Inspection on 07/06/05 for Meadowcroft

This inspection was carried out on 7th June 2005.

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 24/11/06

Meadowcroft 09/01/06

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 197-199 Bushbury Lane Bushbury Wolverhampton WV10 9TY Lead Inspector Bhag Jassal Announced 7 June 2005 09:00 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Meadowcroft Address 197-199 Bushbury Lane, Bushbury, Wolverhampton, WV10 9TY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 370170 01902 370170 info@sclcare.co.uk SCL Care Limited Mrs Yvonne Farrington Older People 17 Category(ies) of Old Age (17) registration, with number of places Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Females over 60 years and males over 65 years. Date of last inspection 23.01.2005 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, one of which is specifically designated as a smoking lounge. 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. Externally and internally, the Home appears to be in good decorative order. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 9.00 am, and lasted 8 hours and 15 minutes. 15 places were occupied and two beds remain vacant. The inspection included discussions with service users, staff, relatives/friends and other professionals. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities was also undertaken. What the service does well: What has improved since the last inspection? The home has implemented a programme of social and leisure activities for the service users and appropriate records maintained. The senior carers have completed training in safe handling of medication. The NVQ Level 2/3 and safe working practice topics training programme is being implemented. All staff has been CRB and POVA checked. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 6 The home has continued to redecorate bedrooms and where needed carpets have been replaced and/or professionally cleaned. The home has implemented its Quality Assurance system in which the views of service users and their relatives have been sought and the home is to undertake similar exercise with other stakeholders – i.e. professionals. All the recommendations contained in the Fire Safety Officer’s inspection report dated 14 October 2004 have been implemented. A suitable thermostat has been fitted to the hot water outlet in the kitchen for safe use of kitchen staff. 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 E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 The home has a comprehensive admission procedure providing effective needs assessment and suitability evaluation for both privately funded service users and those placed by the Local Authorities. EVIDENCE: A sample of four service users’ care plans and files were seen at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The acting care manager also carryout assessments and these details are documented on care plans, which are drawn up by the senior staff with the assistance from the service users and their relatives. There was evidence to show that all the service users have been provided with contracts. The home has a good admission procedure, which is made available to all prospective service users and their relatives/representatives. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Staff are aware and sensitive to the needs of each service user and meet these needs in a professional manner. There is a clear and consistent care planning system in place, which provides the information they require to meet the service users’ health and personal care needs. Lack of accredited training in safe handling of medication by care staff potentially could place service users at risk. EVIDENCE: There was evidence to show all the service uses undergo a comprehensive assessment of their needs prior to admission to the home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans are implemented. Four service users’ care plans were examined and these were kept up to date and reviewed on a monthly basis. The daily care recording format was also examined and the acting care manager stated that the care staff would be asked to make detailed records of the care received by the service users. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 10 The home maintains records of all health checks carried out by the doctors, opticians, dentists, district nurses and chiropodists. The home also ensures that nutritional screening is undertaken, including weight gain or loss records are maintained and appropriate action is taken if required. Case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought. It was observed on the day of inspection that no personal care interventions were taken in communal areas. In addition, consultations with health and social care professionals are carried out within the service users’ bedrooms. The Inspector spoke at some length with ten service users and all of them commented positively about their care and they felt that they have every thing that they need. Several service users stated that “the carers are very good and and kind as well and they look after us very well”. Three other service users said that the carers are always there to help. The Registered Provider stated that four senior members of staff who are responsible for safe handling of medication have completed the training in safe handling of medication. The other carers are still to undergo this mode of training and they are being enrolled to receive this training shortly. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, and 15 Meadowcroft provides a good quality of care and promotes individual lifestyles for the service users in residence. The service users maintain contact where they wish with family, friends and the local community. Meals at Meadowcroft are of a good homely type offering both choice and variety and careering for special needs. EVIDENCE: There was evidence to show that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation – social and leisure activities and cultural interests. Records of activities enjoyed by the service users are maintained. All the service spoken to stated that they are in touch regularly with their friends and family members and spoke about their visitors and of “ entertaining” them throughout their daily routine. The visitors’ book showed considerable activity. Relatives of one of the service users stated that they visit at various times of the day as they wish. All the relatives and friends who spoke to the Inspector said they are given a warm and friendly welcome by the staff whenever they visit. The service users also keep contacts with the local community facilities – i.e. church services, local shops and park. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 12 There was evidence to show that the home provided a varied, wholesome, and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. The Registered Provider stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector “the food was very nice”. Two relatives of the service users also stated that the food was very good offering a good variety. The cook is to continue to keep daily detailed records of food received by the service users. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Concerns or complaints are dealt with promptly and professionally. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a complaints procedure, which is referred to for information in the Service Users’ Guide. There is a satisfactory system of recording complaints. It was noted that that there was only one complaint directed to the Commission for Social Care Inspection within the previous 12 months. All the issues arising from the above complaint were addressed immediately and appropriately by the Registered Provider. The service users spoken to by the Inspector stated that their views are always listened to by the staff and the owner – Mr.Tank. The home has a good policy and procedure in place with regard to the protection of service users from abuse. The Registered Provider stated that the staff has been made aware of the adult abuse and protection issues. The staff also has received induction and formal training on these issues. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24, 25 and 26 The general standard of the environment is good providing service users with a homely place to live. The high standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has ample communal space – lounges and dining areas. The home is safe and is suitable for its purpose. The home has a rolling programme of redecoration to maintain good standard. The garden and grounds are also being well maintained. There are adequate toilets and washing facilities and maintained in working order. The home has undertaken an assessment of the premises and facilities by an occupational therapist. The home has also provided suitable aids and adaptations in the home to meet the appropriate needs of all the service users. There is reasonable standard of furniture and fittings provided in the service users’ bedrooms. It was also noted that the bedrooms have personalised by Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 15 the service users. However, the carpets in bedroom 1 and 9 must be replaced. The required level of hot water temperature is maintained in all hot water outlets. During the inspection the home was found to be reasonably clean, tidy and free from any unpleasant odours. The home has good policies and procedures regarding infection control, and several members of staff have received training in infection control. The acting care manager stated that all stag have received induction training in infection control and they are also made aware of the dangers of cross infection. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The home is adequately at all times, which ensures the quality of care provided, and ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has satisfactory staff recruitment policies and procedures. EVIDENCE: The information provided by the home and the available staff rotas showed that the home is now adequately staffed to care for 15 service users. It was noted that several members of staff have completed their NVQ level 2 qualification, and four carers are currently undertaking their NVQ level 2 and two doing their NVQ level 3 training. The Registered Provider stated that the remaining carers would enrol shortly to undergo this mode of training. It was also evidenced that several members of staff have completed their safe working practice topics training and those who have not yet received this training must do so as a matter of priority, including in dementia and adult protection from all forms of abuse. Discussion with the Registered Provider and the acting care manager and examination of the most recently recruited staff files demonstrated that thorough recruitment procedures had been followed in line with the home’s recruitment policy. Two written references and enhanced CRB and POVA checks are being undertaken before new staff actually commences their duty. The Registered Provider is aware that any member of staff with criminal Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 17 records would not be employed in accordance with the Department of Health Guidance issued in July 2004. The home has introduced the TOPSS induction and foundation training for all new members of staff. The Registered Provider also should consider providing training courses in mental health, disability awareness, dementia and adult protection from abuse. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36 and 38 The home is managed satisfactorily, but the vacant post of the care manager must be filled as a mater of priority. The staff is clear of their roles and responsibilities. Good systems of communication are in place to seek the views and feedback from the service users and their relatives/friends. The service users’ monies are appropriately handled by the acting care manager. Staff is regularly supervised to enable them to carry out their work professionally. Health, safety and welfare of the service users and staff are promoted by safe working systems put in place by the Registered Provider and the staff. EVIDENCE: It was noted that the home has been without since late March 2005. However, the Registered Provider has taken action to advertise this vacant post and now Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 19 the suitable candidates are being interviewed. The Registered Provider stated that a suitable and experienced person would be appointed shortly. The home has developed quality assurance systems and also undertaken some work on obtaining feedback through questionnaires from service users and their relatives. The feedback analysis report was being produced shortly. The home must also obtain feedback from other stakeholders (i.e. professionals). The final report must be produced and made available to all stakeholders, including the CSCI. The home has good financial procedures and current business and financial plan (financial statement) showed the financial viability of the home. The home assists several service users with their monies. There is a safe in the home for storage of money and valuables. A sample of four service users’ money was checked and found to be satisfactory. The records of all financial transactions are appropriately maintained. There was evidence to show that all staff is appropriately being supervised on regular basis. Records of supervision meetings were examined during the inspection. Accidents and fire prevention records were examined, which found to be appropriately maintained. Matters pertaining to fire safety and environmental health were found to be satisfactory and all the issues were appropriately addressed. The Registered Provider stated that all those members of staff who as yet not received the safe working practice topics training would do so as soon as possible and all newly appointed members of staff would also complete their induction and foundation training in accordance with the TOPSS specifications and standards. (See NMS 30 above). Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x 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 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 3 x 2 3 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 Standard No 16 17 18 Score 3 x 3 1 x 2 3 3 3 x 3 Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP 24 OP 30 Regulation 23 18 Requirement The Registered Provider must ensure that the carpets are replaced in bedrooms 1 and 9. The Registered Provider must ensure that all those remaining members of staff who as yet not received the safe working practice topics training must do so as a matter of priority. The Registered Provider must take apropriate and swift action to appoint a care manager who is qualified, competent and experienced to run the home and meet the homes Statement of Purpose, and its aims and objectives. The Registered Provider must ensure that the views/feedback from all the stakeholders,( including professionals) are sought on how the home is achieving goals for service users, and make a written report available in the home and for inspection by the CSCI. Timescale for action 30/11/05 31/03/06 3. OP31 9 The home states this has been completed. 4. OP33 24 31/12/05 5. 6. Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The Registered Provider should consider that the care staff who as yet have not received accredeted training in safe handling of medication should do so as soon as practicable. The Registered Provider should consider making provision for training for staff in adult protection, dementia, disability awareness and mental health awareness. 2. OP 30 Meadowcroft E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 E56 000020895 Meadowcroft V225656 AI 070605 Stage 4.doc Version 1.30 Page 24 - 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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