Inspection on 23/11/05 for Meadowside

This inspection was carried out on 23rd November 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

Meadowside 25/02/09

Meadowside 12/12/06

Meadowside 16/08/05

Meadowside 11/01/05

Meadowside 13/07/04

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

CARE HOME ADULTS 18-65 Meadowside 35 Plymouth Road Tavistock Devon PL19 8BS Lead Inspector Graham Thomas Unannounced Inspection 23rd November 2005 9:15 Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 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 Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 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 Adults 18-65. 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. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Meadowside Address 35 Plymouth Road Tavistock Devon PL19 8BS 01822 614336 01822 614336 anne.hine@virgin.net 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) Mr Roger Hine Mrs Anne Hine Mrs Anne Hine Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named Service User over the age of 65 years Date of last inspection 16th August 2005 Brief Description of the Service: Meadowside is a large extended Victorian House close to the centre of Tavistock. The home offers care to 10 people (under the age of 65) who have mental health needs. The majority of people who live at Meadowside have done so for many years, and whilst the home promotes independence the home does not offer intensive rehabilitation. The house has a lower ground floor where there is the kitchen and two bedrooms. There is a lounge, dining room and two single bedrooms on the ground floor. On the first floor there are four bedrooms and on the second floor there are two bedrooms. The home is staffed 24 hours per day, at night there are sleep in staff. At the time of this inspection, substantial building work was continuing which will extend the building and reconfigure the existing arrangement of rooms. This will provide two ground floor bedrooms with en-suite facilities and level access to the outside of the building. Staff accommodation is being improved and the homes office will be moved from the basement to the ground floor. Additional communal space is to be provided. An application to register the home for one additional place has been received. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was to review the requirements and recommendations made at the last inspection. Inspection against new key standards introduced since the last inspection was also conducted. The Inspector spoke with Mrs. Hine and interviewed a new member of staff. Three service users were seen individually. Systems concerning the use of medicines in the home were inspected. A variety of documents were examined. What the service does well: 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. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prospective service users can feel confident that the home will meet their needs and aspirations. EVIDENCE: Discussion with a new member of staff confirmed that she was receiving comprehensive induction training to national standards. This included material directly relevant to the particular needs of service users at Meadowside. Staff training files and certificates on display in the home demonstrated staff access to a range of training including health and safety topics, the Protection of Vulnerable Adults and the Management of Challenging Behaviour. The home conducts pre-admission assessments and has policies and procedures concerning admissions. A copy of a letter to the most recently admitted service user was seen. This confirmed that the home was able to meet the person’s needs. It is recommended that material already available in the home concerning independent advocacy should accompany such correspondence. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards was inspected on this occasion Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards was inspected on this occasion Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home’s policies and procedures concerning medication ensure adequate protection for service users. EVIDENCE: Systems concerning the use of medicines in the home were examined. Medicines administrations were found to be accurate and up to date. No controlled drugs were in use. No homely remedies were in use though there is a policy in place concerning their use. All medicines were securely stored. Certificates of staff training in the use of medicines were seen. A record of a recent Pharmacist’s inspection was also examined. A flexible system is in place which allows individuals to manage some aspects of their own medication, depending on their ability. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards was inspected on this occasion Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards was inspected on this occasion Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 36 Service users are supported by adequately competent and qualified staff who have undergone a thorough recruitment process. EVIDENCE: The most recently recruited member of staff confirmed that she had undergone a comprehensive induction. This included topics directly relevant to supporting service users at Meadowside. There is a stable and experienced staff group at the home, 50 of whom are qualified to at least NVQ level 2 in care. One member of staff received her level 2 certificate on the day of inspection. Three other staff are signed up for NVQ courses. Mrs. Hine and her assistant manager are NVQ assessors. Each staff member has an individual training plan and there were numerous certificates on display confirming staff attendance at various relevant courses. Staff files and discussion with staff confirmed a sound recruitment process. Prospective staff complete a formal application which requires two references and employment history. Checks of criminal records and checks against the national list of unsuitable staff (POVA) are conducted. Prospective staff visit the home and have a formal interview as part of this process. Statements of terms and conditions are provided to all staff as well as the Code of Conduct of the General Social Care Council. Appointment is subject to a probationary period. At the time of inspection, Mrs. Hine was working towards improving the frequency of staff supervision. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 14 Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 Service users live in a home which is generally well-managed by appropriately qualified staff. EVIDENCE: The home is managed by Mrs. Hine with an assistant manager. Mrs. Hine is a Registered Mental Nurse. She already holds a qualification in Operational Management and is undertaking the Registered Managers Award. The Assistant Manager holds level 4 NVQ qualifications in care and management. Both are NVQ assessors. At the time of inspection, building work was continuing in the home with much inevitable disruption. This process was being effectively managed to minimise the effect on service users. Since the last inspection there has been improvement in notifying the Commission of significant events. Service users’ views are sought concerning the day to day operation of the home. A meeting for service users had taken place since the last inspection at which changes to the menu had been suggested by service users. These changes had been implemented. A more comprehensive quality assurance system remains under development. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 16 Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Meadowside Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000003752.V268533.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 YA39 Good Practice Recommendations The Registered Provider should complete the development of a quality assurance system and integrate this into the homes annual development plan. Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Meadowside DS0000003752.V268533.R01.S.doc Version 5.0 Page 20 - 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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