Inspection on 27/01/06 for Meadowside & St Francis

This inspection was carried out on 27th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 & St Francis 12/02/07

Meadowside & St Francis 07/09/05

Meadowside & St Francis 07/12/04

Meadowside & St Francis 02/06/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Meadowside/St Francis Meadowside/St Francis 5 Plymbridge Road Plympton Plymouth Devon PL7 4LE Lead Inspector Mandy Norton Unannounced Inspection 27th January 2006 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/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 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/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Meadowside/St Francis Address Meadowside/St Francis 5 Plymbridge Road Plympton Plymouth Devon PL7 4LE 01752 337938 01752 346682 meadowsidestfrances@btopenworld.com 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) A J & Co (Devon) Limited Mrs Gina Marie Paterson Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (10), Physical disability of places over 65 years of age (69), Terminally ill over 65 years of age (9) Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service Users aged 65 years and over PD(E) Maximum registered 69 service users (both) TI(E) Maximum registered 9 service users (both) OP Maximum registered 25 service users (both) Physical Disability under 65 years of age (10) Date of last inspection 7th September 2005 Brief Description of the Service: Meadowside and St Francis Care Centre is situated in a residential area in Plympton, Plymouth, Devon. The Care Centre is divided into 2 units; one provides nursing care for a maximum of 44 service users (St Francis) the other provides personal care for up to 25 service users (Meadowside). The home caters for persons over the age of 65 years, male and female, with physical frailty, illness or disability (the home is able to take up to 10 people under 65 at any one time). The accommodation is provided on three floors, all but 5 rooms are accessed by a passenger lift; more able service users can access the other 5 rooms by stairs or stair lift. Each unit has dedicated communal areas including lounges and dining rooms, service users from either unit can socialise in either area. Some bedrooms fall below 10 square metres, a formal assessment of individual needs and consideration to choice is given when these rooms are utilised. The home benefits from spacious grounds, which are well maintained and accessible to wheelchair users. Service users who have an interest in gardening are encouraged and facilitated to continue to help around the gardens. The home is owned by A.J. & Co (Devon) Ltd, who own another care home in Cornwall. Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3 hours and 50 minutes (between 11.10 am and 3 pm) and was conducted with the manager. The inspector spoke generally to some clients during the course of the inspection. One of the purposes of this inspection was to assess the key standards that were not considered during the last inspection and to ensure the requirements and recommendations made following the last inspection have been acted upon. A tour of the home took place and a variety of documentation was examined. Following the inspection 2 requirements and 3 recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: All of the windows on the first floor need to be restricted to comply with Health and Safety legislation. The fridge described above should have its temperature taken and recorded every day. Care and ancillary staff should be given some protection of vulnerable adult training at least annually in order that they are up to date with the latest information on the subject. Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 6 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/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed during this inspection EVIDENCE: Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. The health care needs of the residents are identified and met. The medication at the home is generally well managed, promoting good health. EVIDENCE: Five care plans (from the nursing unit) were looked at in detail during the inspection. They all set out in detail the actions to be taken by staff to ensure all aspects of health and personal care are being delivered. They had all being regularly updated and included risk assessments for tissue viability, manual handling and nutritional status. The care staff document details of clients personal care and in the nursing unit these are assessed by the trained nurses who then make any necessary changes to the care plan. A tour of the home confirmed that there was sufficient equipment available for the promotion of tissue viability and treatment and prevention of pressure sores. Records are kept of all medicines received and administered. The medication administration records examined were completed correctly. Trained nurses administer the medications on the nursing unit and carers with Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 10 NVQ level 4 who have been assessed as competent by the manager (level 1 nurse) administer the medications on the residential unit. The medicines stored in the fridge in the dining room are now in an airtight container that is clearly labelled. On examination there were no documented fridge temperatures and the fridge temperature felt warmer that it should have done (the temperature was not measured accurately by the inspector during the inspection, the manager was asked to look into the situation and feedback to the inspector). One of the treatment room doors was found to unlocked during the inspection (see standard 38). During the tour of the home staff were seen and heard being respectful to the clients. When personal care is been undertaken the staff ensure that privacy is maintained at all times. Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed during this inspection EVIDENCE: Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 12 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. The home has a satisfactory complaints system. Staff have some knowledge and understanding of adult protection issues which helps to protect clients from abuse. EVIDENCE: The complaints procedure is displayed within the home and is in the homes brochure. The staff policies and procedures file available to staff at all times has the complaints procedure included in it. There has been one complaint since the last inspection. The documentation, seen by the inspector during the inspection, confirmed that the complaint had been handled according to the laid down procedure. The manager said that the trained nurses have had vulnerable adults training from an outside trainer but that the carers and ancillary staff have not yet received any adult protection training. She said the ‘alerters guide’ and the homes policies and procedures regarding adult protection are available in the home and that staff who have undergone NVQ training will have had some adult protection information. Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 13 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): None of these standards were assessed during this inspection EVIDENCE: Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 14 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): 29 and 30 The homes recruitment policy and practice protect the clients. Clients needs are met by a satisfactory mix of nurses, carers and ancillary staff who are trained and competent to do their job. EVIDENCE: The home has a policy of having 2 written references and a CRB check on file for all staff. Several staff files were examined during the inspection and all included 2 written references, up to date CRB information and a photograph of the staff member. The manager uses a standard interview format and ‘scores’ prospective employers according to their response. She uses this to help make a judgement as to the persons suitability for the post. Several staff training files were also examined during the inspection and contained certificates of all training undertaken. Most of the training is provided by an outside training company. Information about what is contained in their courses was also available to look at during the inspection. The carers and ancillary staff are to have some adult protection training (see standard 18). Induction training is in line with the National training organisation guidelines. Some completed induction files were seen during the inspection. Within the staff group are link nurses for wound care and infection control who attend meetings and cascade information to the rest of the staff about the latest best practice guidelines. Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 15 Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 16 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): 33, 35 and 38. There are comprehensive, regular reviews of performance through a programme of self review and consultation, which includes seeking the views of the service users, relatives and staff. The systems in place in the home promote and protect the welfare of the clients and staff. EVIDENCE: The manager sends out questionnaires out to clients, relatives and staff on a regular basis and acts on general issues and individual issues on an ongoing basis. Clients/ relatives meetings are held to discuss any concerns/ issues when it is necessary. The need to carry out more in depth audits in the future was discussed during the inspection. The manager said that clients are encouraged to handle their own financial affairs if possible. If the home deals with personal allowances the amount each individual has is recorded and any transactions that take place are documented Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 17 with receipts kept to check against. The money is kept in a secure facility as are any valuables that are stored on behalf of the client. The training files examined showed that statutory training in safe working practices such as fire training and lifting and handling is undertaken as necessary. A tour of the home confirmed that some of the windows required to be restricted following the last inspection are stall to be done. The treatment room door on the nursing unit was found to be unlocked and the fridge storing medications had no temperatures recorded and did not seem to be cold enough. A discussion was held about the need to use a more advanced risk assessment when deciding if to use bed rails for a client. This risk assessment has to be documented and seen by the person signing the consent form. Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X 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 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 1 Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 19 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 OP24 Regulation 12 (4) (a) Requirement Those rooms that are not fitted with locks must be provided with locks or evidence shown that clients have been asked whether they want locks or not. (carried forward from 01/10/04). Those windows on the first floor not yet restricted, as required by Health and safety legislation, must be restricted. Timescale for action 01/04/06 2 OP38 12 (1) (a) 01/04/06 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 OP38OP9 Good Practice Recommendations The food fridge located in the dining room on the nursing unit, that also stores some medications (in an airtight labelled container), should have the temperature taken and recoded on a daily basis. The care and ancillary staff should be given some protection of vulnerable adults training/information at least annually. Treatment room doors should be locked at all times. DS0000056816.V269109.R01.S.doc Version 5.1 Page 20 2 3 OP18 OP38 Meadowside/St Francis The risk assessment used to decide whether to use bed rails for a client should be more comprehensive and seen by the person signing the consent form. Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Meadowside/St Francis DS0000056816.V269109.R01.S.doc Version 5.1 Page 22 - 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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