Inspection on 26/02/07 for Radcliffe Meadows Mental Nursing Home

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Radcliffe Meadows Mental Nursing... 30/04/09

Radcliffe Meadows Mental Nursing... 30/04/08

Radcliffe Meadows Mental Nursing... 03/01/08

Radcliffe Meadows Mental Nursing... 27/02/06

Radcliffe Meadows Mental Nursing... 16/08/05

Radcliffe Meadows Mental Nursing... 04/02/05

Radcliffe Meadows Mental Nursing... 22/07/04

Radcliffe Meadows Mental Nursing... 08/03/04

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Clover House

Parkside

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Park Lodge

Mere Hall View

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

CARE HOME ADULTS 18-65 Radcliffe Meadows Mental Nursing Home Off Twiss Green Lane Culcheth Warrington Cheshire WA3 4DJ Lead Inspector Sue Dolley Unannounced Inspection 26 February 2007 and 9 March 2007 10:05 th th Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 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 Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Radcliffe Meadows Mental Nursing Home Address Off Twiss Green Lane Culcheth Warrington Cheshire WA3 4DJ 01925 765550 01925 767636 june@radcliffemeadows.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) Warrington Community Living Ms June Gilbody Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 12 service users to include: * Up to 12 service users in the category of LD (learning disability excluding dementia). * Up to 1 named service user may be category of MD (mental disorder). Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines, which may be issued through the Commission for Social Care Inspection. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 27th February 2006 2. 3. Date of last inspection Brief Description of the Service: Radcliffe Meadows is purpose built. The home provides nursing care for twelve younger adults who have a learning disability accompanied by behavioural/mental health needs and/or physical or sensory needs. The home is situated close to the local village and is within a short walking distance of a bus service. The philosophy of the home is to enable residents to lead an independent and fulfilling lifestyle by providing opportunities to exercise their rights, and to enjoy the same range of options available to all members of society. The home is a single storey building that provides twelve single bedrooms, three lounges, two dining rooms, a games room, two bath and shower rooms, four toilets, a laundry, kitchen, and large enclosed gardens to the rear of the property. Fees are individually arranged and are to provide accommodation, food heat, laundry and a high standard of nursing care according to the amount of support needed. The minimum fee is £6038.84 and is four weekly. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days, on 26th February 2007 and 9th March 2007 and over a total period of 8 hours. This was to assess if the residents, needs were being met at the home. A tour of the premises took place and included the majority of the bedrooms and all shared areas such as the lounges, dining rooms, shared bathrooms and toilets, the kitchen and laundry. The registered manager, several staff members and residents contributed to the inspection of the home. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose, service user guide and home brochure are to be reviewed in the near future to provide up to date information, easy to read information for prospective residents, existing residents and their supporters. Housekeeping, cleanliness and maintenance within the home could be improved upon and information about the daily menus could be made available to service users. Recruitment procedures could be more thorough to ensure all necessary staff checks are undertaken prior to commencement of employment. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 6 The recording of medication and the recording of fire training could be improved upon and some staff members need training in various subjects to help inform their practice. The quality assurance system is still being established and better records of activities undertaken could be kept. 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. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 7 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 Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 8 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 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. The Statement of Purpose and Service User Guide provide information to prospective residents, but these need to be reviewed so that they are made available in formats suitable for residents to understand. EVIDENCE: Radcliffe Meadows provides 24 hour nursing care to people over 18 years. The criteria for admission is explained in the Statement of Purpose explains that the criteria for admission are needs relating to learning disabilities and another need such as challenging behaviour, uncontrolled epilepsy or mental health issues. The statement of purpose, service user guide and home brochure are to be reviewed in the near future to provide up to date, easy to read information for prospective residents, existing residents and their supporters. The home provides each resident with a client handbook, which contains useful information including a copy of a service agreement, details of how to make a complaint, details about house rules and fire procedures etc. Many of the existing residents have lived at the home since the opening in 1993 and vacancies occur infrequently. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 9 The care files of three residents were checked and contained very thorough nursing assessments of needs and useful summaries to describe the level of care and support necessary and the action to be taken to address all care needs. Pre admission assessment information had been gathered from a variety of sources to build a complete picture of each resident prior to them entering the home. Personal details were carefully recorded and all necessary contact information was provided. Each care file contained care plans and risk assessments, which had been regularly reviewed and evaluated. Medical reports were available and the daily records of care which were kept, were informative and provided evidence of continuity of care. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Resident’s needs and goals are reflected in their individual plans of care. Residents know that they are supported to take risks as part of an independent lifestyle and are assisted to make choices and decisions about their lives. EVIDENCE: The three individual plans of care had been positively written and were person centred. Life histories had been written from the resident’s perspective and provided evidence of individualised care and support. The plans set out how current and anticipated specialist requirements were to be met, through positive planned interventions, structured environments and when needed through one to one support. The plans established individualised procedures for residents likely to present challenging behaviour, focusing on positive behaviour, ability and willingness. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 11 Questionnaires were sent to various Health Care Professionals prior to the inspection to ascertain their views about Radcliffe Meadows. A number of positive comments were received. Staff were reported to be ‘always pleasant, approachable and knowledgeable of each resident and clearly they are well motivated and care a great deal about the residents’. Another respondent said this is a ‘good home, always sociable, good rapport of staff and no medical concerns’. The plans had been drawn up with the involvement of residents together with family members, other supporters, professionals, and with advocates as appropriate. Resident’s personal goals had been recorded and it was evident from the records kept and from discussions that staff members had provided residents with the information, assistance and communication support they had needed to make decisions about their own lives. Risk assessments were in place as appropriate to eliminate and reduce risks, regarding falls, the development of pressure areas, safer handling, and all activities of daily living. Risk assessments had been completed prior to outdoor activities and holidays and as an incentive towards developing independent daily living skills one resident had agreed to undertake some domestic household tasks for an agreed amount of payment. Each care file described the resident’s personality and needs well and a photograph was included to aid identification. In one care file the personal description was incomplete and did not include details of eye colour, chest size, inside leg measurement, shoe size and likes and dislikes. A bowel movement record had not been completed. Details of the resident’s dentist and optician had not been included and although a preadmission assessment had been completed the signature of the assessor was unreadable. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 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): 12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. Residents are encouraged to take part in a range of appropriate leisure activities. But access to further education, training and employment is limited and does not enable residents to develop and live fulfilling lives outside as well as within the home. Food offered at Radcliffe Meadows is healthy, varied and appetising and is enjoyed by residents. EVIDENCE: Radcliffe Meadows is located in a small village community and residents are able to access local facilities including shops and pubs. Residents are encouraged to attend special events in the village and activities co-ordinators are employed to arrange and facilitate a number of activities for individuals and groups such as fishing, bowling, walking and swimming. Residents attend a local luncheon club and sometimes go out for meals. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 13 The home employs activities organisers. Apart from photographic evidence there was little written evidence of individual and group activities facilitated by the organiser. The opportunities for residents to find out about and take up opportunities for further education, vocational, literacy and numeracy training have been limited. Recent attempts by staff members to secure short six week educational placements at a local college have failed and opportunities for work experience have also been very limited. The registered manager intends to help address these issues and pursue appropriate placements with staff in the near future. Residents are encouraged to participate in the day to day running of Radcliffe Meadows. There is residents action group to give residents a forum to voice their opinions, suggestions and concerns, to have information shared with them and to help them make decisions. Radcliffe Meadows has an open visiting policy; although visitors are asked to contact the home prior to arriving to make sure the resident is available. Staff members can accompany residents and their family members on trips if necessary to assist should behavioural problems arise. Family members are invited to the home to participate in special events and there is close liaison with resident’s supporters and the home for the benefit of residents. Residents are supported to maintain relationships, which are important to them. Currently there are plans to convert a little used communal room to a lounge in which residents can greet and entertain their visitors. Residents at Radcliffe Meadows were observed to enjoy their lunchtime meal. Menus are varied and alternative meals are always available to suit resident’s preferences. Special diets are catered for. Residents who present with chewing and swallowing difficulties are referred to Speech and Language therapists for assessment and recommendations. The kitchen was visited and was very well organised and clean but with little storage space available for dry and tinned goods. Currently menu boards are not available for residents to advise them of food choices. Pictorial menu boards could be used to show meal selections. The small kitchen areas in each of the dining rooms were in need of tidying and cleaning. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 14 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): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. Residents receive attentive care, which is respectful and supportive. The administration and recording of medication needs improvement to ensure that residents receive their medication as prescribed and are safeguarded. EVIDENCE: Resident’s personal care needs are detailed within their individual Care Plans. Three care plans were checked. Individual care needs were identified in detail and all personal support needs were described fully. Pre- admission assessments had been completed thoroughly and care files contained details of resident’s life histories, nursing and risk assessments. Residents’ health is closely monitored and potential complication and problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. There was evidence of support from a variety of health professionals to assess and provide for residents health care needs. Health care reports from General Practitioners and Consultants, Speech and Language therapists etc. were available to provide additional information, support and Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 15 advice. Care plans had been regularly evaluated and updated and residents had been referred for counselling and for advocacy support when appropriate. Daily reports and incident logs were informative and provided evidence individualised support and continuity of care. Staff members were observed to promote resident’s dignity and privacy when offering personal care. Currently care staff members are involved in a pilot study to develop an anticipatory care calendar to be used as part of the care plan documentation and to improve care planning. Medication is ordered from a local pharmacy and stored securely. Medication policies and procedures were available to staff members to refer to. The medication administration records were checked. Ten of twelve medication administration records did not contain a photograph of the residents to aid identification. Medication administration records relating to three residents contained a total of ten unexplained gaps in the recording of prescribed medication. This indicates a need for improvement in the accuracy of recording and administration of medication to ensure residents are safe and receive medication as prescribed. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service There is a clear and effective complaints procedure in place to enable residents and their supporters to express their views and concerns and to gain responses. The majority of staff members have received training to help protect residents form abuse. EVIDENCE: There is an effective complaints procedure in place to ensure concerns and complaints are thoroughly investigated. The pre- inspection questionnaire stated that there had been one complaint during the previous twelve- month period. Documentation relating to this complaint was read. The complaint had been well recorded and investigated and appropriate action had been taken to respond to the complainant and to reach a resolution. The policies and procedures regarding the protection of vulnerable adults at Radcliffe Meadows are appropriate and linked to the Procedures of the local authority. Staff members have a copy of the ‘No Secrets’ documentation to refer to and to guide their practice. Eighty per cent of staff members have received training to enable them to recognise the signs of abuse and to respond appropriately to protect residents. Twenty per cent of staff members are awaiting appropriate training. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. Residents have a comfortable and safe environment in which to live. The standards of housekeeping could be further improved to ensure the home is clean and hygienic. EVIDENCE: During the site visit a tour of the premises was undertaken. All the communal areas, communal bathrooms and toilets, the majority of bedrooms, the kitchen and laundry were checked. The registered manager explained that some refurbishment work to three bedrooms was planned and that all windows to the building are to be replaced. Two housekeeping staff members work a total of 55 hours each week. During the site visits the standards of cleanliness, housekeeping and maintenance were found to be in need of improvement throughout the home. Flooring to some areas needed cleaning, some areas needed dusting and a considerable amount of paintwork to corridor areas was in need of cleaning. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 18 The small kitchen areas in the dining areas were untidy and in need of cleaning. The bedrooms seen were personalised to suit individual needs and preferences. One bedroom carpet was stained and in need of cleaning. One bedroom carpet was odorous and in need of thorough cleaning or replacement. One bedroom did not have a light bulb to the central ceiling light. There was broken tiling to one shower area. One shower was not in working order and a radiator to a toilet area was not safely and securely fixed to the wall. One lounge chair was badly stained and in need of replacement and a diffuser was missing from the fluorescent light in the laundry. The kitchen and laundry areas, as previously mentioned were well organised and clean. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 19 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): 32,34 and 35 The quality rating in this outcome group is adequate. This judgement has been made using available evidence including visits to this service. Although some training needs are yet to be met, staff members are qualified and competent in their caring roles. The homes recruitment procedures need to be closely followed to ensure all necessary staff checks are undertaken and resident’s interests are safeguarded. EVIDENCE: During the first site visit several of the staff team were attending a study day to inform their practice. At Radcliffe Meadows there are ten first level registered nurses, eighteen care staff and 5 ancillary staff members. Fifteen of the care staff have achieved NVQ level 2 or above. The staff team now includes 3 NVQ assessors. Nine of the staff team have been trained to administer medication. All except three new care staff have received basic food hygiene training and basic first aid training. Several nursing assistants are to undertake NVQ training in relation to infection control. 27 of 31 staff members had completed health and safety training to date. New staff members work through an orientation checklist to introduce them to their workplace, they are provided with a Health and Safety handbook, and a copy of the Code of Practice for Social Care Workers to inform their practice. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 20 The pre- inspection questionnaire material provides evidence of frequent and appropriate training for staff members, and a record is kept of all staff training. Radcliffe Meadows operates a recruitment procedure to try to ensure the protection of residents. The Registered Manager invites potential recruits to look around prior to interview and they get an opportunity to meet residents at this time. Interviewees get to meet residents again on the day of the interview, and feedback from residents is sought as part of the employment process. Three recruitment files were checked during the site visits. One member of staff had been appointed prior to a First Protection of Vulnerable Adult check being completed and received. All other checks had been undertaken as appropriate and references and proof of identification were available on each file. One reference had been placed in the wrong file. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 21 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): 37,39 and 42. The quality rating for this outcome group is adequate. This judgement has been made using available evidence including visits to this service. The home is well managed and residents benefit from the supportive environment. However the quality assurance process needs to be developed to ensure standards are maintained, the service is developed and residents feel their views are considered. The current arrangements for fire safety and fire training do not ensure that residents are safeguarded. EVIDENCE: The registered manager has a great deal of experience of working with people with learning difficulties. She has worked in a variety of hospital settings and positions such as a Nursing Sister prior to leaving the N.H.S. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 22 Radcliffe Meadows operates a friendly, open and relaxed environment in which residents are enabled to develop their abilities and realise their preferences needs and wants. Although there is an annual development plan the quality assurance and quality monitoring systems are in their infancy and need to be further developed. This will ensure that feedback is actively sought from service users and their supporters, about the services provided and that their views underpin all self –monitoring, review and development by the home. The registered manager ensures safe working practices including moving and handling, first aid, food hygiene and infection control. A hazard- reporting log is kept to identify and take the necessary action to repair any broken equipment. The fire and emergency records were checked and fire drills had been recorded. The numbers of staff attending fire and emergency drills had been recorded but the names of staff attending had not been recorded. The certificate relating to the maintenance of portable fire extinguishers had expired in January 2006. The paperwork to record weekly checks of the fire fighting equipment indicated that the checks had been undertaken on a monthly basis. The accident records were checked and accidents had been well recorded, with appropriate action taken as a result. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 23 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 CHOICE OF HOME Standard No Score 1 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 1 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 2 X X 2 X Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 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 YA20 Regulation 17(1)(a) and Schedule 3 13(2) Requirement The registered person must ensure that a photograph of each resident is kept to aid identification. The registered person must make arrangements for the recording, handling, safekeeping, safeadministration and disposal of medicines received into the care home. The registered person must make arrangements, by training staff or by other measures, to prevent residents being harmed or suffering from abuse or being placed at risk of harm or abuse. The registered person must ensure that the care home is kept in a good state of repair, both externally and internally. The registered person must ensure all parts of the home are kept clean and reasonably decorated. The registered person must ensure all recruitment checks are undertaken including a First Protection of Vulnerable Adult Check, prior to the appointment DS0000005156.V312063.R01.S.doc Timescale for action 30/04/07 2 YA20 30/04/07 3 YA23 13(6) 31/08/07 4 YA24 23 (2)(b) 31/07/07 5 YA30 23 (2)(d) 31/07/07 6 YA34 19 Schedule 2 (7) and (8) 30/04/07 Radcliffe Meadows Mental Nursing Home Version 5.2 Page 25 of new staff members. 7 YA35 18(1)(c) The registered person must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. The registered person must ensure that the Quality Assurance System and Annual Development Plan are further developed. This requirement remains unmet from a previous inspection on 27th February 2006. 31/08/07 8 YA39 24(1) 31/05/07 9 YA42 23(4)(c)(iv) The registered person must after consultation with the fire authority make adequate arrangements for the maintenance of all fire equipment. 30/04/07 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 YA1 Good Practice Recommendations Review the statement of purpose, service user guide and home brochure, to provide up to date, easy to read information for prospective residents, existing residents and their supporters. Monitor the completion of care plan documentation to ensure all areas are fully and appropriately completed. Ensure residents have access to further education, training and employment and ensure activities undertaken within the home are adequately evidenced. Pictorial menu boards should be used to show meal selections. The small kitchen areas in each of the dining rooms should be kept clean and tidy. DS0000005156.V312063.R01.S.doc Version 5.2 Page 26 2. 3. 4. 5. YA6 YA12 YA17 YA17 Radcliffe Meadows Mental Nursing Home 6. YA42 Ensure that the record of fire and emergency training drills includes the names of all staff attending. Radcliffe Meadows Mental Nursing Home DS0000005156.V312063.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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