Inspection on 28/06/06 for The Meadows

This inspection was carried out on 28th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Meadows 20/02/06

The Meadows 02/08/05

The Meadows 07/03/05

The Meadows 11/08/04

The Meadows 26/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Meadows Wrenbury Crescent Berryhill Stoke on Trent Staffordshire ST2 9JZ Lead Inspector Peter Dawson Unannounced Inspection 28 June 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Meadows DS0000032500.V300907.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Meadows Address Wrenbury Crescent Berryhill Stoke on Trent Staffordshire ST2 9JZ 01782 234750 F/P 01782 234751 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) Stoke on Trent City Council Mrs Diane Marie Ackley Care Home 54 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (54), Physical disability (5), Physical disability over 65 years of age (54) The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 Physical Disability (PD) - Minimum age 55 years on admission Date of last inspection 20th February 2006 Brief Description of the Service: The Meadows is owned by Stoke on Trent City Council and managed by Stoke Social Services Department. The home was registered under the Care Standards Act to provide care for up to 54 elderly residents with a variety of needs, and five persons [min age 55] with physical disabilities [P. D.]. Currently work is almost completed to furnish it for the provision of Intermediate Care for 33 residents. Former permanent residents have been accommodated in a separate unit on the ground floor, and the intention is to take no new permanent residents into this unit, so that eventually it will close, and the providers will at that time, apply for a variation to reduce the number for whom the home is registered, from 54 to 33. Accommodation is currently provided in single bedrooms on two floors serviced by a lift. All areas have been, or are in the process of being upgraded, this includes all bedrooms and communal areas. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Meadows has been in the process of change over the past year, from a 54 bedded traditional care home for older people to a rehabilitation service for elderly people to provide a comprehensive and multi-disciplinary intense programme of intermediate care enabling a return to their own home with improved independence. Additionally no new admissions for permanent care will take place, but the existing number of 12 permanent residents will remain. The transition over the past year has been difficult for both residents and staff, but there has been a remarkably smooth transition. Health care professionals have been integrated into the home and now working closely with care staff. Retraining of care staff and integration of new staff from other closed care facilities have also taken place. Staff have responded very positively to the new challenges. Further details are outlined throughout this report but in the opinion of the inspector has been very successful with minimal disruption to permanent residents - confirmed in written and verbal feedback from them. This unannounced inspection was carried out following completion of a preinspection questionnaire by the Manager. Written feedback was received from 8 residents, 7 relatives, a GP and District Nurse. Additionally most permanent residents and some Intermediate Care residents were spoken to and two visiting relatives seen. All care staff and members of the Intermediate Care Team were seen and their views solicited. The inspection was carried out initially with 2 Assistant Managers and from mid-morning with the Manager and Service Manager with direct responsibility for the home. All areas of the environment were seen which included a sample of bedrooms on each floor. At the time of this inspection there were 12 permanent residents and 20 Rehabilitation residents. In written feedback residents expressed positive views about the care provided. Four said that activities were not always available, although one stated “We have lots of activities” The programme of activities were seen covering the 7 day week and appeared adequate. There were many examples of additional activities being provided. The Manager will further discuss this matter with residents. In written feedback residents made general positive comments: “Everyone is quite helpful, nothing is too much trouble for them” “They listen intently to everything I say”. “All staff very approachable. Not found any faults in 3 years” “Well satisfied” “Very happy” Discussions with residents during the inspection further confirmed the positive views expressed in writing. Written feedback from 7 relatives similarly expressed high levels of satisfaction care. Four said that they did not have access to inspection records, but on the The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 6 day of this unannounced inspection a copy of the last inspection reports were available in the reception area of the home. One relative did comment upon the fact that meat was not cut up for his relative with a digestive problem. The Manager was unaware of this problem which will be checked with medical records and arrangements put into place immediately to deal with the matter. The same relative when spoken to by telephone also wished to say that both his parents had been residents at the Meadows over a period spanning 12 years and he had been completely satisfied with the care they had received. Written feedback from a visiting GP and District Nurse express a view of satisfaction with overall care at The Meadows and good communication with staff. A resident on the Intermediate Care Programme awaiting weekly review meeting with his family expressed very positive views about his stay of 5 weeks. He said that he had been helped considerably - staff were excellent and that the placement had restored his confidence allowing him to return to his own home the following week. He had previously been in hospital and returned home directly from there “too early” and his discharge had failed. He said that this time he was “sure he would be able to look after himself at home”. The current standard charge for this service is £328 per week. This information given by the Manager on inspection day. What the service does well: What has improved since the last inspection? The Intermediate Care Team have been completely integrated with the care staff at The Meadows. New methods of working have been established by all staff to meet common goals. Staff have shown a flexibility and commitment to multi-disciplinary working. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 7 Further work has been completed to comply with the Fire Officers requirements although this still needs to be finalised. Further refurbishment work has been carried out on the first floor upgrading bedrooms and communal areas. Two additional lounge/dining areas for 5/6 people have been created. Some work to finish those rooms is to be completed soon. 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 Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–6 The quality of this outcome is good. This judgment is made using available evidence including a visit to the service and discussions with staff and residents. EVIDENCE: The Statement of purpose and service users guide have been revised and updated to reflect the changed operation and purpose of the home. There will be no new admissions of permanent residents. The number of rehabilitation residents is currently up to 22 and will increase to 33 as new facilities are completed. Rehabilitation residents do not have contracts due to length of stay. These residents are admitted after assessment usually in hospital where the need for the service is deemed appropriate. The practicality of this means that assessment is made usually by nursing/hospital team referred to the home for swift admission often later the same day and decisions made upon paper assessments. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 10 This decision is made by the homes staff jointly with the Intermediate Care Team comprising nurse, social worker, OT, Physiotherapist. The timescale and pressure for decision making does not allow any time for visits/introductions to the home by prospective resident or family. This does not concord with standard 1:5. The Manager and ICT are presently attempting to improve/review those arrangements. In instances where a paper assessment indicates doubt about meeting needs the Manager/Nurse do visit and make an assessment in the persons location. The facilities of the home and the services of the multi-disciplinary team provide an excellent service to maximise independence and return home. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 11 The quality of this outcome is good. This judgement is made using available evidence including a visit to the service. EVIDENCE: Care plans were sampled for both permanent and short term residents undergoing a period of rehabilitation. They contained good and comprehensive information concerning the health and social care needs following assessment. Daily notes provided updated information on progress. The emphasis in the records required for both categories of resident has differed slightly but adjusted to take account of the needs of both categories and form a fairly uniform structure for the recording of all information. An example of this is the chronological health care record for residents which has also been applied in addition to the clinical recording of the health care personnel. There is daily dialogue between The Meadows staff and Intermediate Care Team (ICT) and regular weekly reviews of all rehabilitation residents on a multi-disciplinary basis. Tracking relating to a permanent resident showed that a request for GP change had been actioned and arranged. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 12 A referral to Consultant Psychiatrist following death of a close resident friend. This was out of concerns of possible depression. Counselling had been offered also. The review of this resident had apparently been carried out monthly but not recorded, dated and signed recently. This will be pursued by the Manager. Two GPs are allocated to provide a service to Rehabilitation residents and other GPs to permanent residents. A good service was reported from all visiting GP’s. A GP in feedback direct to the Commission indicated positive close working, good communication and an expressed view of satisfaction with the overall care provided by the home. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The quality of this outcome is adequate. This judgement is made using available evidence including a visit to the service. EVIDENCE: The changes made at The Meadows over the past 6 months have been significant with considerable work carried out on the building and changes the provision of care. The 12 permanent residents are located on the ground floor with considerable space available to their small group. There is a large living/dining area which adjoins the kitchen providing excellent serving facilities direct to tables. Another large areas has been separated by a partition but is well appointed with several “areas” which include TV/lounge, library/reading area a music corner and including karaoke equipment. The space allows for activities of all types at varying times. There is a selection of the usual indoor games including large piece games etc. Half the residents in written feedback to the Commission indicated that they were satisfied “sometimes” with the activities provided, although one also said “we have lots of activities” There is a daily activities programme (7 days) providing a range of varying activities. This is not a rigid programme and spontaneity was applied as residents wished. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 14 Residents spoken to said that they were satisfied with activities provided. One did say that she did not like ongoing TV and sometimes found this not to her satisfaction in the lounge area, but stated she goes to her bedroom if she prefers more relaxed occupation. Several residents have been at this home for many years and those spoken to were highly satisfied with all aspects of care including activities provided. The Manager will take account of the comments made and review arrangements with both residents and staff. Visitors are reported to be made welcome into the home and this was confirmed by a visiting daughter with her grandchild attending a review, she stated that all staff were welcoming and included her and her family in all aspects of care and discussion. Residents spoken to said that they were highly satisfied with the quality and quantity of food. Menus inspected confirmed a varied diet with choice of all main dishes. Discussions with the cook confirmed that meals were served individually and took account of known likes/dislikes, quantity and diet. A relative in feedback indicated that his relative and another resident had swallowing difficulties and food (meat) was not cup up for them. The Manager was unaware of a swallowing condition of the resident but will pursue the matter further and check medical records etc. The other related to a resident without dentures who did say that meat was sometimes difficult for her to eat. This will also be pursued. The relative making the comments also added that both his parents had been resident at The Meadows for over 12 years in total and that he had never had any complaints to make, he was delighted with the care provided. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 17 The quality of this outcome is good. This judgement is made using available evidence including a visit to the service EVIDENCE: The home is owned and operated by Stoke on Trent City Council. The Authority’s complaints procedures have just been revised and include complaints, compliments and comments. It is an easy to read booklet and is given to all residents and relatives, with copies in the home for visitors. The booklet is available in 7 languages if required. The leaflet is easy to understand and to use with Freepost return if required. Details of how to contact the Commission are included. There have been no complaints to the home since the last inspection or to the Commission. Several compliments were see received from relatives of former/deceased residents. Residents spoken to knew how to make a complaint. Abuse procedures were not inspected on this visit. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 The quality of this outcome is good. This judgement is based upon available evidence and also a visit to the service. EVIDENCE: There have been considerable changes to the environment over the past year with the changed use of the home to incorporate facilities for Intermediate Care. The first floor has been refurbished to provide sleeping and communal accommodation to a good standard to bring this 40 year home to the standards of the Care Standards Act 2000. Bedrooms have been refurbished and provide pleasant rooms with wash-hand basins and good furnishings. Decoration of the rooms are light and provide a soft spacious and bright appeal. Some rooms are in fact around 10sq. m. which is acceptable for home pre-existing 2002. The inspector was impressed with the presentation of the bedrooms and smaller lounge/dining areas which were well-appointed and provided a comfortable, homely setting. Further work is in progress/planned to create further small lounge/dining areas to compliment refurbished bedrooms. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 17 A laundry for use of residents is to be installed in a first floor bathroom. The recessed toilet in this area has exposed pipe-work at the side of the toilet suite, this must be covered immediately to ensure the safety of residents using this toilet. The natural movement for residents when rising from the toilet would be to lean upon the exposed hot pipework. New fire doors have been fitted throughout on the first floor and all have privacy locks, some with keys and the facility to enter in the event of emergency. The ground floor area has been separated to provide accommodation for the 12 permanent residents. This accommodation is satisfactory. Space is adequate and a large lounge/dining area adjoins the kitchen servery. Additionally a room adjoining has been partitioned to provide pleasant, adequate facilities for lounge and activities. Access direct to the garden area is good and the area is safe. Work is to commence on further refurbishment of this area including the reception area which needs updating from its 1960’s original presentation. All areas are double-glazed. A replacement door to the rear of the reception area has been fitted and this will be the main entrance upon completion from the car park at the rear of the building allowing easier and safer access to car-parking facilities which are to be extended. This area requires ramping and is schedule to be completed soon. A smoke room has been upgraded on the ground floor with tiled floor and new seating and fittings. A door opens directly onto the garden area where residents can also sit in the summer months to enjoy smoking. The whole area is safe and pleasant and not intrusive to other residents. There are no en-suite facilities in the home. There are 2 bathrooms and 7 toilets on the ground floor and adequate numbers on the first floor. Previous requirements have been made to comply with the recommendations of the fire officer and considerable work is reported to have been carried out. Linda Cumberbatch, Service Manager was present during the inspection and reported that most work has been completed in conjunction with Stoke Property Services and shortly to be approved/signed-off after further inspection and meeting with the Fire Officer. This will be monitored with the Fire Officer and is subject to a further requirement of this report. It was noted in the ground floor lounge area that the call system was not readily available to residents and this should be moved to a point where access is easy. Permanent residents were asked directly if the building work changes had affected them. The unanimous response was that there had been no disruption to them and in fact they had been interested in all the activity it had attracted. All areas of the home were clean and hygienic, there were no mal-odours and good infection control practices were evidenced. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The quality of this outcome is good. This judgement is made using available evidence including a visit to the service. EVIDENCE: In its new role The Meadows undertakes the care of two separate groups of individuals, with differing assessed needs and short and long-term outcomes. Needs are met using a mixture of directly employed Social Care staff, Health Care staff to whom it plays host and external facilities from hospitals, clinics surgeries and other specialist centres. The first admissions for Rehabilitation commended in November 2005. Since that time the different staff groups (Social Care and Health) have worked together closely each shown a tolerance and understanding of the principles and operation of the other. There have inevitably been difficulties but both groups said that they had been resolved by discussion and agreement. Both staff groups shared an office originally believing that to be the swiftest way of integration but the facilities were crowded and inadequate, consequently the two groups have separate offices but come together daily and on an ongoing basis. This was seen to work very well, the inspector spending time with both staff groups. Communication is good and relaxed exchanges observed. This guarantees the progression of a very positive integrated service. The care staff group at the Meadows faced a daunting task in the changed operation of the home. The care staff of 2 other short term care facilities in Stoke were integrated with Meadows staff. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 19 All had to undergo swift and extensive training in the changed focus and operation of the home and having to retain a core of permanent residents but embrace people referred for short term rehabilitation. It is a credit to all staff that this formidable transition has been undertaken very successfully. Staff confirmed that changed methods or working and priorities had been of initial concern but they had positively embraced those changes and felt the progression was positive and brought additional areas of work satisfaction ultimately for them and a changed and improved service for all residents. The day staffing levels of the home for the current resident group – which comprises up to 22 Intermediate Care places and 12 permanent residents – allows for 2 Care Workers plus Assistant Manager on the ground floor and 5 Care Workers plus Assistant Manager on the first floor. Additionally, of course the ICT Team comprises Nurse, Social Worker, OT, Physiotherapist and 2 Health Care Assistants. Additionally the Manager works supernumerary and an additional Assistant Manager works on the day of reviews for ICT residents. Night staffing levels are 3 Waking Night Care Assistants and one Senior person sleeping in and on call. Staffing levels are adequate for the current perceived dependency levels of the resident group. Any increase in total number of ICT residents (which are planned ) would required a review of those levels. Staff files were sampled and contained all required information on each employee under Regulation 19 & Schedule 2. References were seen and CRB clearances obtained by the HR Section of Social Services. Any recorded criminal offences are discussed with a Senior Member of the Management team, who makes a decision regarding employment. Staff training has been abundant in the home as stated previously, to equip staff with the necessary knowledge and skills to provide a changed service. Additionally the usual statutory training is in place. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37,38 The quality of this outcome is good. The judgment is made using available evidence including a visit to the service. EVIDENCE: The Meadows is owned and operated Stoke on Trent Social Services Department. The functions of the home have changed dramatically over the past year and major changes and refurbishment work to the home continues at a rapid pace. The home is overseen by the Social Services Management Team but directly supervised by the Service Manager who was present during this inspection and provides the required monthly visits and reports under Regulation 26 to the Commission. This is a monthly audit of the home covering the major aspects of care and service provision. This provides direct support and supervision to the Registered Manager and there appears a very positive relationship. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 21 There is a quality assurance system in place to inform of user satisfaction and identify areas where improvements can be made. Views of residents, relatives, social workers, GP’s and other health professionals are sought as a means of widening the QA process. These comments were not inspected on this visit but have been previously very positive and helpful in providing measuring the quality of service. The Registered Manager takes a positive lead in the home and managed the changes with hard work, sensitivity, diplomacy and with considerable success. Staff spoken to were very positive about the changed service and the future and the changes appear to have made a more cohesive staff group. Regular residents meetings and also staff meetings are held and minutes taken. Records inspected were generally to a good professional standard. Fire records seen indicated that regular checks of systems and equipment were carried out. The Fire Officer has specified considerable work which must be done to complete the required fire safety of the building. This is reported to be almost complete (delayed temporarily recently by an outbreak of illness in the home), the further work now in process following which a further inspection from the Fire Officer will be requested prior to a meeting arranged for 3rd August with the Fire Officer and other officials to formally agree completion. A further requirement is made in this report to comply with those requirements. A safety risk identified and mentioned earlier in this report to cover pipework in the first floor toilet area is also subject to a requirement of this report. On inspection of the kitchen area it was clear that a fridge was recently replaced with a smaller domestic model, which is clearly unsuitable and inadequate in size for its purpose. This was a used item brought from another home but should be replaced with a commercial fridge of more suitable size. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 2 1 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 2 The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 23 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 OP38 Regulation 23 (4) Requirement Outstanding recommendations made by the Fire officer must be implemented by the agreed time of 31 March. Pipework in toilet area identified must be covered to ensure safety to residents. Care plans must be reviewed monthly, dated and signed by reviewer and Manager Relocate call point in ground floor area to ensure system is accessible to residents. Timescale for action 31/08/06 2. 3. 4. OP38 OP7 OP22 13 (4) 15(1) 12(1)(a) 29/06/06 29/06/06 15/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP38 Good Practice Recommendations It is recommended that the domestic style fridge is replaced with a large commercial model. The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 The Meadows DS0000032500.V300907.R01.S.doc Version 5.2 Page 25 - 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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