PIQ said the following training had taken place. Fire Safety Training, safe handling of medication, slips trips and falls, Person centred care. Excel 1 & 2 and Microsoft outlook. Managing complaints. NVQ 3 promoting independence. Pre admission assessment. Assertiveness. Managing Health and Social Care. Basic food hygiene. Cultural awareness. Care planning and foot care. Training planned for the future includes an MSC in Diversity Management. NVQ Level 4 for four staff. On going NVQ 3 training. Common Induction Standards for new staff. Moving and Handling updates. Health and Safety Awareness. Seated exercise for Older People. Medication training. Falls risk assessment training, and risk assessment updates. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35, 36, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed and run in the best interests of residents. EVIDENCE: The manager has the skills and experience to manage the home. Residents’ benefit from her good knowledge of their needs and she tries to pass this on to staff by example, at handover meetings and staff meetings. The proprietors of the home offer good management support in the form of Principal Unit Managers who are responsible for providing the support and any advice the managers might need. Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 23 I saw records of income and expenditure on behalf of residents’, these were satisfactory. The home is managed and run by Bradford Metropolitan District Council, and it is therefore reasonable to assume that the residents are safeguarded by the Financial and Accounting systems in place. Residents meetings are held and any suggestions to improve services are taken on board. Staff meetings are also held and minutes were seen of these. The manager said that she meets with staff all the time as part of the working day, and regular informal meetings are held to discuss any issues that might arise, i.e. changes in the home or with residents needs. The manager said that staff supervision is provided six times a year and staff I spoke to during the visit confirmed this. She said that informal staff supervision is provided much more often by her and the wing managers. On the day of the visit the Principal Unit Manager for the home arrived to give all the staff some important information. All Health and Safety checks are carried out annually, and there was evidence to support these. There is also an in depth risk assessment of the building. Meadowcroft DS0000033608.V323652.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 4 3 3 X 3 4 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 2 3 3 4 3 3 3 2 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 3 X 3 Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The registered provider must a. Ensure all medications brought into the home are counted and recorded on the MAR chart. And b. That a new MAR chart is used each time a resident is admitted to the home. The registered provider must ensure all parts of the home are kept in a good state of repair. (With particular regard to the main kitchen) The registered provider must ensure the unsafe practice of hand sluicing soiled linen stops. This negates infection control policies and procedures. Timescale for action 01/07/07 2. OP19 13(4) 23(2) 01/09/07 3. OP26 13 (3) 01/06/07 Meadowcroft DS0000033608.V323652.R01.S.doc Version 5.2 Page 26 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 DS0000033608.V323652.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000033608.V323652.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. 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