CARE HOMES FOR OLDER PEOPLE
Meadowcroft Meadowcroft 197-199 Bushbury Lane Bushbury Wolverhampton West Midlands WV10 9TY Lead Inspector
Mr Ian Harris Unannounced Inspection 08:00 9 January 2006
th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Meadowcroft Address Meadowcroft 197-199 Bushbury Lane Bushbury Wolverhampton West Midlands WV10 9TY 01902 307170 01902 307170 info@sclcare.co.uk 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) SCL Care Limited Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Females over 60 years and males over 65 years. Date of last inspection 7th June 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 DS0000020895.V261531.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 4 of the 20 care staff were on duty, and 6 of the 13 residents were spoken to. All the residents who could express themselves in a meaningful way stated that they were happy and contented and, “well looked after” “The girls are very good” and “ I wouldn’t know how I manage without them” were some of the comments made. What the service does well:
Meadowcroft continues to provide a high standard of care for the residents. The Acting Care Manager and staff are to be commended on their efforts to encourage the residents to maintain their independence through social activities both within and outside the home. Observations during the inspection saw very attentive staff providing for the individual needs of the residents. A number of residents confirmed the care staff are very supportive and caring. The home has a very good staff- training programme, which all staff are involved in, this ensures that they are improving their knowledge and skills to meet the changing needs of the residents. The home provides spacious accommodation, which is being maintained to a good standard. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 The home provides clear and accurate information to prospective residents on the services provided, enabling them to make a properly informed choice about the home. All residents are given a written contract on admission to the home. EVIDENCE: Each resident is provided with a detailed service users guide and statement of terms and conditions when they move into the home. Residents are encouraged to visit the home prior to admission. An introductory visit is always offered to prospective residents, on some occasions the visits are declined and relatives visit on behalf of the prospective resident prior to admission. A trial period is included in the statement of terms and conditions of residence and the homes contracts. It was confirmed by a resident recently admitted to the home that they had been invited to the home for lunch before moving in. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 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 the following standard(s): 7 and 9 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local the G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the care Plans are being carried out and reviewed on a monthly basis. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out
Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 10 of their area the Acting Care Manager ensures that, these services are provided by local practitioners. The records indicate that resident’s medical needs are being met. Medication is administered by means of a monitored dosage system. From observations made and inspection of the records, the system appears to be working well. The home receives good support from the local pharmacist however three monthly audit of the home’s medication are not taking place. All Senior Care Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and procedures that are an integral part of the staff induction programme. It was noted that the home is storing medicines and creams in the kitchen refrigerator. It is recommended that a refrigerator for medicines is provided. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 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 the following standard(s): 12 and 15 The home provides a good programme of social activities within and outside of the home, which are designed to meet the resident’s capabilities. The meals in the home are good, offering both choice and variety and also catering for special dietary needs EVIDENCE: There was evidence that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. Records of activities enjoyed by the residents are maintained. They include Musical evenings, Music and movement, Church services, shopping trips to the local shops and Pub Lunches. The residents stated that they had enjoyed the Christmas festivities. There was evidence to show that the home welcome the residents’ relatives and friends to visit the home at reasonable times. The visitors’ book showed considerable activity. All relatives and friends who spoke to the Inspector said they are given a warm friendly welcome by all the staff whenever they visit. The observations made, examination of menus and the comments received from the residents and their relatives confirmed that particular attention is given to the residents’ individual preferences. Comments made by residents
Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 12 regarding the quality, quantity and variety of food provided were highly complimentary. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 The home has a satisfactory complaints procedures and there is evidence that residents’ and their families feel that their views are listened to and acted upon All residents are assisted to exercise their legal rights, either by family, staff or where appropriate by an advocate provided by Care Aware. EVIDENCE: The home has a comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence the service users guide copies of which, are placed on the notice board in the hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaint since the last inspection and residents stated that all minor complaints are dealt with appropriately and quickly. Residents are assisted to exercise their legal rights, either by family or care staff. All permanent residents are registered on the electoral register to vote. They may vote if they wish either by post, or they are assisted to go to the polling station if this is requested and most residents voted in the last general election. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The standard of the environment within the home and the garden is high providing the residents with a very attractive, comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. EVIDENCE: The home is well established and was purpose built in order to provide appropriate accommodation for 17 older people. The home has a rolling programme of redecoration and refurbishment and is maintained to a high standard, as are the gardens and grounds and provides a comfortable homely and safe atmosphere. However it was noted that the carpets in the ground floor corridors are becoming shabby and should be programmed for replacement. The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and the staff have received training in food hygiene and Infection Control.
Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 15 Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 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 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 and 29 The home is staffed to a level that ensures that residents’ needs are met at all times. There is a stable staff group working positively and enthusiastically to provide the residents with a quality of life that meets their individual requirements and aspirations. The home has satisfactory staff recruitment policies and procedures. EVIDENCE: The inspection of staff rotas and discussions with residents and relatives’ indicated the home is adequately staffed by caring and competent staff. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. Discussion with 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. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 36 The home is managed satisfactorily but the Acting Care Manager must be registered as a matter of priority. The staff are clear about their roles and responsibilities. A system of communication is in place to seek the views and feedback from the service users and their relatives/friends. EVIDENCE: There is an Acting Care Manager in place who has submitted an application for registration, which is being processed. The Acting Care Manager is qualified in both care practice and management and has considerable experience in caring for older people in a residential home setting. There is evidence that she has very good links with other agencies whom she consults with in order to improve the service provided by the home. There are clear lines of accountability within the home and the manager is very supportive of staff and residents. The home has introduced a quality assurance system into the home to monitor performance and it was noted that copies of the regulation 26 visits
Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 18 to the home are being sent to the commission on a monthly basis. All the records and administrative procedures within the home that were, inspected were found to be well ordered and maintained Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 3 X X Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP31 Regulation 9 Requirement Timescale for action 01/03/06 2 OP8 13 (2) The Registered Provider must take appropriate 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 01/03/06 provide a refrigerator for the storage of medicines and creams. 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 OP19 Good Practice Recommendations To replace the carpets in the ground floor corridors. Meadowcroft DS0000020895.V261531.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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