Inspection on 24/10/05 for Meadowside

This inspection was carried out on 24th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Meadowside 27/07/07

Meadowside 15/05/06

Meadowside 04/05/05

Meadowside 31/08/04

Meadowside 05/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Meadowside Meadowside Knowle Park Avenue Staines Middlesex TW18 1AN Lead Inspector Damian Griffiths Unannounced Inspection 24th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Meadowside DS0000013716.V261343.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 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. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Meadowside Address Meadowside Knowle Park Avenue Staines Middlesex TW18 1AN 01784 455097 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) samantha.taylor@anchor.org.uk Anchor Trust Ms Samantha Jayne Taylor Care Home 51 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (51), of places Physical disability over 65 years of age (12) Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 65 YEARS AND OVER Of the 51 service users accommodated within the home, up to 20 may fall within the category DE(E). Of the 51 service users accommodated within the home, up to 12 may fall within the category PD(E). 4th May 2005 Date of last inspection Brief Description of the Service: Meadowside is managed by ‘Anchor Trust’ and is one of many managed by the company. The Home is Registered as a care home for older people with physical disabilities and dementia over the age of sixty-five years-of age. Meadowside is registered for a maximum of fifty-one residents. The accommodation comprises fifty-one single rooms divided into seven units: each unit has its own lounge/dining room and kitchenette area. The accommodation is situated over two floors with a lift providing access to the upper floor. The home is situated in a residential area close to shops and Staines town centre and set in its own grounds with parking space at the front of the building. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 6 ½ hrs and was the second inspection to be undertaken in the Commission for Social Care Inspection Year April 2005 to March 2006. Lead Inspector Damian Griffiths was assisted throughout the inspection by the Registered Manager Sam Taylor representing the establishment. A tour of the premises was conducted and the inspector sampled five residents care plans and five staff files. Four residents, three staff members and one relative were consulted. Care plans, health care, complaints, staff training and recruitment practices were also inspected. A new lift was being fitted therefore a stair-lift had been installed to ensure that residents could access the upper floor. The inspector would like to extend his thanks to the residents, staff and management at Meadowside for their assistance and hospitality. What the service does well: The residents consulted stated that they were well cared for, staff were courteous, respected their privacy and the food was good. Residents said they were satisfied with the activities available and residents appreciated the efficiency of the homes laundry: clothes were regularly cleaned and residents consulted were happy with the system in place. NVQ Level 2 training was available for staff and the second part of the falls prevention training had been planned to take place. The staff consulted were happy in their work and felt supported by the registered manager. Information was available for residents and their relatives detailing the last inspection report and comment/complaint cards were available. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The information available to the residents and their relatives needs to be more prominently displayed. Care plans to be regularly reviewed and maintained to include, summary of resident care, updated risk assessments and include the contract of residency. Following up the conclusion of adult protection investigations. Attention to offensive odours that greet the visitor. Health and safety risk assessment of the stair-lift and related issues. Checking and reviewing all new staff records to ensure all the necessary details have been received and are in good order. The registered manager must receive regular formal supervision. Quality Assurance Monitoring was due. Good practice recommendations included attention to the following: Keeping a chronology of events when involved with vulnerable adult investigations. Investing in more ozone purification units and all other areas of odour control. Complete fire checks and drills during and after renovation/repair work. Ensuring all agency staff receive full information about the residents that they will be working with. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 7 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 DS0000013716.V261343.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,and 5. Resident’s contracts were not in evidence. Residents and their relatives were confident that their needs would be met and have the opportunity of visiting before a decision is made regarding admission to the home. EVIDENCE: Four residents files were inspected but only one contained a contract with terms and conditions of residency. Relatives and residents consulted were confident that the home was able to meet their needs when considering Meadowview and had every opportunity to visit before a decision was made regarding possible admission. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 10 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): 7,8,10 and 11. Care plan formats were good but the information contained in them was incomplete. Service users health care needs were well managed and residents were treated with respect. The sensitive area of residents planned funeral arrangements had not been adequately addressed. EVIDENCE: Four residents care plans were inspected and contained details of their daily care needs and risk assessments. Three of the four care plans were without summaries of the resident’s daily care needs as they were kept in another file. Risk assessments varied, some were incomplete and did not cover the relevant needs of the resident, such as, not recording aggression or the risk of falling when it was evident that this was a risk. Care plans are required to be comprehensive as reported at the last inspection. Full access to information is needed to ensure the health and welfare of residents and staff. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 11 A health professional interviewed during the course of her duties commented on the positive working relationship developed with the home that has fostered good practice. Senior staff regularly record the residents health care needs that required her attention. This system was helping to keep health related problems to a minimum. Residents consulted said they were well looked after by staff when they were unwell. Staff were observed to always knock on a residents door before entering and relatives stated that staff always welcomed them when they visited. Residents consulted confirmed that their privacy was respected. Details of resident’s funeral arrangements were incomplete and contained very little information, ie, religious preferences only. Issues relating to staff awareness of death and bereavement need to be reviewed in order for this aspect of care to be properly addressed. Please see the requirements and recommendations section. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 12 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): This standard was not accessed. EVIDENCE: Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 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 18. Complaints were dealt with accordingly and protection of vulnerable adult procedures had been followed but one investigation had not been fully concluded. EVIDENCE: Residents were regularly consulted about their views and had the opportunity to attend residents meetings where issues of concern can be discussed. Complaints /comment cards were available at the entrance of the home. Residents and their relatives all knew they could talk to the registered manager if they were unhappy or had a complaint to make. There were three complaints contained in the logbook at the time of the inspection and one vulnerable adult enquiry. The complaint’s had been concluded satisfactorily. Residents consulted felt well cared for and safe at the home despite some instances of money that had allegedly gone missing. The Surrey Multi-Agency Procedures for the protection of vulnerable adults had been followed with one investigation but remained unresolved at the time of the inspection. The recording of this action was handwritten and would have benefited from being typed and a chronology of events recorded. Staff were aware of the whistle blowing procedures and most felt confident enough to discuss any concerns with the registered manager first. The Anchor staff handbook ‘Right and Responsibilities’ does not refer to this as whistle blowing but states that it is the responsibility of the staff member to contact Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 14 the appropriate agencies, i.e., the local Social Care Team or the Commission for Social Care Inspection. Please see the requirements and recommendations section. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 15 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): 19,21,22 and 26. Meadowside ensures that resident’s facilities are clean and in good order there were some safety concerns relating to the lift refurbishment. The lift was being replaced and specialist equipment had been installed while work was in progress. There continues to be a malodorous problem that lets down the best efforts of the home. EVIDENCE: A stair lift had been installed at one end of the building as a temporary measure during the installation of the new lift. Risk assessments had been recorded for staff to ensure safe use however there were no references to the safe storage of the stair lift when not in use or safe lifting of wheelchairs up the stairs. Staff were able to assist residents experiencing a fall by using specialist-lifting equipment in line with a safe manual handling policy. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 16 The Sunflower unit bathroom had been decorated and the other six bathrooms found on each unit were in good order. The home was well served with information including the last inspection report that was situated on the notice board at the entrance to the home. The notice board was however lying on the floor and not accessible to residents at the time of the inspection due to refurbishment. The laundry area was busy and efficient resident clothes were correctly stored and full sluice facilities were available. On entering the home there was a malodorous smell that grew stronger when entering one of the ground floor units. On inspection the rooms were being cleaned but the staff were under pressure due to there being only one ozone humidifier available to eliminate the offensive odour. Health care professionals are regularly involved with continence advice and action however this has proved to be an ongoing difficulty with the home. Please see the requirements and recommendation section. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 17 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): 28 , 29 and 30 Staff where well trained to ensure the safety and welfare of the residents however some of the recruitment procedures were incomplete. Staff were confident and happy in their work and had received an appropriate range of training. EVIDENCE: Five staff files were inspected and two were incomplete one staff member had not submitted a full employment history and another had not signed their employment contract. Three staff members were interviewed in the course of their work and two out of three had obtained an NVQ level 2 and were confident with the level of support they were able to give residents confirming that they had enough time to complete their daily tasks. Commissioning of agency staff was being kept to a minimum by encouraging regular staff to work additional shifts. There was some concern expressed by residents relating to the use of agency staff who understandably did not know the residents as well as the regular staff. The residents understood the need for agency staff when required but they did not feel confident with the level of experience of the agency staff or their accountability when mistakes were made. Rota’s were inspected at the end of the inspection and a full compliment of staff were available for the night shift. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 18 More work had been created due to the lift being out of use however the staff had responded admirably and residents consulted had not suffered any inconvenience as a result. Seven staff files were inspected for training details and staff had received a full range of training. A falls programme was in place and staff were due to undertake their second stage of training in this very important area of care. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 19 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): 32,33, and 36. The service users and staff at Meadowside were happy with the style of management however quality assurance monitoring was due for completion. Staff other than the registered manager received regular formal supervision. EVIDENCE: Residents and staff consulted where satisfied with the management ethos however quality assurance monitoring would help establish a wider view for example the homes policy when commissioning short-term agency staff and their accountability. Residents consulted stated that they would like to be more involved with decision-making within the home. The manager operates an open door policy and staff and residents consulted all stated that they were felt confident about approaching the registered manager. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 20 Records showed that staff where receiving regular supervision however the registered manager had not received formal supervision on a regular basis for over a year. Please see the requirements section. Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 21 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 2 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 3 X X X 2 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X X 2 X X Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 22 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 OP2 Regulation 5 (3) Requirement Residents must be issued with a written contract/statement of terms and conditions including fees. Residents must have a full documented care plan in order to ensure their needs are met and all agency staff be provided with full information about the residents they will be working with. The registered manager must promote and make proper provision for the health and welfare of residents and take account of their wishes and feelings regarding funeral arrangements. The registered manager must ensure that arrangements are made to protect residents from abuse and to inform the Commission of actions taken. The registered manager must ensure that any unnecessary risks relating to health and safety are identified and so far as possible eliminated The registered manager must DS0000013716.V261343.R01.S.doc Timescale for action 24/12/05 2. OP7 15(1)(2) (a)(d) 24/12/05 3. OP11 12(1)(a) (b) 24/12/05 4. OP18 13(6) 24/12/05 5. OP19 13(c) 24/12/05 6. OP26 16(2)(k) 24/12/05 Page 23 Meadowside Version 5.0 7. OP33 24(1)(a) (b) (2) (3) 8. OP36 18 (2) ensure that offensive odours identified must be eliminated. This is the second time this requirement has been made and new timescale has been agreed. The registered manager must ensure that quality assurance monitoring is completed and the results are circulated. A copy must be forwarded to the Inspector. The registered manager must receive regular supervision from her line manager. This is the third time this requirement has been made and a new timescale has been agreed. 24/12/05 24/12/05 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 OP18 Good Practice Recommendations It was recommended as good practice to ensure that notes taken during adult protection vulnerable adult enquiries that are handwritten are typed and that a chronology of events are recorded. It was recommended as good practice to provide adequate odour control equipment to reduce staff workload and reduce offensive odours. It was recommended as good practice to conduct fire safety exercises during the refurbishment of the premises. 2. 3. OP26 OP38 Meadowside DS0000013716.V261343.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000013716.V261343.R01.S.doc Version 5.0 Page 25 - 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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