Inspection on 10/03/06 for Mereside

This inspection was carried out on 10th March 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mereside 24/10/07

Mereside 08/11/06

Mereside 08/09/05

Mereside 16/03/05

Mereside 13/10/04

Mereside 17/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Mereside 42 St Bernard`s Road Olton Solihull West Midlands B92 7BB Lead Inspector Kerry Coulter Unannounced Inspection 10th March 2006 09:45 Mereside DS0000004557.V286457.R01.S.doc Version 5.1 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 Mereside DS0000004557.V286457.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 Adults 18-65. 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. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mereside Address 42 St Bernard`s Road Olton Solihull West Midlands B92 7BB 0121 707 6760 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) Mr Tom Eyton Mr Tom Eyton Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May also provide care, subject to appropriate and ongoing assessment, to people with a Learning Disability over 65 years of age. 8th September 2005 Date of last inspection Brief Description of the Service: Mereside is a privately owned Care Home, for adults with learning disabilities. The owner is also the registered care manager. The Home, which opened in 1986, is registered to provide accommodation, board and support for up to 15 adults. Some of the residents have severe learning disabilities with challenging behaviour and profound communication difficulties. The lack of a vertical lift combined with steep steps to the second floor makes the Home unsuitable for very frail or people with a physical disability. The Home, which blends in with its surroundings, is located in a residential area and easily accessible by public transport. Local amenities such as GP’s surgeries, churches and a grocery shop are within walking distance. The Home is approximately three miles from the centre of Solihull. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one Inspector over five and a half hours. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from September 2005. At this inspection time was spent observing care practices, interactions and support from staff. A partial tour of the home was made. Resident care plans, risk assessments and a number of Health and Safety records were inspected. The Inspector had the opportunity to talk with several service users, members of staff, the Manager and the Deputy Manager. What the service does well: What has improved since the last inspection? Work is underway to make the service user guide available in more suitable formats for the residents. Pre-admission questionnaires have been expanded to seek more information about prospective residents. New formats have been developed to record behaviour management strategies to ensure that staff are managing such behaviours in a consistent way. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 6 A new format has been introduced for key worker reviews with headings that direct staff on what needs to be included. Written agreements have now been developed regarding residents contributions for the homes vehicle, and the Manager is in the process of getting these signed. The Deputy Manager has worked hard to create a log of risk assessments, cross referencing them to care plans. Health action plans have been developed, this is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. Staff have received refresher fire training, ensuring they know how to respond safely in the event of a fire occurring. Training has also been completed in challenging behaviour. Requirements regarding medication administration have been met, the medication system is now satisfactory. Procedures for complaints and adult protection have been amended to ensure complaints and concerns are appropriately responded to. A new en suite bathroom is in the process of being installed for one resident. Consultation has taken place with staff to establish if they are satisfied with the night time staffing arrangements in the home. The provision of call bells has been reviewed and one of the more dependent residents has been provided with a personal alarm for his bedroom. The Manager has also purchased a call bell, which once installed will sound in the sleep in room when activated. Records show that water temperatures are now being monitored regularly to ensure the water is at a safe temperature for residents. What they could do better: The development of the care planning system needs to continue. Written assessments need to be available for all identified risks to residents. The Manager must ensure that incidents and accidents are reported to CSCI as required by regulation. The dining room carpet was quite stained and had quite a ridge running across it. This will need deep cleaning and refitting to ensure residents do not trip over it. Consideration should be given to an alternative flooring, of a type that is homely in style but easier to keep clean. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 7 Consultation needs to be extended to residents to establish if the practice of staff sleeping in the lounge impacts on them. Sampled residents records often did not show how the general health and well being of residents was tracked. Records did not show that adequate opportunities for activities were being offered. Significant work is needed to ensure residents records meet the required standard. 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. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 The Statement of Purpose and Service User Guide provide prospective service users with relevant information about the home to enable them to make a choice about if they want to live there. The home undertakes assessments of service users to ensure they are suitable for the home, or that their needs can be met. EVIDENCE: The service user guide and statement of purpose were found to meet the required standard at the last inspection. However a recommendation was made for further consideration to be given to producing the guide in a variety of formats to suit the individual needs of residents. It is positive that work is being done to meet this recommendation. The Speech and Language Therapist has assisted the home to produce a picture format and a video of the home is also being developed. It was recommended at the last inspection that the pre-admission questionnaire used by Mereside is expanded to include possible risks, behaviours that may challenge the service and night time support needs. This was observed to have been done. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Development of the care planning system is in progress to ensure all staff are provided with all the information they need to satisfactorily meet residents needs. People are supported to take responsible risks, written assessments need to be available for all identified risks. EVIDENCE: The care documents of three service users were assessed. The care plans included how staff were to support the service user to meet their needs. These included mobility, social and leisure, behaviour, daily living skills, family contact, communication, choice, privacy, dignity, rights, independence, fulfilment, health and self-care. However some care plans need to include specific details of the nature of support required for each individual, and exactly how that support should be delivered. Individual short and long- term goals were identified. The care plan is reviewed annually by the home and then again after six months. It was observed that often some documents were undated within the plan, for example the date on which the six monthly review took place. The Manager needs to ensure that these records are dated and signed to show that the review actually took place within the six month time frame. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 11 Some residents have behaviours that include verbal and or physical aggression. At the last inspection it was identified that not all of the behaviour management strategies sampled contained enough information to ensure that staff are managing such behaviours in a consistent way. A new format for the recording of strategies has now been developed, this includes sections that detail triggers for behaviours and detail both pro-active and reactive strategies. Whilst these have not yet been completed for all residents that need it the home has made some good progress in completing some. It is good practice that key-workers complete a monthly summary within the care plan. However the quality of the content of these was observed to be variable. To address this a new format has been introduced with headings that direct staff on what needs to be included. Work needs to continue on making individual files as current as possible, by removing old or superseded material, as indicated at the time of the last inspection. It should be acknowledged that this is a work in progress, as plans continue to be updated. Discussion with the Manager and Deputy Manager indicates that they hope to move towards more involvement from residents in care planning. The Deputy Manager is soon to attend training on person centred planning and it is planned that following this person centred plans will be introduced. It is evident that residents can make decisions about their day-to-day lives. Regular residents meetings are held in the home, records of these were available. Residents contribute towards the cost of the home vehicle. However up to date agreements for this were not available at the last inspection detailing how the cost is worked out and signed by the resident or their representative, ideally this should be someone external to Mereside such as a relative or advocate. Written agreements have now been developed and the Manager is in the process of getting these signed. There is evidence that residents are supported to take manageable risks, and staff encourage individuals to have an independent lifestyle. Risk assessments have been completed for a wide variety of activities that could pose a risk. However several residents often use an electric walking machine, this had not been risk assessed. Since the last inspection the Deputy Manager has worked hard to create a log of risk assessments, cross referencing them to care plans so that the reader is naturally directed from one to the other. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 17 Records do not show that residents participate in a wide range of fulfilling activities. Residents are offered a healthy diet. EVIDENCE: The majority of residents attend day placements at local day centres or supported work placements. One resident works at a farm several days a week. However it was difficult to evidence from records that residents are also offered adequate opportunities to participate in other age, peer and culturally appropriate activities. Records did show that activities participated in included shopping, using the treadmill, walks, bonfire parties. However the activity record for one resident from 11th November to 27th January recorded only three activities. The Deputy said that residents participated in lots of activities but acknowledged that the records needed to improve to reflect this. The inspector had the opportunity to eat lunch with one resident. Staff also ate with the resident and the atmosphere was friendly, relaxed and unhurried. The lunch provided was well presented and tasty. Food stocks were observed to be plentiful. Menus and records of food were observed to be satisfactory at the last inspection. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Health action planning is now underway but systems to monitor residents general well being needs to improve. Procedure and practice with regard to the management and administration of medication is satisfactory. EVIDENCE: Each resident is registered with a local GP. Resident records sampled included details of health appointments attended. Records sampled indicated that where appropriate service users are referred to health professionals including the community nurse, psychiatrist, psychologist and speech and language therapist. At the last inspection it was identified that residents did not have health action plans. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. The Manager has obtained a format for health action planning from the Community Nurse and was able to evidence that the completion of plans has now commenced, it is hoped this will soon be completed. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 14 Sampled residents records often did not show how the general health and well being of residents was tracked. For example the record for one resident showed they had been sick in their sink. There was no follow up entry to record if they had been monitored by staff, seen the GP or had felt better. This is further detailed in Standard 41. It was identified at the last inspection that the CSCI had not been notified of all incidents/ accidents in the home, as required under regulation 37. The Manager must reinforce with all staff that this needs to be done as sampled records showed not all incidents are being reported. For example, one resident was pushed over by another resident resulting in a lump to their head. Discussion with the Manager and observation of the homes training records indicates that staff have received accredited medication training. Medication was observed to be stored securely in locked cabinets. Medication administration records were sampled and observed to have no gaps. Some residents are sometimes given ‘as required’ medication for behavioural reasons. It was required at the last inspection that clear protocols on the use of all ‘as required’ medication are available to direct staff as to when they should be given. These have now been completed but needed further detail to be added. This was addressed by the Manager at the time of the inspection. As required previously copies of prescriptions are now retained in the home. The Manager is also completing medication stock audits, however it is recommended that a more formal record of this is introduced. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents are listened to. The complaint procedure is satisfactory. Arrangements for protecting residents from abuse are adequate. EVIDENCE: At the last inspection residents spoken with said they feel that staff listen to them and they said there is always someone to talk to if they are not happy about something. Records of residents meetings show that they have been made aware of the complaints procedure. The procedure was observed to require minor amendment to make it clear that the CSCI can be contacted at any stage with a complaint, this has now been done. The CSCI has not received any complaints about this service in the last twelve months. Required amendments to the adult protection procedure have now been made. The Manager has also obtained a copy of the Solihull Multi Agency Guidelines on Adult Protection. Staff have received adult protection training. The recruitment records for a new member of staff showed that all the necessary checks had been done. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29 The standard of the environment within this home is generally high providing residents with an attractive and homely place to live. EVIDENCE: The home has undergone recent building works to provide all residents with a single bedroom, increase the number of en suite bathrooms and re-site the laundry. The kitchen has been upgraded and a new office is in use. Décor throughout the home was observed to be in good order, although the main lounge is starting to look a little worn. The Deputy Manger said plans were in place to redecorate this room in the near future. The dining room carpet was quite stained and had quite a ridge running across it. This will need deep cleaning and refitting to ensure residents do not trip over it. Consideration should be given to an alternative flooring, of a type that is homely in style but easier to keep clean. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 17 The Home provides a number of safe and accessible communal areas for both shared and private use. These consist of a dining room, large lounge next to which is situated a smaller sitting room. All are located on the ground floor. The larger of the sitting rooms overlooks a private and secure garden. The home now benefits from staff sleep in facilities. When the alterations were taking place it was anticipated that this would resolve the unsatisfactory practice of the sleep in member of staff having to sleep in the communal lounge. Unfortunately, due to the increase to two sleep in staff the main lounge is still being used as a sleep in room for one member of staff. This is not ideal. Since the last inspection the Manager has completed written consultations with staff. The result of the consultation was that staff were happy with the sleep in arrangements. This consultation needs to be extended to residents to establish if the practice of staff sleeping in the lounge impacts on them. It may be that it would be less of an impact if staff used the small sitting room rather than the main lounge. The home provides a variety of specialist equipment. This includes walking frames and wheelchairs as well as aids to assist with bathing. A new bath lift has been installed since the last inspection. Call bells are not provided in most bedrooms, but two call bells are sited on each landing. As required at the last inspection the provision of call bells has been reviewed and one of the more dependent residents has been provided with a personal alarm for his bedroom. The Manager has also purchased a call bell, which once installed will sound in the sleep in room when activated. The Manager said that planned improvements to the premises included a covered walkway to the outside laundry. This will provide a shelter for residents and staff when it is raining or snowing. Currently work is in progress to install an en-suite bathroom in one bedroom. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Residents are supported by staff, who are appropriately qualified to meet their needs. Recruitment policy and practice supports and protects people living in the home. EVIDENCE: It was noted that both staff and residents appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. Ten staff have completed an NVQ 2 or 3 in care, this meets the standard of having at least 50 of staff having completed an NVQ. Discussion with the Manager indicates the home is fully staffed and has no vacancies. The home has a stable staff team. Agency staff are not used in the home. Staffing levels in the home during the day are satisfactory. Usually there are two staff and the Manager and Deputy Manager on the early shift and three staff on the late shift. It was identified at the last inspection that the arrangements of having two sleep in staff at night might not be adequate due to one resident often being up during the night. Discussion with the Manager and records show that this resident usually now sleeps well through the night. The Manager also consulted with staff as to whether they were happy that staffing arrangements at night were meeting residents needs. All staff stated they were happy with the current arrangements. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 19 It was identified at the last inspection that staff meetings need to occur more frequently, this is now happening. The file of one new member of staff was sampled. This had details of the application form, references, CRB checks and identification details to evidence that residents are protected by the homes robust recruitment procedures. Evidence was available to show that the new staff had received appropriate training, to include the TOPPS induction. Staff receive regular training to include adult protection, health and safety, manual handling, first aid, ‘Safe Handling of Medicines’, food hygiene, COSHH and falls awareness. As previously required staff have now received training in managing challenging behaviour and have done refresher fire training. The Manager has also purchased a new fire video and training pack for future use with staff. Staff have also recently received diabetes training from the Dietician. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 41, 42 Significant work is needed to ensure residents records meet the required standard. Health and safety of staff and residents was adequately managed. EVIDENCE: The style of management in the home is relaxed, open and inclusive, and the Manager is making clear efforts to develop the service for the benefit of the people living there. The Manager has a significant amount of experience in care and is a registered nurse, as well as having a NVQ 4 qualification. The standard of record keeping in the home was variable. Improvements have been made to administration systems since the last inspection as a colour coded system for files has been introduced, making it quicker to locate the required records. Some records were well maintained to include staff files, medication records and health and safety checks. However residents records required significant improvement. Staff presently record care given to residents on loose sheets of paper, entries were observed not to follow chronologically. It is therefore recommended that bound books are used for this purpose. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 21 As stated earlier in this report records did not always detail the well being of residents. Entries that recorded residents being unwell were not followed up with any outcome. One entry recorded a resident being pushed on 31st December by another resident causing a lump to the head, it was of concern that there was no further entry until 14th January. As staff do not make a daily entry for each residents it is difficult to track their well being and also ensure that care plans are being adhered to. Separate activity records were also observed to require improvement. This area of the service requires significant work to ensure that records detail well being, all care offered and response to care. The homes fire records were observed, these indicated that regular testing of the alarms and emergency lighting is carried out. Certificates of servicing were available for the fire alarms. Records evidence that a recent fire drill had been conducted. It is an area of good practice that the home has completed individual risk assessments for evacuation in the event of a fire, these are reviewed after a drill has taken place. Staff have received refresher fire training as previously required. Since the last inspection the home has received a visit from the West Midlands Fire Service who made some requirements, one of these related to access to the fire escape. This has now been acted on, a corridor has been provided to the fire escape exit so that people evacuating do not have to go through a residents bedroom. Records show that water temperatures are now being monitored regularly to ensure the water is at a safe temperature for residents. Current certificates of registration and employers liability insurance were on display. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 23 CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 2 29 3 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 3 X 3 X X X 2 3 X Mereside DS0000004557.V286457.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 YA6 Regulation 12(1) 15 Requirement Timescale for action 30/04/06 2 YA7 17(2) Sch 4(9) Care Plans: Ensure all reviews are dated and signed. Review all behaviour management strategies to ensure they include triggers for behaviours, link to the use of any as required medication and detail both pro-active and reactive strategies. (Work in progress) Outstanding requirement from 30/10/05. Care plans need to include specific details of the nature of support required for each individual. Documented agreements 30/05/06 must be in place to demonstrate how each individual contributes to vehicles costs. These must demonstrate that cost is equitable to use and provide value for money for the individual. These should be signed by the service user or their representative. Outsanding requirement from 30/11/05, but work in progress. DS0000004557.V286457.R01.S.doc Version 5.1 Page 25 Mereside 3 YA9 12(1) 13(4) 4 YA12YA19YA41 12(1) 5 6 7 YA19 YA28 YA28 37 23(2)(b) 23 (3)(b) Ensure all risks to service users are appropriately assessed to include use of motorised treadmill. The Manager must ensure service user records detail their general well being, activities offered, all care offered, and response to care. Outstanding requirement from 15/09/05. Ensure accidents/incidents are reported to CSCI as required. Dining room carpet requires cleaning and refiting. Sleep in staff must be provided with satisfactory facilities. The practice of staff sleeping in the lounge must be reviewed. (Review completed with staff, but needs to include residents). 30/04/06 30/04/06 30/03/06 30/04/06 30/05/06 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 2 3 4 Refer to Standard YA20 YA28 YA35YA41 YA41 Good Practice Recommendations Introduce a more formal system for the auditing of medication. Dining room. Consideration should be given to an alternative flooring, of a type that is homely in style but easier to keep clean Staff should receive further training in record keeping practice. Bound books should be used for the recording of residents well being. Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Mereside DS0000004557.V286457.R01.S.doc Version 5.1 Page 27 - 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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