Inspection on 05/10/06 for Meadowfield Lodge

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Meadowfield Lodge 04/10/07

Meadowfield Lodge 01/02/06

Meadowfield Lodge 17/08/05

Meadowfield Lodge 16/02/05

Meadowfield Lodge 12/10/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

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 Meadowfield Lodge 22 Meadowfield Road Bridlington East Yorkshire YO15 3LD Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 5th October 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Meadowfield Lodge DS0000039795.V314555.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. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadowfield Lodge Address 22 Meadowfield Road Bridlington East Yorkshire YO15 3LD 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) 01262 675214 F/P01262 675214 Hexon Limited Stephen Paul Hepworth, Mr Trevor David Cruxon Susan Bennett Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24) of places Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Meadowfield Lodge is a care home offering personal care and accommodation for up to 24 elderly people. It is a three-storey building with passenger lift access to all floors. The home is situated near the centre of the seaside town of Bridlington and has good access to the shops, transport and social and recreational activities of the local community. The award winning south beach is a 5-minute walk from the home. Accommodation is available in a choice of single or twin rooms, the majority having en-suite facilities. The statement of purpose, that tells people about the services the home offers, is made available for all service users and their families. The range of the weekly fees charged at the date of this site visit were between £317.00 and £365.00. Additional charges are made for hairdressing, chiropody, newspapers and personal toiletries. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a pre inspection questionnaire; Comment cards returned from 8 service users and 3relatives and 1 GP. A visit to the home carried out by one inspector. The key inspection included a site visit and lasted for eight hours, including preparation time. Six service users and six staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at Meadowfield Lodge. The acting manager was available to assist throughout the day and for feedback at the close. What the service does well: Service users enjoy living at Meadowfield Lodge. Staff at the home are fully aware of service user’s needs owing to the thorough assessment and care planning that takes place. Service users have full and open access to any health care professional that they may need. One commented, ‘ Nothing is too much trouble here, the staff get you what you want’ Staff are well liked and treat service users as individuals and with respect. A comment received was, ‘I like to spend time in my bedroom and am able to do this, the staff don’t mind’. Service user’s private accommodation is kept clean and tidy and they are encouraged to personalise their bedrooms. Visitors are welcome at anytime and able to see their relative or friend in private. One service user said, ‘When my visitor comes we are able to sit in my bedroom to chat.’ Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 6 The food provided is good and appreciated by the service users. The cook is aware of dietary needs. 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. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 is not applicable Quality in this outcome area is good Service users are assured their care needs will be met. This judgement has been made using available evidence including a visit to the home. EVIDENCE: Records of service users showed that their care needs had been looked at in detail and information from other sources such as hospitals and care managers had also been considered. This means that staff are fully aware of these needs before a person comes to live at Meadowfield Lodge. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 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): 7,8,9,10. Quality in this outcome area is good Service user’s health care needs are met. This judgement has been made using available evidence including a visit to the home. EVIDENCE: Each service user has a written care plan in place that addresses their individual health and social care needs. Staff spoken with were knowledgeable about the service users needs. There is evidence within the plans that service users have access to healthcare professionals and service users spoken with confirmed this. One commented, ‘We are all well looked after here’. Service users confirmed that staff always knock on their bedroom doors before entering. Some female service users had requested female only carers. This was documented in the care plans and staff said they were aware of the arrangements. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 10 A GP who returned a comment card indicated that the staff had a clear understanding of service user’s needs and that they were satisfied with the overall care at the home. The care plans were reviewed at regular intervals to ensure that the plans addressed current care needs. Medications are handled stored and administered correctly ensuring that service users receive their medication safely. Service users are provided with lockable facilities in their bedrooms should they wish to keep and administer their own medication. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 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): 12,13,14,15. Quality in this outcome area is good. Service users enjoy their daily lives at this home. This judgement has been made using available evidence including a visit to the home. EVIDENCE: Residents spoken with were satisfied with the lives they lead at Meadowfield Lodge. Comments included, ‘ Nothing is too much trouble here, the staff get you what you want’ and ‘When my visitor comes we are able to sit in my bedroom to chat.’ ‘I like to spend time in my bedroom and am able to do this, the staff don’t mind’. Staff were observed treating service users respectfully. Comments received include, ‘I would always welcome more activities but enjoy what we have. The music man is very good’ Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 12 People’s religious beliefs are respected and arrangements have been made for Church of England ministers to visit to give Communion if requested. People are able to see their visitors in private Food provided at the home is good. People living at Meadowfield Lodge appreciate the variety of food provided. They said, ‘The meals are good’ and ‘ there is always a choice and alternatives available if you don’t like what’s offered’. The acting cook was knowledgeable about resident’s dietary needs. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 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): 16,18. Quality in this outcome area is good Service users are listened to and protected. This judgement has been made using available evidence including a visit to the home. EVIDENCE: Service users said they felt happy to approach the manager and confident she would address any concerns they had. One said, ‘If I had a complaint I would see the manager she comes to see me each day and I know she would sort things out for me’. The procedure is clearly displayed in the entrance hall and in the service users guide. All staff spoken were clear about Protection of Vulnerable Adults recognition and reporting procedures. Most staff had received the training and the home had a copy of the Local authority Multi agency Policy. A recent allegation at the home had been handled correctly with the service user being safeguarded. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 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): 19,26 Quality in this outcome area is poor. Some elements within the environment may place service users at risk. This judgement has been made using available evidence including a visit to the home. EVIDENCE: There are two lounges in the home, one for smokers and one for non-smokers. The smoker’s lounge was not well ventilated and the carpet had numerous cigarette burns. Radiators within the home are guarded to protect service users, however these had been in place for a while and had yet to be painted. The upstairs areas were clean and pleasant and service users are encouraged to personalise their rooms. The domestic member of staff was in the process of checking water temperature in all bedrooms and bathrooms. The records showed they were all within an acceptable range. However the bathroom on the top floor that was unlocked had a hot water temperature of 59.1°c. The manager stated that this bathroom was not used and arranged for the door to be locked. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 15 One bedroom that was vacant was very cold and the bed had bed rails in place despite the fact that no body occupied that room. This could lead to staff using that equipment for service users without carrying out a full assessment of the risk and considering their use. A service users bedroom on the ground floor had been used as a storage room despite the fact that the service user spent most of his time in the room. The staircase in the ‘still room’ is not sufficiently guarded/fenced in. The fire door to the stillroom was wedged open allowing access for service users. Advice about this was sought from Environmental Health Officer from the East Riding of Yorkshire Council. On 23/10/06 they visited the home and agreed that this staircase is dangerous, and needs urgent attention. The area manager of the company has agreed to re site the access door to the still room so that it is safe and to put another door to the stairs that will be kept locked at all times with only staff having a key. Because of the danger that this poses an eight-week formal improvement notice under the Health and Safety at Work Act 1974 has been served. Other fire doors that should have been kept locked were not for example the linen room. Arrangements in the home for laundry are satisfactory and service users were well dressed in nicely laundered clothes. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 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): 27,28,29,30 Quality in this outcome area is adequate. Service users are cared for by well trained staff, however the company’s’ recruitment procedures may place service users at risk This judgement has been made using available evidence including a visit to the home. EVIDENCE: There is a programme of training in place to ensure that staff receive training to enable them to care for the residents efficiently and safely. Evidence was seen of induction training. Staff confirmed that they feel they receive sufficient training to equip them for their role. Rotas show that there are sufficient staff on duty and service users and staff spoken with felt that generally this was the case. Two staff records showed that the staff members had started work without a CRB check in place. One record showed that there were not two written references in place. In order that residents are protected and cared for by safe staff, these checks must always be in place before employment starts. The provider must ensure that this happens from now onwards and that those staff in post without these checks must have them completed. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 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): 31,33,35,38 Quality in this outcome area is adequate. To ensure that the home is well managed the requirements made in this report must be met. This judgement has been made using available evidence including a visit to the home. EVIDENCE: The deputy manager has been acting manager since July 2006 and intends to make application to become registered manager of the home. The key worker system has been developed and staff now have responsibilities for individual residents and attends reviews of their care. Staff said that they receive supervision and records were seen of this. They found this a useful experience. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 18 Service users monies are handled and accounted for correctly. There is a quality assurance system in place, again this is in the process of being developed in order that the management are more fully informed of how well the service is performing. Health and Safety records were looked at. The last electrical wiring certificate had reported that the installation was not satisfactory and a number of works were outstanding, some urgently. A re test certificate was not available although the manager felt sure this had been done. The gas safety certificate had expired and a retest had not been carried out at this time. To ensure that service users remain safe the issues identified within this report must be attended to as a matter of urgency. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 1 1 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 2 X 2 X 3 X X 1 Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 20 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. Standard OP19 OP38 Regulation 13(4(a&c) Requirement Timescale for action 20/12/06 2. OP19 OP38 23(4(c) 3. OP19 OP38 13(4(a)) 23(4(c) 4. OP25 OP38 13(4(c)) The registered person must ensure that the requirements made by the Environmental Health Officer regarding the staircase in the stillroom are met within the timescale stated. The use of wedges to hold open 05/10/06 fire doors must stop immediately. Fire doors may only be held open by the use of authorised means that have been agreed by the Fire and Rescue Department. Immediate requirement issued Service users that wish to smoke 24/11/06 must have a risk assessment carried out and control measures must be put in place for any identified risk. This must include supervision and be included in the fire risk assessment. The registered person must 05/10/06 ensure that a risk assessment is carried out for the water outlet in the top floor bathroom where the water temperature of the bath water was recorded at 59.1°C. Control measures must DS0000039795.V314555.R01.S.doc Version 5.2 Meadowfield Lodge Page 21 5. OP38 13(4(a) 6. OP38 13(4(a) be put in place to reduce any identified risk. Immediate Requirement issued The registered person must 24/11/06 forward a copy of the new electrical wiring certificate to show that a retest of the installation has been completed and is now satisfactory addressing all requirements highlighted in the recent test and subsequent report. A copy of the gas safety 24/11/06 certificate must be forwarded to the Commission for Social Care Inspection 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 2 3 4 Refer to Standard OP19 OP19 OP31 OP33 Good Practice Recommendations The registered person should complete the work to the radiator covers in order to provide a pleasant environment for service users to live in. The registered person should consider replacing the carpet in the smoker’s lounge that is badly marked with cigarette burns. The acting manager should make application to the Commission for Social Care Inspection to become registered. The quality assurance should continue to be developed in order that the views of all stakeholders are sought and acted upon. Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Meadowfield Lodge DS0000039795.V314555.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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