Inspection on 03/01/08 for Radcliffe Meadows Mental Nursing Home

This inspection was carried out on 3rd January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 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... 26/02/07

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 3 and 11 January 2008 10:50 rd th Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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.V351643.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.V351643.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 j.gilbody@wcl.uk.net 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.V351643.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). 26th February 2007 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, lounges, dining rooms, an activities 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 £4886.38 and is four weekly. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that the people who use the service experience adequate quality outcomes. This unannounced inspection took place on two days, on 3rd and 11th January 2008 over a period of 6 hours. This was to assess if the residents needs were being met at the home. A tour of the premises took place and included a number of the bedrooms and all shared areas such as the lounges, dining rooms, shared bathrooms and toilets and kitchen. The chief executive, registered manager, two assistant managers, the administrator and several residents contributed to the inspection of the home. What the service does well: What has improved since the last inspection? Some areas of the home have been refurbished. Some bedroom windows and doors opening onto the garden have been replaced. Some redecoration work has taken place in bedrooms and corridors. A communal lounge has also been created to provide a pleasantly decorated and furnished space where residents can entertain their visitors and meetings can be held. A new quality assurance document has been developed. Staff members have continued to receive training to inform their practice and care plan documentation has been extended to included personal statements of residents and anticipatory care calendars. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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.V351643.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. 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 a visit to this service. The information available about the home needs updating and should be made available in a user -friendly style to enable people to make an informed choice about the home. The needs of prospective service users are thoroughly assessed prior to being placed at home, to ensure their needs can be addressed and met. EVIDENCE: Radcliffe Meadows provides 24 hour nursing care to people over 18 years. 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 provide information to prospective residents. To help people make an informed choice about Radcliffe Meadows, these documents need to be reviewed, updated and made available in formats suitable for residents to understand. Representatives of a local Speech and Language Therapy Department have been assisting with planning to produce new documentation. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 9 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 residents have lived at the home since the opening in 1993. Vacancies occur infrequently. Since the last inspection one new placement has been made. The care files of three residents were checked and contained very through nursing assessments of needs and useful summaries to describe the level of care and support necessary to address all care needs. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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. 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 a visit 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: Within each of the three care files checked it was evident that pre admission assessment information had been gathered from a variety of sources to build a picture of each resident prior to them entering the home. A number of assessments in one of the care files had not be signed or dated and the care plan had not been agreed with the resident or their family supporters. Nor had details regarding important friendships been completed. There is a need to monitor the completion of care plan documentation to ensure all areas are fully and appropriately completed. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 11 Within the care files there was a good standard of daily recording, giving a full account of support provided and of activities undertaken. The daily recording provided evidence of close monitoring of changing care needs. They also provided evidence of continuity of care. The files contained communications from various health professionals who had been involved in providing assessments and undertaking reviews so that all staff members were kept fully informed. The three individual plans of care had been positively written. Each resident had been encouraged, to provide an account of their life, circumstances, likes and dislikes and hopes for the future. Life histories had been written from the resident’s perspective and provided evidence of individualised care and support. There were guidelines to help staff support people presenting with challenging behaviour and the planned interventions in place, had been made known to residents. Each care file described the resident’s personality and needs well and a photograph was included to aid identification. Reviews had taken place and care plans had been compiled with the involvement of each individual. A variety of risk assessments had been completed. These were appropriate to residents personal needs to eliminate and reduce risks relating to for example pressure area care, safer handling, activities of daily living, challenging behaviour and outdoor activities. Any limitations imposed to reduce risks had been discussed with the resident and support plans had been explained. The advice and opinions of other health professionals were clearly reflected in the care plans. It was evident that residents had been encouraged and supported to participate in decision- making processes relating to activities within the home and to the running of the home. Residents regularly attend an Action Group to discuss the running of the home and to air their opinions, make choices and express their wishes. The staff members at Radcliffe Meadows intend to help residents access a local Advocacy Group and become involved in a Speak Up Group. During the last twelve months residents involved in the Action Group at the home have become more involved in planning the menus and planning and coordinating activities for their fellow residents. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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. 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 a visit 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 restricts people’s opportunities to live fulfilling lives outside of the home. EVIDENCE: Radcliffe Meadows is located in a small village community and residents are enabled to access the wide range of local facilities including shops, pubs and banks etc. Two residents spoken with confirmed that staff members had helped them, to participate in activities of their choice. Residents spoke of shopping trips and fishing trips and other activities outside of the home. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 13 Minutes of The Action Group were read and recorded residents thoughts about selecting menus, choosing holiday venues and activities and planning special celebrations and events throughout the year. Activities records were seen and provided information about what each resident liked to do so that appropriate activities could be planned. Activities timetables were in place to ensure that sufficient staff members were available to support people with their activities and residents could be reminded of their regular activities. Photographs of residents enjoying various activities were seen displayed around the home. Although residents are encouraged to take part in a range of appropriate leisure activities, access to further education, training and employment is limited. This does not enable residents to develop and live fulfilling lives outside as well as within the home and more needs to be planned to enable a appropriate level of participation and involvement. Redecoration is currently being planned to convert a previously little used communal room into an activities room, which will allow residents more space for creative activities and to provide space in which people can socialise. One lounge had been completely refurbished. It has created a pleasant space in which residents can greet and entertain their visitors and in which confidential meetings can take place. There is also separate access to this room from the outside of the building. At feedback to the inspection the manager was advised to ensure that visitors to this room sign the visitors book. 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 supporters 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 a close liaison with resident’s supporters to maintain relationships, which are important to them. A number of bedrooms were checked during the site visit and each bedroom had been decorated, furnished and personalised to suit each individual. Since the last inspection visit, pictorial menu boards have been made available to help residents with meal selections. Menus were varied and special diets had been catered for. The kitchen was visited during a tour of the premises and was very well organised and clean. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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. 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 a visit 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: All residents have detailed care plans to describe what should be done to support people and to describe how this support should be provided to suit each individual. Pre admission assessments take place and include as much life history information as possible. Nursing and risk assessments provide comprehensive information to ensure people are supported in the best way possible. Working closely together with other health and social care agencies and professionals ensures that rapid and positive responses are achieved when referrals for help and assistance are made. Resident’s health and wellbeing is carefully monitored and any care needs are swiftly addressed. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 15 There was evidence of continued and attentive support and advice from general practitioners and consultants, and other health care professionals to help support and care for residents. The care plans seen had been reviewed regularly and adjustments to care had been made as necessary. Anticipatory care calendars are in place and are used to plan and make provision for appropriate health care. A good and clear communication system is also in place to ensure any changes in peoples care needs are reported at staff handovers. 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. Seven of twelve medication administration records contained anomalies. There were several gaps in the recording of medication and some medication had not been given as frequently as prescribed. When two medication administration records were in use for individuals, only one of the records contained a photograph of the individual to aid identification. These matters indicate a need for improvement in the accuracy of recording and administration to ensure residents are safeguarded and receive their medication as prescribed. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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. 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 a visit 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. All members of the staff team have received training to help protect residents from abuse. EVIDENCE: There is an effective complaints procedure in place to ensure concerns and complaints are thoroughly investigated. No complaints had been received since the last inspection visit. 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. All staff members have received training to enable them to recognise the signs of abuse and to respond appropriately to protect residents. Safeguarding referrals had been made as necessary. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortably furnished and provides residents with a clean and hygienic environment in which to live. EVIDENCE: During the site visit a tour of the premises was undertaken. All the communal areas, communal bathrooms and toilets and approximately fifty percent of the bedrooms were checked. All areas were clean and hygienic. Some areas of the home have been refurbished recently. Some bedroom windows and doors opening onto the garden have been replaced. Some redecoration work has taken place in bedrooms and corridors. A communal lounge has also been created to provide a pleasantly decorated and furnished space where residents can entertain their visitors and meetings can be held. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 18 The bathrooms had been modified to promote independence and privacy and to provide safe working environments. Improvements had been made to two shower rooms. The shower rooms had been refurbished to create wet rooms. Cleaning schedules within the home were checked and had been maintained to ensure a pleasant environment was provided. A maintenance record was kept and provided evidence of work undertaken to prevent hazards. On 5th December 2007 the local Community Services Directorate, Food Safety Section awarded the home a five star hygiene rating of excellent. The kitchen was also seen to be orderly, clean and well organised during the inspection visit. Advice was given at feedback to the inspection regarding the dining room known as ‘Meadow View’, as a cooker top was in need of cleaning and there was a broken drawer front on one of the kitchen units, needing repair or replacement. Discussion was also held with the manager about the perimeter fence to the approach side of the building. It detracts from the rest of the environment and is in a very poor state of repair with many fence panels missing. Discussions are to be held with the landowners to try to encourage repair work to the fence. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members are well trained and competent in their caring roles. The homes recruitment procedures ensure all necessary staff checks are undertaken and resident’s interests are safeguarded. EVIDENCE: At Radcliffe Meadows there is a highly trained and qualified staff team. There are ten first level nurses and eighteen care assistants. All staff members have achieved National Vocational Qualifications at Level 2 and a number of staff have completed an additional training unit regarding team building. All staff members receive core training. Any 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. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 20 All staff members receive supervision and appraisal. Their practice and their training needs are reviewed to ensure there is a good mix of competent and confident staff. Currently some staff members await training regarding The Mental Capacity Act and regarding undertaking Physical Interventions. The home is hoping to implement a more appropriate recording system to prompt the need for refresher training. Radcliffe Meadows has achieved an ‘Investors in People Award’. There is a low staff turnover and an effective recruitment procedure in place to safeguard people living and working at the home. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 and 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and residents benefit form the supportive environment provided. The quality assurance process needs developing to ensure standards are maintained, the service is developed and residents and their supporters feel their views are considered. 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.V351643.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 are encouraged to voice their preferences and desires. The home is run in the best interests of residents and their wishes are heard individually and through The Action Group. The Quality Assurance System needs further development to ensure that feedback is actively sought form service users and their supporters, and to ensure action is taken to address any matters arising. The surveys provided to gain peoples views about the service were distributed in late October 2007 and the results have not yet been collated and published. The registered manager is responsible for ensuring safe working practices including moving and handling, first aid, food hygiene and infection control. A hazard -reporting log is kept to identify and take any necessary action to repair any broken equipment. Fire drills and training had been recorded and accident records were complete with any necessary follow up action detailed. The records relating to checking fire fighting equipment and emergency lighting were incomplete and did not indicate checks during September November and December 2007. These checks must be undertaken on a monthly basis and more frequently as necessary. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 2 X X 2 3 Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.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 YA1 Regulation 4 Timescale for action The registered person must 01/06/08 ensure that information about the home is updated and made available in a user -friendly style to enable people to make an informed choice about the home. The registered person must 31/01/08 make arrangements for the recording, handling, safekeeping, safe-administration and disposal of medicines received into the care home. This requirement remains unmet from previous inspections on 27th February 2006 and 26th February 2007. The registered person must 31/01/08 ensure that the Quality Assurance System is further developed. This requirement remains unmet from previous inspections on 27th February 2006 and 26th February 2007. Requirement 2 YA20 13 3 YA39 24 Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 25 4 YA42 23 The registered person must 31/01/08 ensure arrangements are in place for the checking and maintenance of all fire-fighting equipment and emergency lighting. This requirement remains unmet from a previous inspection on 26th February 2007. 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. Refer to Standard YA6 YA12 Good Practice Recommendations 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 to aid their development and to help them to live fulfilling lives outside the home. Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Radcliffe Meadows Mental Nursing Home DS0000005156.V351643.R01.S.doc Version 5.2 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. 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