Inspection on 27/07/07 for Meadowside

This inspection was carried out on 27th July 2007.

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 15/05/06

Meadowside 24/10/05

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 Chris Woolf Unannounced Inspection 27th July 2007 08:45 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.V337332.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. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 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 keri.sherwood@anchor.org.uk Anchor Trust Ms Samantha Jayne Taylor Care Home 51 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (51), Physical disability over 65 years of age (12) Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2006 Brief Description of the Service: Meadowside is one of many homes managed by the ‘Anchor Trust’, a not for profit organisation. It 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 The home is registered as a care home for a maximum of 51 older people with physical disabilities and dementia, over the age of 65. Accommodation comprises 51 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 current fees for the service at the time of the visit range from £400 per week for people funded by social services to £659 per week for privately funded service users. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is jane.squire@anchor.org.uk. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is based on an annual quality assurance assessment carried out by the home and an inspection site visit to the home lasting 7 hours. The site visit included discussions with the trainee manager, a number of service users, several staff, a visitor and two visiting professionals. Observations included a mealtime, administration of medication, ‘musical bingo’, the interactions between staff and service users and the general friendliness of the home. Inspection of a variety of records included care plans and assessments, staff files, quality assurance documentation, risk assessments and health and safety records. What the service does well: What has improved since the last inspection? All of the requirements on the last report have been met. The recent changes in management have led to an overall improvement in standards of care. Health needs assessments take place; improvements have been made to the medication recording; nutritional screening has been introduced; care plans Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 6 are all in the process of being updated; there is a more detailed risk assessment. Activities in the home have increased and are more varied. There is a more positive atmosphere in the home, and staff are working better as a team. A visiting professional commented, “It’s much more friendly now”. Staff rotas have been assessed to meet the needs of the service users resulting in the recruitment of more staff. Staff training has increased and a full year’s training programme has been planned. There have been a number of improvements to the environment. The manager’s office has moved to a more central location, and the reception desk has also moved. Decoration, new carpets, new curtains and provision of new furniture has taken place in various areas of the home. Two of the bathrooms have been totally refurbished. A new washing machine has been purchased. Health and safety training and assessments have taken place in all units and the home has received a ‘safe site’ award. A new smoking procedure has been implemented to comply with recent legislation. There are now more regular meetings both for residents and for staff. Letters received by the home about improvements included the following comments. The first is from a Care Manager, and the second from a staff member:‘Xxx (relatives) feel that there has been an improvement in the care that xxx (service user) receives and are happy for her to remain at Meadowside’. ‘In the last couple of months the changes here have been brilliant, the home is looking much brighter and more cheerful and residents are much happier’. What they could do better: The manager needs to ensure that a thorough documented assessment is completed prior to any new service user being admitted to the home. Written entries on Medication Administration Records must be double signed and dated and protocols need to be developed for the administration of ‘as required’ medication. The staff toilet needs to be descaled and the staining should be removed. More detailed information about the care given should be included in the care plans. The home should continue with its recruitment of additional staff. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 7 The home should continue with its planned NVQ training for staff. 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. The summary of this inspection report can be made available in other formats on request. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 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.V337332.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 is not applicable in this home Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have access to sufficient information about the home, and their needs are assessed prior to admission. Occasional failures to document assessments could result in service users not receiving the care they need. EVIDENCE: A copy of the service users’ guide and the last report are now available in the entrance hallway of the home, as required at the last inspection. The home undertakes a comprehensive assessment of needs of prospective service users and also obtains a copy of the joint assessment for any service users with care management involvement. Assessments are in place for the majority of both permanent and respite service users. However, although one respite service user had visited the home for a day’s assessment there was no documented assessment of her needs available. Although it has since been confirmed that this assessment has been completed, it is important that all Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 10 assessments, including respite care service users, are undertaken prior to the service user being admitted to the home; therefore a requirement has been made regarding this. This home does not offer the facility of intermediate care. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are treated with respect, and the staff, supported by a multi-disciplinary health care team, meets their health & personal care needs. EVIDENCE: There is an individual care plan in place for each all service user, based on information received during the pre-admission assessment and updated to reflect current needs. The new trainee manager is working hard to update all of these plans to the new, much improved format that has been introduced and this process is scheduled for completion within the next couple of months. Care plans include personal information including spiritual, cultural and religious needs and whether they prefer a male or female carer. They also include a variety of risk assessments. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 12 Care plans are regularly reviewed and the trainee manager intends to ensure that they are now reviewed with the service users on a regular monthly basis. However, the care plan viewed for the service user whose assessment had not been documented did not contain all of the details needed to enable staff to be able to fully care for her needs. The daily record sheets for service users also need to be more detailed and reflect both the physical and social care delivered; these issues were discussed with the trainee manager on the day of the site visit and she has since confirmed that she has implemented the actions discussed; therefore a recommendation rather than a requirement has been made regarding these issues. The home, together with a multi-disciplinary health care team, promotes and maintains service users’ health. District nurses visit the home three times a week and provide advice and support to the residents and staff and any specialist equipment that is required for the well being of the service users. A concern had been raised about a service user being transferred to another home with pressure sores. This was investigated and it was found that the home had received support from the district nurses and had followed all of the correct procedures. As they felt they could no longer meet this service user’s needs, a transfer to a nursing home was requested. Staff commented, “I have had training in tissue viability”, and “The nurses come in, and we have Airflow cushions and special mattresses”. Other support in the home is received from the GP, dentist, chiropodist and optician. Hearing tests are provided at the local health centre. The home now undertakes nutritional screening on admission and monitors and records weights on a monthly basis. An improvement started in the past few months is the introduction of health needs assessments, and this has resulted in three service users being moved to nursing homes to ensure that they received the specialised care they needed. Since the last inspection a new hoist has been purchased. Service users commented, “The home certainly looks after my health care needs”, “The staff hoist me, they are very good”, and “I’m well looked after”. A visiting professional said, “The care on the whole is good”. The recording of receipt, administration and disposal of medication is sufficient to allow for an audit trail. Medication storage meets the requirements. The medication administration record now contains residents’ photographs. Handwritten instructions on the medication record sheets need to be double signed and dated and a recommendation is made regarding this. The home also needs to develop protocols for the administration of ‘as required’ medication to ensure that staff are clear as to when and why to use them, and this has been added to the above recommendation. Since the inspection the trainee manager has confirmed that both of the issues raised in the recommendation have been addressed. All staff who administer medication have been trained and have their competency monitored. The home uses the monitored dosage system for their medication and the local pharmacist has recently undertaken a medication audit. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 13 Staff at the home respect the privacy and dignity of service users. Staff spoken to confirmed the ways in which they do this which included, “I always knock on their doors and introduce myself before entering”, “We ask them if they have any preference of gender of carer”, and “I call them by their preferred name, when they first come in I say Mr or Mrs until they say I can use their first name”. Service user comments included, “Staff always knock before coming into my room”, “The staff always show me respect”, and “The staff painted my nails for me”. As well as some service users having their own private telephone lines, the home has provided a small room with a chair and a door that shuts for privacy for service users to use as a ‘telephone box’. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to lead a lifestyle that meets their needs and expectations. They are given choices in all aspects of their daily lives, and they receive a wholesome and balanced diet. EVIDENCE: The routines of daily living in the home are flexible and designed around the needs of the service users. The home employs a full time activity co-ordinator who arranges a variety of activities for service users, from cake icing to quizzes and musical bingo to manicures. The home has its own mobile shop and this visits service users weekly. Larger events have included an Abba afternoon, a boot sale and barbecues. A day trip to the coast is currently being planned. The activities co-ordinator attends the National Association for Providers of Activity for Older People meetings every six weeks. The activities organiser, together with some of the care staff, are booked to attend a training session on activities, and is also hoping to learn about providing exercise sessions for the service users. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 15 Service user comments included, “I go down for golf and one or two other activities”, “I go outside sometimes”, “I am going to the musical bingo this afternoon”, “I don’t do activities”, and “I like the bowling”. Staff commented, “The activities are getting better, xxx has come up with ideas, we have even done cake icing”, and “xxx is working well, it’s improving all the time”. The current service users’ religious needs are being met through a monthly visit from the local Church of England vicar and regular visits from the Catholic priest. There are currently no other faiths being practiced by service users at the home, but these would be addressed on an individual basis if and when the need arose. Service users are encouraged to maintain contact with their family and friends and visitors are welcomed into the home. Service users commented, “My sister comes to visit me, she is always made welcome”, “I don’t do badly for visitors, the staff give them a cup of tea”, and “Visitors are made very welcome”. Choice is given to service users in all aspects of their lives, and they are encouraged to maintain their independence as far as they are able. Staff members commented, “They can choose what time they get up and go to bed, breakfast is normally 9 o’clock but if anyone wants a lay in they can have one”, and “They have choices about everything, whether to have male or female carers, times of getting up and going to bed, when they want a cup of tea, if they want the family or us to do their washing, what to eat, what to wear, when to have baths, just everything”. The home provides a home cooked, balanced and nutritious diet to service users. Choices are given at the time of the meal and do not have to be decided in advance. Service users commented, “The food is very good, and I like my food. It’s well cooked and prepared”, “I like the food, and I like the fact that I don’t have to eat it all if I don’t want it”, “We have a cooked breakfast twice a week and look forward to that, but we would not want it every day”, and “I like the food very much, I look forward to it”. Two comments were received about having a better variety of vegetables available. This was discussed with the trainee manager who was going to arrange this with the chef. Staff said, “The meals are brilliant”, “The food is good, they get plenty”, and “It’s improved a lot, there is a lot more choice now”. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users concerns and complaints are listened to and acted upon, and the home makes every effort to protect from them from abuse. EVIDENCE: The home has a clear and accessible complaints policy. A copy of the policy is on display in the entrance hallway, and a copy is also kept in each service user’s care plan. Complaint recording has been updated to meet the requirements of data protection, and includes the recording of outcomes. Some concerns about the home have been passed to CSCI since the last inspection but these have since been resolved. There have also been eight complaints made directly to the home since the last inspection. All were dealt with within the stated timescale and have since been resolved. No complaints have been received in the home since the project team and new trainee manager have been in post. The company indicates that the home has improved its complaints procedures by having an approachable project team, an open door policy and responding to complaints and resolving them immediately. The trainee manager meets with the local authority monthly to iron out any concerns. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 17 Service users commented, “I have no complaints”, and “No complaints, I am very happy”. Staff confirmed that they would know the actions to take if someone wished to make a complaint. At the time of the last inspection requirements were made about protecting the service users from abuse. There have been two safeguarding adults alerts since the last inspection. These both took place prior to the project team and trainee manager taking over the management of the home, and have both now been resolved. The majority of staff have received training in the protection of vulnerable adults. No new member of staff is employed until a satisfactory check of the protection of vulnerable adults register has been received. Staff are encouraged to ‘whistleblow’ if they are suspicious of potential or actual abuse and all staff spoken to understood the importance of the whistleblowing policy. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, comfortable and homely environment with rooms that are personalised to meet their needs. EVIDENCE: The home is well set out with a large airy entrance hallway, staircase and landing. The manager’s office has been moved to a more central location where the manager is better able to monitor what is going on in the home; and there is a new reception desk in the hallway. Fresh flowers are delivered to the home each week. A lot of decoration, new carpets, curtains and furniture has taken place in various areas of the home since the last inspection. New pictures have also been hung throughout the home. Further refurbishment is scheduled on the home’s development plan. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 19 Service users’ accommodation is set out in seven separate units, each with its own lounge/dining/kitchenette area and its own toilet facilities and bathroom with assisted bath. The grounds are accessible, safe, tidy and attractive and have a variety of sitting areas. New trellis and gazebos have been purchased since the last inspection and a tree surgeon is booked to carry out works to some of the trees. Staff commented, “The home looks so much nicer with the new decorating and furniture, it would be nice to have the staff room as nice”, and “I think it’s lovely that it’s so much better for everyone”. In addition to the lounge/dining areas within the separate units, there is also another large lounge on the ground floor. This lounge is available to all service users and is the area where most activities take place. New furniture units have been fitted in this room and there is a large picture, made by the service users, on display. Two of the assisted bathrooms have been totally refurbished since the last inspection and the ones not yet refurbished are on the schedule of works for completion. Service users’ bedrooms are personalised to meet their own needs. Service users commented, “The rooms are nice”, “I have got some of my own bits and pieces around me”, and “I have got a nice room”. The home has a shaft lift to give access from the ground to the first floor and a platform lift for access from the first floor to one unit that would otherwise require service users to be able to climb a few stairs for access. The home is generally clean, and has good infection control procedures in place. A visiting professional commented, “It’s always clean, no odours”. The laundry area is now clean and tidy as required on the last report, and a new washing machine has been purchased. On the day of the visit one of the units had an unpleasant odour. This was discussed with the trainee manager and she has since confirmed that all carpets on the unit have been shampooed and treated, that the odour has now completely gone and that the actions taken will be repeated monthly. The staff toilet had a lot of limescale and was very stained and a requirement has been made regarding this. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are cared for by a dedicated team of staff who have been properly recruited and who receive training to do their jobs efficiently. EVIDENCE: The home has had some problems with staff shortages from holidays and sickness, but these shortages are being addressed by the project team and trainee manager who is currently running the home. A new staff sickness procedure is in place and attendance is being managed. Staff rotas have been revised to meet the needs of service users. There has been a staff recruitment drive, some new staff have already been recruited and once all of the necessary paperwork is returned the trainee manager will be able to confirm more new staff in position. Staff commented, “We are recruiting but there have been times when there are not enough staff”, “We work as a team but it stretches us when we are short staffed”, and “I have confidence that it will improve”. A recommendation has been added that the home continues with its recruitment drive to ensure that there are sufficient staff on duty at all times to meet the needs of the service users. The staff are smart and well presented and the management is now ensuring that uniforms and ID badges are worn consistently. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 21 The home has not yet met the level of 50 of care staff trained to NVQ 2. However, NVQ training is ongoing and there are internal assessors to assess candidates completing NVQ Levels 2 and 3. The trainee manager is organising weekly NVQ workshops in order to achieve the 50 level as quickly as possible. A recommendation has been added that NVQ training continues as planned to ensure that a minimum of 50 of care workers are trained to NVQ Level 2 or above. A staff member commented, “I am working towards my NVQ, I already have a City in Guilds in Care”. Recruitment procedures in the home are sound. No member of staff is employed until an enhanced disclosure has been submitted to the Criminal Records Bureau, and a satisfactory check of the Protection of Vulnerable Adults register and two satisfactory references have been received. All staff are issued with a contract of employment. All new staff receive induction training to meet Skills for Care specifications. The home now has a full year’s training planned and all policies and procedures relating to training are in place. Mandatory training is up to date and refreshers are booked where necessary. All staff have now been trained in adult protection, and all staff who administer medication have had medication training. Dementia training has also taken place. The activities co-ordinator and nine care staff have been booked on a course of activity training for older people. Training is planned for all staff in equality and diversity. Staff said, “I have done a five-day dementia care course”, “We do moving and handling each year”, “I have done intermediate food hygiene”, and “I am booked to do an activity training course”. Service users’ comments about staff included, “The staff are very kind”, “No complaints about the staff, they are very good”, and “The staff are very good”. Comments from the staff included, “We work as a team here”, and “I love it here”. A visiting professional said, “They are very obliging”. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users. The health, safety and welfare of service users and staff are protected. EVIDENCE: Since March 2007 a project team and trainee manager have run the home. The trainee manager has NVQ Level 3, is just finishing her Registered Managers Award and is going on to do Level 4 in Care. She has also achieved her NVQ assessors’ award. The company has followed all of the correct procedures to ensure that the current management is satisfactory. The trainee manager operates an open door policy and she and the project team support all service users and staff, listen to what they have to say and take on board their wishes and concerns. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 23 A Service user commented, “The manager is good”. Staff said, “I get support from the manager”, “It has improved greatly recently with the project team and trainee manager”, and “She is doing her best”. The home has an effective quality assurance system. Questionnaires have been sent out to service users to gain their feedback and to improve the home. Once a sufficient time has elapsed for return of the forms an analysis of results will be published. Questionnaires to families and visiting professionals are currently being planned. The providers undertake regular monthly visits, and a series of regular in-house audits are undertaken. Residents’ meetings and staff meetings have been introduced and are now held regularly. The company has a managers’ network to ensure that their managers receive peer support. The home keeps a compliments file and comments witnessed included one from staff, ‘To Jane, You have done a brill job here, thank you’, and from relatives, ‘Thank you for all your help and attention. What a difference it has made’, and “Thank you so much for all the love and support you gave to our dearest mum. You were my extended family in the last days of mum’s life’. The home encourages service users or their representatives to deal with their own finances although they do hold some ‘pocket money’ for service users who have been in the home for a long time. All transactions are signed and regularly balanced in accordance with Anchor’s policies. The home protects the health, safety and welfare of the service users and staff. Training in mandatory health and safety related subjects is up to date, as is servicing of equipment. Food hygiene procedures are sound. Accident reporting is satisfactory and accidents are reviewed for trends. Service user and environmental risk assessments are in place. Health and safety training is now in place on all units. The company has a health and safety team who support the home by auditing the standards of the home and the home has now received a ‘safe site’ award. Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 24 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 3 3 X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP3 Regulation 14 (1) (a) & (c-d) Requirement A thorough assessment must be completed for all service users, including those coming in for respite prior to admission to the home and this assessment must be documented. Timescale for action 30/09/07 2 OP9 13 (2) 31/10/07 Handwritten instructions on the Medication Administration Record sheets must be double signed and dated and a protocol must be developed for the administration of ‘as required’ medication to ensure that staff are clear as to when and why they should be used The staff toilet must be thoroughly cleaned to remove the limescale and staining. 31/10/07 3 OP26 23 (2) (d) Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations Care plans should contain sufficiently full details to enable staff to be able to fully care for service users’ needs. The daily record sheets for service users should be more detailed and reflect both the physical and social care delivered, and daily sheets must be completed daily. The home should continue with its staff recruitment to ensure that there are sufficient staff on duty at all times to meet the needs of the service users. NVQ training should continue as planned to ensure that a minimum of 50 of care workers are trained to NVQ level 2 or above. 2. OP27 3 OP28 Meadowside DS0000013716.V337332.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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