Inspection on 04/05/05 for Meadowside

This inspection was carried out on 4th May 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 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 24/10/05

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 Knowle Park Avenue Staines Middlesex TW18 1AN Lead Inspector Joe Croft Unannounced 4 May 2005 10:30 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 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 H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Meadowside Address Knowle Park Avenue Staines Middlesex TW18 1AN 01784 455097 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust Samantha Taylor Care Home 51 Category(ies) of DE(E) Dementia over 65 - 20 registration, with number OP Old Age - 51 of places PD(E) Physical Disability over 65 - 12 Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be 65 years and over - implemented 1 April 2002 Of the 51 service users accommodated within the home, up to 20 may fall within the category DE(E) - implemented 21 May 2004 Of the 51 service users accommodated within the home, up to 12 may fall within the category PD(E) - implemented 21 May 2004 Date of last inspection 31 August 2004 Brief Description of the Service: Meadowside is managed by Anchor Trust and is one of many Residential Homes managed by the company. The home Is Registered as a Care Home only, within the Service User Categories: Old age, not falling within any other category, Dementia, over sixty five years of age and Physical Disability over sixty five years of age. The home is Registered for a maximum of fifty one residents. The accommodation comprises of fifty one single roonms divided into seven units. Each unit has its own lounge/dining room and kitchenette area. The accommodation is situated in two floors with a lift providing access to the upper floor. The home is in a residential street in Staines and is set in its own grounds close to local amenities. Parking space is provided to the front of the building. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours with one inspector. A tour of the premises was undertaken and staff and care records were sampled. Discussions took place with the registered manager and staff were spoken to individually and during the course of their duties. Discussions took place with five residents and some family members. All residents spoken to were very complimentary about the staff and care they received. The residents received accurate information before they decided to move into the home, and each resident received a written guide about the facilities the home will offer them. The home provides the residents with choices about their daily lives and activities they would like to join in with. Residents spoken to stated that they were happy living in the home. Bedrooms were appropriately decorated and personalised. Residents were able to have a direct telephone line put into their bedrooms if they wished to. Residents stated that the meals at the home were good, and a choice of food is always offered. Family and friends are welcomed and encouraged to visit the home as often as they could. What the service does well: This is a home where the residents say they are respected and cared for. Staff who work in the home spend time talking to the residents, listening to them and helping them to live active and fulfilling lives. Weekly activities are offered for residents to take part in if they wish to. Residents stated that they can make decisions about their daily lives and how they want to live. Residents have regular monthly meetings in the home where their views of how the home should run are listened to, and when appropriate, acted upon. Residents are consulted about the menus at these meetings. Residents and their family members stated that they were consulted in the pre – admission process and writing of care plans. Care plans are detailed with risk assessments, and are reviewed on a monthly basis. During discussions with key workers, and evidencing care plans, it was shown that keyworkers were knowledgeable of the contents of the care plans for the residents with whom they key work. The home currently has 30 of staff NVQ qualified to levels 2 and 3, and a further 48 of staff are working towards completing their NVQ levels 2 and 3 training. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3 Residents are sent the information they need to make an informed choice about where to live. The home has an appropriate admission procedure in place that includes an individual assessment of prospective residents needs, and offers them an opportunity to visit the home. EVIDENCE: The home has a comprehensive Statement of Purpose that includes all as stated in Schedule 1 of The Care Homes Regulations 2001. Residents and their families receive a copy of this when they make initial enquiries to the home. Discussions with residents and relatives present at the time of the inspection evidenced that they had received a copy of the Statement of Purpose. All residents have a signed statement of terms and conditions, which indicate the room they will occupy, the fees charged and the period of notice required by both parties for terminating the agreement. Contracts were in place for residents whose files were looked at. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 9 The home’s manager and deputy manager undertake pre-admission assessments on all prospective residents. Residents and their relatives spoken to stated that they were consulted in the assessment process. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, and 9 The resident’s health, personal and social needs were documented in an Individual Living Assessment that evidenced their health care needs were being met. EVIDENCE: Each resident has a comprehensive care plan that is developed from the pre – admission assessment. Residents and their family members stated that they were involved in writing their care plans. The residents’ key worker discussed the care plan with the resident and members of their family. Care plans sampled evidenced that care and health needs were being met. These are reviewed on a monthly basis, and the resident’s key workers maintain daily records. During discussions with staff it was evidenced that they know the contents of the care plan for the resident they key work with. Staff stated that daily records are comprehensive and easy to follow. All medicines are kept secure in locked cabinets and are dispensed by staff that are trained to do so. This was evidenced in the staff training records. No resident self medicates in the home. Two community nurses attend the home twice a week, and will attend more often if requested. They provide training Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 11 and support on incontinence, and risk assess pressure sores. The manager stated that there are no residents who currently have pressure sores. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 14 The home offers opportunities to residents to make choices about their lifestyles, activities and preferences whilst living at the home. Family members and friends are actively encouraged to visit the home. EVIDENCE: The manager stated that this is the residents’ home and they choose how they wish to live their lives. Monthly meetings take place for the residents where their views about the home are discussed and acted upon. Discussions with residents evidenced that they are able to make choices about their lives whilst living in the home, and that they attend monthly resident meetings. One resident stated that she had bought her own bed when she moved in. Other residents stated that they have the freedom to make choices that affect their lives, they can choose to join in with social activities, have a choice of menu at meal times and choose to stay in their rooms to eat their meals if so desired. The home now employs a full time activities co-ordinator who displays the week’s programme of activities in the day room. Discussion with the activity organiser evidenced his enthusiasm for his role. The activities offered are varied and aimed to help residents socialise and have fun. Residents go to the local shops and use local facilities with the support of care and family members. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 13 Residents are encouraged to maintain contact with family and friends, and some residents have their own telephone lines that enable them to do this. Family members present at the time of the inspection stated that they are always made welcome when they visit the home. The home has a guest room where residents can meet in private with their family and friends if they wish to. Some family members spoken to stated that they visit every day. Telephone numbers for external agencies are displayed in the front entrance hall for residents and their families to contact if they so desire. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 and 18 The home has a satisfactory complaints system with evidence that residents and their relatives feel that their views are listened to and acted upon. Procedures were in place in for the Protection of Vulnerable Adults. Training and induction was available for staff. EVIDENCE: The home has a comprehensive Complaints Policy and Procedure that is made available to staff, residents and their family members. Complaints leaflets are available on the reception desk for all visitors to the home. A complaints poster is situated in the entrance to the home. Discussions with residents and their relatives evidenced that they knew how to make a complaint, and stated that all complaints are taken seriously. One resident and his relative spoken to stated that they had made a complaint that was currently being investigated by the home’s manager. This was evidenced in the complaints book. Other residents stated that they are able to raise concerns in the residents’ monthly meetings where these would be addressed. Discussions with staff evidenced that they have read the complaints policy, know to whom they would take a complaint and were aware that they could report concerns to the Commission For Social Care Inspection. However, not all staff were aware of the home’s Whistle Blowing Policy. Staff spoken to stated that they would report all incidents of bad practice to the manager or deputy manager. Policies and procedures are in place to ensure that the residents are protected from abuse. Residents spoken to stated that the staff are very caring and kind. The ‘Anchor Homes’ booklet, which all staff receive, gives very clear guidelines on abuse, how to recognise signs of abuse of older people and the procedures Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 15 that must be followed when abuse has been suspected or identified. Training on the Protection of Vulnerable Adults took place in September 2004. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19, 20, 21, 22, 23, 24 , 25 and 26 The home offers a comfortable well maintained environment for residents and was clean, and orderly. Bedrooms were personalised and generally the facilities and equipment meet resident’s needs. Three of the residential units were identified as requiring attention. EVIDENCE: The majority of the home is well decorated and maintained, however, a requirement has been made for one bathroom that was identified as being in need of redecoration. Two units in the living accommodation were not free from offensive odours. An immediate requirement has been made for these areas to be addressed. Each living unit has its own dining/living room with television, video and stereo music centres. Residents are able to choose where they would like to eat meals, when and where to watch television, and have unrestricted access to Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 17 communal areas within the home. The home is fitted with the appropriate adaptations and specialist equipment that helps to maximise the residents’ independence. Residents stated that they enjoyed the freedom they have in the home, find it very relaxing, and are pleased that they are able to bring their own possessions. Some residents have their own small pets. The home has sufficient numbers of toilets and baths in each of the units that meet the National Minimum Standards for Older People. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 The manager stated that the home follows the ‘Anchor Homes’ Recruitment Policy and Procedure. Staff files sampled did not contain all as in Schedule 2 of The Care Homes Regulations 2001. EVIDENCE: The manager stated that they have recently had a recruitment campaign that had resulted in recruitment for 600 hours, and offers of employment are subject to the outcome of the current checks as required by Schedule 2 The Care Homes Regulations 2001. During discussions, staff stated that when they applied for a post at the home, they had to submit a completed application form, two referees, CRB form and proof of identity. Eight staff files were sampled. Whilst the majority contained all the necessary information as required, one had no references and some files had letters stating that the CRB checks were clear, but did not include the reference numbers. Requirements have made in respect of these. The manager maintains records of evidence that the information specified in Schedule 2 of The Care Homes Regulations 2001 has been obtained for each agency and bank worker. These were evidenced during the inspection. The manager stated that the home now only uses agency staff approximately three times a week. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 19 New staff to the home undergo an induction period for two weeks. The manager stated that training since the last inspection has included Protection of Vulnerable Adults, dementia care, fire training, back care, basic first aid, health and safety, food handling and hygiene, and care planning. These were verified during discussions with staff, and evidenced in staff training records. The home currently has 30 of staff NVQ qualified to levels 2 and 3, and a further 48 of staff are working towards completing their NVQ levels 2 and 3 training. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 Staff supervision was in place for all staff other than the home manager. Health and Safety for residents and staff is promoted throughout the home. EVIDENCE: All care staff receive formal supervision on a regular basis, records of which were evidenced at the time of the inspection. However, it was identified that the manager of the home does not receive regular supervision from her line manager. This was made a requirement at the last inspection and must now be addressed immediately and without further delay. The home has a comprehensive Health and Safety Policy that is available to residents and staff. Training in areas of moving and handling, fire safety, food handling and hygiene, first aid and control of infection had been delivered in the home during the past twelve months. Evidence in staff training records was seen. Records were evidenced that annual servicing of gas and electric appliances, lifting equipment and fire equipment had been undertaken. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 21 The manager maintains records of accidents and injuries, and reports to the authorities as appropriate, these were evidenced at the time of the inspection. An additional health and safety issue was identified under Standard 26 of this report. Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 x COMPLAINTS AND PROTECTION 3 3 2 3 3 3 3 2 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x 2 x 3 Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 23 YES 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 18 Regulation 21 (2) Requirement The manager must ensure that all care staff have read and understand the homes Whistle Blowing Policy. The bathroom in the Sunflower unit must be redecorated. Offensive odours identified in Willow Court and Bracken Court must be eliminated. Two written references must be obtained for all staff. Staff files must include all the information as stated in Schedule 2 of The Care Homes Regulations 2001. The manager must receive regular formal supervision from her line manager. Timescale for action 4/6/05 2. 3. 4. 5. 21 26 29 29 23 (2) (b) 16 (2) (k) 19 (4) (b) (i) 19 (4) (b) (i) 18 (2) (a) 4/7/05 4/5/05 Immediate 4/5/05 Immediate 4/5/05 Immediate 4/5/05 Immediate 6. 36 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 Good Practice Recommendations Meadowside H58 s13716 Meadowside V224691 040505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection The Wharf Abbey Mill 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. 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