Inspection on 30/04/08 for Radcliffe Meadows Mental Nursing Home

This inspection was carried out on 30th April 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 2 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... 03/01/08

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 28/09/2008.

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 30 April and 1 May 2008 09:40 Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.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.V364054.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.V364054.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.V364054.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 in the category of MD (mental disorder) 3rd January 2008 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. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.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 30 April and 1 May 2008 over a period of nine 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 kitchen and laundry, six of the bedrooms and all shared areas such as the lounges, dining rooms, shared bathrooms and toilets and kitchen. The manager, two assistant managers, an administrator and several residents also contributed to the inspection of the home. What the service does well: The home is well maintained, clean and inviting so that people live in safe, comfortable surroundings. The assessment of resident’s needs, care plans and reviews are generally well written to make sure that staff know how to meet people’s care needs, although there are a few gaps in the recording of information. Staffing levels are generous and staff members have time to spend with individual residents so they have a good knowledge of the people they care for. Staff members are encouraged to undertake training to inform their practice and to enable them to do their job well. Residents are encouraged to express their views about the care and accommodation provided so residents’ views are listened to and acted upon. People living at the home are encouraged to participate in housekeeping routines and efforts are made to help residents maintain their interests and their relationships so they can live fulfilling, active lives according to their preferences. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: More thorough arrangements must be made for accurate recording and safe administration of medicines in the care home to ensure people cared for receive their medication as prescribed and are safeguarded. Arrangements must be in place for the checking and maintenance of all fire fighting equipment and emergency lighting to ensure the home is well maintained and safe. The pictorial version of the service user guide should be reviewed and amended with the help of speech and language therapists to make the guide user friendly. The completion of care plan documentation needs regular monitoring to ensure all areas are fully and appropriately completed to make sure that people who live in the home are receiving the care that they need. People cared for need opportunities to have access to further education, training and employment to aid their development and to help them live fulfilling lives outside of the home. The home could provide protective clothing for visitors to the kitchen area. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 7 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.V364054.R01.S.doc Version 5.2 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 Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The service user guide awaits review and amendment to provide information in a user -friendly style so people who use the home may understand it more easily. The needs of people are thoroughly assessed prior to being placed at the 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 people considering the home and help them to make an informed choice. The service user guide has recently been provided in a pictorial format and is due to be further reviewed in mid May 2008 with the help of representatives of the local Speech and Language Therapy Department, to help make it more user friendly. Two examples of initial assessments were checked and provided evidence of each person’s needs being identified and assessed to ensure that the home was able to provide the appropriate levels of care and support. Pre admission Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 10 assessment information had been gathered from a variety of sources to build a picture of each person. The home provides each person living at the home with a client handbook, which contains useful information including a copy of the service agreement, details of how to make a complaint and details about house rules and fire procedures etc. The majority of people have lived at the home since the opening in 1993 and have previously lived in the local area. All except one person who had been recently admitted had a completed service agreement to show the terms and conditions of their placement. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 11 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, 8 and 9 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Personal goals are reflected in each individual plan of care and people living at the home are supported so they can make decisions and take risks as part of an independent lifestyle. EVIDENCE: The care files of three people living at the home were checked. An overall improvement in the organisation of the care files was noted. Each contained very thorough nursing assessments of needs and useful summaries to describe the level of care and support necessary to address all care needs. The care planning information was incomplete to varying degrees. In one file, the personal description was incomplete, the person’s likes and dislikes had not been recorded and the anticipatory care calendar was also incomplete. A second care file contained a personal description but this didn’t indicate the person’s weight, size or height, distinguishing marks and diagnosed physical illness. The date of admission, religion and contact information regarding the Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 12 person’s brother, dentist and social worker were not recorded. A personal needs assessment was included but this did not record the date the assessment had been undertaken. Another file provided a better example of record keeping but the anticipatory care calendar had not been completed fully and an incident regarding challenging behaviour had not been fully explained. There is a need to monitor the completion of care plan documentation on a regular basis to ensure that records are fully and appropriately completed and provide all necessary information. 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 and 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 plans of care had been positively written. Each person had been encouraged to provide an account of their life, circumstances, hopes and aspirations. Life histories had been provided. There was evidence of individualised care and support and staff had been provided with guidelines to help them support people presenting with challenging behaviour. The care files contained positive descriptions of each person, described each personality well and included photographs to aid identification. Care needs had been reviewed at regular and appropriate intervals and a variety of personal and environmental risk assessments had been completed to help reduce risks and to keep people safe. There was evidence of good medical care and people had been referred for specialist medical care promptly. The advice and opinions of other health care professionals was clearly reflected in the care plans. People living at the home had been encouraged and supported to participate in decision-making processes relating to activities within the home and to the running of the home. Some of the people living at the home access a local advocacy group and are also involved in a Speak Up group. Minutes of weekly Action Group meetings were read. The meetings had enabled the people living at the home to air their views, to discuss the running of the home and to make choices and express their wishes. As a result of listening to people, activities and menus had been altered and some areas of the home had been redecorated and refurbished. It was clear that people living at the home had been encouraged and supported to choose furniture, decoration and personal effects for their own Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 13 rooms to reflect their personality. Dependent on ability, individuals have keys to their own rooms to promote privacy and independence. Staff members ask permission to gain entry to bedrooms. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 14 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): 11, 12, 13, 14, 15, 16 and 17 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People living at the home are encouraged so they can take part in a range of appropriate leisure activities. Access to further education, training and employment is very limited so restricts people’s opportunities to live fulfilling lives outside of the home. EVIDENCE: Radcliffe Meadows is located in a small village community and people living at the home are enabled to access the local facilities including shops, pubs and banks. Activity plans were available on each of the care files seen. Staff members encourage and enable people to pursue interests such as walking, fishing, craft and music. Local events are brought to the attention of people living at the home through meetings and flyers. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 15 The home has the use of three cars to ensure people are able to get out and about and one of the cars has been modified to enable wheelchair access. People are supported to carry out personal shopping as they choose. People living at the home can invite their family and friends to participate in activities at Radcliffe Meadows. There is an open visitors policy and a refurbished, comfortable, quiet room has been made available for visits. Several people living at the home have recently been enabled to visit a local project, which provides nightclub facilities for people with learning difficulties. Although people are encouraged to take part in a range of appropriate leisure activities, access to further education, training and employment has not been available. This restricts people’s options and opportunities, their level of involvement and participation. Two of the people living at Radcliffe Meadows help in the day to day running of the home by undertaking small household tasks and they receive a small payment for the work undertaken. Pictorial menu boards are available to help people make meal selections. A three- week menu is discussed at the action group, changes are made by request and alternatives are suggested. Meals provided are varied. The main meal of the day is served in the early evening except on Sundays when the main meal is provided at lunch- time. Sometimes take away meals are ordered and brought in and usually birthdays and special events are celebrated with a special meal. A dietician is approached for advice to help prevent significant weight gain and weight loss and the speech and language therapy department are available to provide advice if a person has swallowing difficulties. The kitchen was visited during a tour of the premises. The food store, fridges and freezer were well stocked and the premises were very well organised and clean. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 16 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. People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. People living at the home receive attentive care, which is respectful and supportive. The administration and recording of medication needs improvement to ensure people receive their medication as prescribed and are safeguarded. EVIDENCE: Each person living at the home has a detailed care plan to describe what needs to be done to support people and to describe how the support should be provided to suit each individual. Examples of pre-admission assessments were seen and provided a substantial amount of life history information. Nursing and risk assessments were comprehensive and provided evidence of health and social care professionals working closely together to gain rapid and positive responses when people’s health deteriorated. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 17 There was evidence within the care files of people’s health and wellbeing being carefully monitored and any care needs swiftly addressed. The care plans had been reviewed regularly and adjustments to care and support had been made as necessary. Anticipatory care calendars are in place and are used to plan and make provision for appropriate health care. One member of staff has received training in counselling and was providing a counselling service to three people living at the home. Notes of counselling sessions are kept in three individual diaries. Advice was given, as provision needs to be made for these diaries to be kept in an accessible but more secure place. Changes in people’s care needs are verbally reported at staff handovers, within a staff communication book and within the care files. A staff handover was observed and informed incoming staff of changing needs. Staff members may need to have a written record of people they are responsible for during their shift and may need a written note of pertinent changes to keep as an aide memoire. In an attempt to improve the medication system, the supply of medication is shortly to be provided by a different pharmacist mainly in a monitored dosage system. The new pharmacist has already provided training to the majority of staff regarding administration. Medication was securely stored and medication policies and procedures were made available for staff members to refer to. Since the last inspection a drugs record book has been established to record any anomalies. This provided evidence of many recent anomalies including drugs running low, drugs miscounted, drugs signed for and not given, also for medication held for people no longer prescribed items, and records not signed. The records of drug anomalies were poorly kept in a small diary; they were unclear and difficult to read and to check. The drug audits had not been fully completed on a daily basis and when undertaken did not spot every anomaly. Although full drug counts were supposed to be undertaken nightly, some drug counting had not been completed. The medication administration records were checked in detail during the inspection. Anomalies throughout April 2008 included prescribed medication not signed as given, incomplete drug counts, incorrect stock balance and discrepancies of information between the drugs record book and medication administration record. A repeated, unmet requirement has been made at previous inspections regarding medication. The anomalies persist despite an action plan/improvement plan developed by the provider. This along with the above matters indicate a need for improvement in the accuracy if recording and Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 18 administration to ensure people living at the home are safeguarded and receive their medication as prescribed. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 19 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. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There is a clear and effective complaints procedure in place so people living at the home and their supporters can express their views and concerns and to gain responses. Staff members are trained so they can protect people who live at the home from abuse. EVIDENCE: There is an effective complaints procedure in place to ensure concerns and complaints are thoroughly investigated. The complaints records were checked. 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. The most recent adult protection training was provided to staff members in December 2007. Safeguarding referrals have been made in the past as necessary. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 20 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. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Radcliffe Meadows is well furnished so it provides people with a comfortable, clean and hygienic environment in which to live. EVIDENCE: During the visit the premises were checked. All the communal areas, shared bathrooms and toilets and five of the bedrooms were checked. All areas were clean and hygienic. Two bedrooms were due to be redecorated as people were moving to different bedroom space. New wallpaper and furniture had been obtained for a TV lounge. The activities room also awaited redecoration. One dining room had been provided with new furniture. The oven in the same dining room was due for cleaning and replacement. Advice was given at feedback to the inspection regarding the following housekeeping matters. The rear door to the laundry had been left unlocked. The lighting to toilet room numbered 43 was in need of attention. The Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 21 bathroom numbered 6 was in need of a window covering, some repainting to the rear of the toilet was necessary and the toilet paper holder was broken and in need of replacement. The outside of the building was well presented. Staff members and people living at the home had been busy planting hanging baskets and gardening and the garden areas were pleasant, well maintained and colourful. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 22 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, 34 and 35 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Staff members are well trained and qualified in their caring roles. The home’s recruitment procedures are thorough to ensure that people living at the home are safeguarded. EVIDENCE: At Radcliffe Meadows, there is a highly trained and qualified staff team. The staff team is of mixed gender and ages to ensure that people’s needs and preferences can be met. The staff team consists of first level registered nurses and nursing assistants. Staff members receive training in moving and handling, emergency aid, adult protection, food hygiene etc and their training is regularly updated. All nursing assistants have achieved NVQ 2 in social and health care and housekeepers have NVQ in domestic service. Staff training records are to be stored on a computer database in the near future to provide a clearer record of training, which will enable forward planning for 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.V364054.R01.S.doc Version 5.2 Page 23 Staff turnover is low. The recruitment practices are thorough and potential staff members have all the necessary recruitment checks to help safeguard people living at the home. Four recruitment files were checked of staff members most recently employed. All checks necessary checks had been undertaken. One reference could not be located during the inspection. In discussion with the manager, it was found that the reference awaited filing. All staff members receive supervision and appraisal. A number of staff members spoken with during the inspection confirmed that they received regular supervision and support and said that their training needs were met. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 24 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 and 42 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well managed so people living there benefit from the supportive environment provided. The quality assurance process in place helps to ensure standards are maintained, the service is developed and people feel their views are considered. EVIDENCE: The 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 NHS. Radcliffe Meadows provides a friendly, open and relaxed environment in which people are helped to develop their abilities and encouraged to voice their opinions. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 25 Quality assurance surveys have enabled people living at the home and their supporters to have a voice and be involved in future planning for the home. Results of quality assurance surveys are published and action taken as a result is documented. The manager is responsible for ensuring safe working practices including moving and handling, first aid, food hygiene and infection control. A hazardreporting log is kept to identify and take any 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. Protective clothing was not available to visitors to the kitchen area. The manager was made aware of this at feedback to the inspection. The fire prevention record book was checked. This showed that a fire procedures review had not been undertaken in 2007 and was overdue. A fire and emergency evacuation was also due. There was no evidence of an emergency lighting test for April 2008. This was undertaken immediately after the inspection and prior to telling the manager of the findings of the inspection visit. A fire alarm servicing certificate was awaited and a copy of the certificate is to be supplied to the Commission for Social Care Inspection. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 26 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 3 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 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 1 X Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 27 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 13 Requirement The registered person must 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, 26th February 2007 and 30th January 2008. The registered person must ensure arrangements are in place for the checking and maintenance of all fire fighting equipment and the emergency lighting. This requirement remains unmet from a previous inspection on 26th February 2007 and 3rd January 2008. Timescale for action 31/05/08 2 YA42 23 31/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 28 No. 1 Refer to Standard YA1 Good Practice Recommendations The pictorial version of the service user guide should be reviewed and amended with the help of speech and language therapists to make it easier for the people who use the service to understand. The completion of care plan documentation should be monitored to ensure all areas are fully and appropriately completed. Action should be taken to 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. Protective clothing for use by visitors to the kitchen area should be provided to make sure that proper hygiene is maintained. 2 YA6 3 YA12 4 YA42 Radcliffe Meadows Mental Nursing Home DS0000005156.V364054.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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.V364054.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!