CARE HOMES FOR OLDER PEOPLE
Meadowyrthe Comberford Road Tamworth Staffordshire B79 8PD Lead Inspector
Mr David Cowser Unannounced Inspection 20th December 2005 09:30 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 Meadowyrthe DS0000034341.V273986.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. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Meadowyrthe Address Comberford Road Tamworth Staffordshire B79 8PD 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) 01785 277088 Staffordshire County Council, Social Care and Health Directorate Mrs Ann Marie Cooper Care Home 50 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (44), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (20), Old age, not falling within any other category (10), Physical disability over 65 years of age (30) Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 10 Dementia (DE) - Minimum age 50 years on admission Date of last inspection 5th July 2005 Brief Description of the Service: Meadowrythe House is a Local Authority home that can accommodate a total of 50 older people. The home is located on the outskirts of Tamworth, close to amenities, and is served by public transport. Accommodation is provided on two floors served with a shaft lift and comprises a total of 50 single bedrooms, twelve of which have an en-suite facility. Adequate communal spaces are provided, with separate lounge areas. The home is pleasantly situated with extensive grounds and adequate car parking, external roadways and pathways are provided. A large patio area is well used by the residents. The home is registered for people in the following care categories; dementia, mental illness, old age, and physical disability. The home manager, assisted by a deputy, care shift leaders, and teams of care assistants provide care. Health service professionals such as district nurse, community psychiatric nurse, and physiotherapist are accessed when required and local GPs and a pharmacist service the home. Special arrangements are in place with the NHS psychiatric services IRIS team (in reach intensive support team), who will respond to meet specific needs of mentally ill service users. Activities, hobbies and entertainment take place, which are organised by a designated staff member. Families and friends are encouraged to take part where applicable, and transport is provided when required. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine unannounced inspection was made on the 20 December 2005 @ 09.30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to seven hours. The care manager was in charge of the home, accompanied by a care shift leader, and eight care assistants. The ancillary staff on duty included; a cook and an assistant, two domestic workers, a laundry person and a maintenanceperson. The head of hotel services was also on duty. These staffing levels were adequate to meet the needs of current 30 residents in the home. The total of 30 elderly residents, aged between 66 and 98 years of age, included; 24 with a dementia related condition and 6 people receiving personal care for needs associate with old age. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with five residents, discussions with all the staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 5 July 2005; there had been no changes to the management of the home, two unsubstantiated complaints had been received, and one additional visit had been necessitated. This home is programmed to be re-furbished and upgraded, starting in the New Year. What the service does well:
Residents and/or their representatives had been able to choose the home, following an assessment and an invitation to visit, prior to admission. Speaking to three residents and three visitors, and inspecting the admission documentation, confirmed this. Residents and visitors asked said that they had been made aware of the terms and conditions of a stay in the home. The statement of purpose along with the service user guide seen reflected the current status of the different parts of the care home. The above aspects had ensured that each resident had been suitably placed, and that the home had the ability to meet their assessed needs.
Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 6 It was evident, from discussions with residents and staff and an inspection of the relevant documentation, that the provision of health and social care had been addressed well. Service user plans seen had been completed and regularly reviewed. The plans were based on the community care plans completed by social workers, and agreed by residents/representatives. There was a good safe system in place for the receipt, storage, administration and disposal of medicines. No errors were noted concerning medicines, and residents asked said that they had their right medicines on time. Privacy, dignity and choice aspects for residents were seen being upheld during the caring process. When asked several residents and relatives said that they were very happy with the health and personal care being delivered by the home. During the past 12 months the number of accidents and reportable events in the home was low and this also reflected the good standards of care being delivered. Activities and entertainment had recently taken place, and were seen documented within the diary. Residents told the inspector that they had appreciated and enjoyed the recent events and activities, and that they were able to choose whether or not to take part. Three visitors confirmed that links had been maintained with them and links had also been maintained with the local community. Catering aspects were good and records seen showed that individual dietary requirements had been met. Residents spoke of choices and said that they were pleased with the food provided. The inspector joined the residents for the main meal of the day, which met all requirements and was well presented. Assistance was seen being given to people with mental health or dementia care needs to help them to make a choice, by staff who had knowledge of the residents likes and dislikes. All of the above had assisted the residents in their daily living and social activities. No incidents or reports of abuse of any kind had been received since the last inspection and policies and procedures seen covered these issues. The two unsubstantiated complaints made since the last inspection had both been investigated well, and recorded. Residents confirmed that they had the opportunity to vote, and the manager stated that an advocacy service would be provided if legal or other advice were required. These aspects had contributed to the protection of service users. The home was fit for purpose, and provided a safe environment for the residents, staff and visitors. A homely atmosphere had been created and the premised were clean, warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities including catering and laundry were adequately provided, and staffed. All residents asked stated that they were happy with the facilities and that they were comfortable with their surroundings. The registered care manager and teams of care staff provided care. A good working relationship was evident with the local GP practices and pharmacist. A
Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 7 visiting GP spoke very highly of the home, and the communication with the home. NHS facilities and both community and hospital health professionals had been accessed when required. Community Psychiatric Nurses were accessed to meet the mental health needs of service users. The IRIS (in reach intervention service) NHS psychiatric services had been accessed when required. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were good. Staff training had been given a high priority, with induction training being followed by NVQ training. In house training in relevant subjects had been on going. These aspects had contributed to the high standards of care being provided by the home. The home appeared to be managed well by a registered care manager. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that the Local Authority adopted suitable accounting/business procedures. The management of health and safety issues had been given a high priority and no shortfalls were noted. The documentation seen evidenced that the premises were adequately maintained. The current insurance certificate was seen. There was a safe system of accounting for residents day to day monies and the ledger reconciled with the money held. All the above had contributed to the protection and well being of residents in the home. Throughout the inspection the people who use, or have contact with, the home expressed only positive views. Many thank you cards and complimentary letters were seen from appreciative relatives. What has improved since the last inspection?
Since the last inspection the percentage of care staff that have achieved NVQ level 2 or above has passed the 50 mark, as required. Staff training has continued in relevant subjects for the registered client groups. The menus have been reviewed and amended, with the input of the service users and care staff. The above was established by speaking to residents and staff, and an examination of the training and catering documentation. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 8 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. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 9 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 Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 10 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): Standards 1,2,3,4,5 Residents had been correctly placed in a home of their choice, which had the ability to meet their needs, following an assessment of their needs and the provision of information on the service. EVIDENCE: The documentation seen, and a discussion with both residents and their representatives, evidenced that residents had been assessed prior to admission and they had been able to make a choice about the home. All had been given the opportunity to visit the home prior to choosing to stay. Two residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within the care plans. A full assessment of each residents needs had taken place before admission and this was seen documented. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Residents asked confirmed that they had been fully involved and were in agreement with the assessments.
Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 11 Residents and relatives asked were also aware of the service users guide. The guides and the statement of purpose for the home were seen available, and were up to date and correct. All of the above had contributed to residents being able to make an informed choice about their stay in the home. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 12 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): Standards 7,8,9,10,11 Individual health, personal and social care needs, as documented within care plans, had been adequately addressed with privacy and dignity afforded during the caring process. EVIDENCE: Several service users, and three relatives spoken to, all commented positively about the care being provided. Relatives made a point of asking to speak of their satisfaction to the inspector. The service user plans and associated documentation seen were complete, reflected the current condition of residents, and had been regularly reviewed. Care aspects had been well recorded and were seen cross referenced to associated documentation such as accident book and incident sheets. Entries seen were meaningful, and weekly summaries were seen on contact sheets. Forms had been completed in anticipation of a resident being transferred to a hospital or other setting. Discussions with both residents and staff members evidenced that health and personal care needs were being well met. A total of three care plans were examined in greater depth, with a check on all aspects of care starting at the pre admission/assessment stage.
Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 13 NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. Local GP practices and a pharmacy service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. The visiting GP spoke very highly of the home and the care delivered. Currently no residents had a pressure area. Community Psychiatric Nurses were accessed to meet the mental health needs of service users. The IRIS (in reach intervention service) NHS psychiatric services had been accessed when required. The medicines within the home, medication administration records, controlled drugs book and drugs returned book, were all checked and no errors were noted. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. The documentation seen evidenced that only senior staff administered medicines, and that they had completed certificated training. No resident was ‘self medicating’, but locked facilities were available. Controlled drugs were checked and the stock reconciled with the accurate records seen. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. Four residents told the inspector that they were treated with respect, and that the staff were very kind. The records and policy documentation seen, along with a discussion with the staff, evidenced that death and dying aspects had been dealt with correctly and in a sympathetic manner. There had been five deaths in the home since the last inspection. All of the above evidence satisfied the inspector that the individual health, personal and social care needs of patients and residents had been addressed in the correct manner. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 Social contact had been maintained and the daily activities, along with autonomy and choice, had contributed to the resident’s lifestyle experiences meeting their expectations. Catering aspects were good and met individual needs and preferences. EVIDENCE: Several residents told the inspector that their views had been listened to, and that they had been able to influence some aspects of the running of the home e.g. mealtimes, menus. These comments had been documented along with the feed back from the resident/relatives questionnaires, and they had been acted upon. Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Residents spoke of their visitors and their involvement with the home. Visitors attending the home during this inspection, told the inspector of the good links and communication with them. A designated person is employed to coordinate and record the activities and entertainment provided. Several residents commented that this work had been appreciated. A discussion took place with the residents in the lounges regarding Christmas and the coming events.
Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 15 Several residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met, including residents’ needs with diabetes, and special diets. The menus had been recently changed with input from the residents and staff knowledgeable of their likes and dislikes. The cook when asked said that fresh good quality food from local suppliers was delivered on a weekly basis, the records seen confirmed this. Adequate supplies of fresh vegetables and fruit were also seen. The care staff spoke with each resident on a daily basis to establish his or her choice of food for the day, and this was seen documented. The inspector joined the residents for the mid day meal and it was well cooked and presented, meeting all requirements. Two residents said that they always had at least two choices and that an alternative to these would be provided if requested. Several residents were unable to make a decision regarding choice of meal, due to their current condition, and the inspector saw them being assisted by staff who were knowledgeable of their likes and dislikes. Residents were seen being discretely assisted to eat in an unhurried manner. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,17,18 An open culture existed where complaints or grumbles are listened to and acted upon. Residents are protected from all forms of abuse, and their legal rights are also protected. EVIDENCE: An examination of the complaints records, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with. Two unsubstantiated complaints had been received since the last inspection. An additional visit was made by a CSCI inspector a part of the investigation. Many ‘thank you’ and complimentary cards were seen from appreciative relatives. No incidents or allegations of abuse of any kind had been recorded or brought to the attention of the CSCI. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen also evidenced that all the above issues had been discussed at length during staff induction, training and on-going supervision. A discussion with the staff and residents evidenced that all residents had been afforded the opportunity to exercise their vote in past elections. The manager confirmed that an advocate would be facilitated if required by a resident. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 17 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): Standards 19,25,26 The home was clean, pleasant and hygienic, and provided a suitable and safe environment for the provision of care, with two environmental exceptions. EVIDENCE: A tour of the buildings, and a check on the maintenance documentation, evidenced that the premises were fit for purpose, clean warm and tidy, and were being maintained. The laundry and sluice facilities were compliant. The redecoration and upgrading work was planned for commencement in January 2006. All remaining heating radiators accessible to residents must be guarded to ensure low surface temperatures. Risk assessments must be continually updated until the guards are fitted. The slabs on the rear patio must be relayed to remove the tripping hazard, as agreed. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 18 The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked had knowledge on infection control, and referred to the relevant documentation. Adequate hand washing facilities, including hand gel, were available throughout the home. The records evidence that maintenance of the premises was being given a priority. The grounds and gardens were seen to be well maintained and were appreciated by residents spoken to. Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. There are no outstanding issues known from the Fire Prevention or Environmental Health departments. Final inspections will be carried out on completion of the upgrading work. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 19 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): Standards 27,28,29,30 Adequate numbers of suitably trained and experienced staff are correctly employed to meet the assessed needs of residents. EVIDENCE: The care manager was in charge of the home, accompanied by a care shift leader, and eight care assistants. The ancillary staff on duty included; a cook and an assistant, two domestic workers, a laundry person and a maintenanceperson. The head of hotel services was also on duty. These staffing levels were adequate to meet the needs of current 30 residents in the home. The records seen and a discussion with the staff evidenced that, individually and collectively, they had the necessary experience and skills to meet the assessed needs of the current service users. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 20 The duty rosters seen, and a discussion with the care managers and the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing 30 service users. The following care staff had been on duty or exceeded; Morning 1 manager 7 care assistants Afternoon. 1 manager 6 care assistants Night time 1 Superintendent 3 care assistants (all awake) Adequate ancillary staff had been provided each week. Several residents asked stated that staff were available when they wanted them, and that the staff were capable. The records seen evidenced that in addition to the registered manager the home employed 40 care staff, of which 21 (52 ) were trained to NVQ level 2 or above. The records evidenced that induction and NVQ training had been given a high priority. General training had also been given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training, which had covered the needs of the registered client groups. Staff asked said that they had been afforded the time off and encouraged to study. The training included dementia awareness and management, and also management of aggression. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 21 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): Standards 31,33,35,38 A competent and experienced care manager is managing the home, in the best interests of service users, and in an open an inclusive atmosphere. The home is being run well, is on a sound financial footing, and has safeguards for the health and well being of residents’ staff and visitors. EVIDENCE: The registered care manager is well experienced, qualified and competent. An open, positive and inclusive atmosphere was observed during the visit and confirmed to the inspector by service users, staff and relatives. Staff when asked also said the manager portrayed a clear sense of leadership and direction which enabled them to relate to the aims and objectives of the home. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 22 From observations made, discussions with service users and staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. Staff supervision sessions, six times per year, had all been completed and documented. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and residents and families had chosen to do so. Day to day monies of residents was checked, and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home, with the exception of the radiator guards and relaying of patio slabs referred to earlier in this report. Not all documentation for the servicing of plant and equipment was examined. The documentation seen for checks and examination of plant and equipment was correct and up to date. All of these documents will be checked during the next inspection. The care manager, and the service development manager, gave assurances that the home was viable and that the Local Authority adopted suitable accountancy and budgeting procedures. The current public liability insurance certificate was seen up to date and correct. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 23 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 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 x x x x x 2 3 STAFFING Standard No Score 27 4 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 4 3 x 3 Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 24 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 OP25 Regulation 23(2)(p) Requirement All remaining heating radiators accessible to residents must be guarded to ensure low surface temperatures. Risk assessments must be continually updated until the guards are fitted. The slabs on the rear patio must be relayed to remove the tripping hazard, as agreed. Timescale for action 31/03/06 2 OP19 23(2)(o) 20/01/06 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 OP19 Good Practice Recommendations The planned upgrading work should commence, as planned, with the identified areas given a priority. Meadowyrthe DS0000034341.V273986.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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