Inspection on 21/11/05 for The Meadows Nursing Home

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Nursing Home 22/07/08

The Meadows Nursing Home 29/06/07

The Meadows Nursing Home 23/05/06

The Meadows Nursing Home 06/07/05

The Meadows Nursing Home 12/12/04

The Meadows Nursing Home 10/07/04

The Meadows Nursing Home 08/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Meadows Nursing Home, The 656 Birmingham Road Spring Pools Bromsgrove Worcestershire B61 0QD Lead Inspector Mandy Burton & Chrissy Presley Unannounced Inspection 21st November 2005 10:00 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 Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 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. Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Meadows Nursing Home, The Address 656 Birmingham Road Spring Pools Bromsgrove Worcestershire B61 0QD 0121 453 5044 0121 453 0212 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) Worcestershire Care Group Limited Care Home 36 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (36), of places Physical disability over 65 years of age (36), Terminally ill (4) Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Home may also accommodate a maximum of three people aged between 55 - 64 years with a physical disability. The Home may also accommodate three persons under 65 years with a learning disability. The Home may also accommodate 1 person aged between 50 - 64 with a physical disability. 6th July 2005 Date of last inspection Brief Description of the Service: The Meadows Nursing home is one of two homes owned by the Worcestershire Care group. It is registered to accommodate a maximum of 36 residents. The home is divided into three units, Pine, Beeches and Willows. Pine and Willow units are on the ground floor and the Beeches unit is located on the first floor and caters for residents who have dementia related illness. A passenger lift provides access to first floor rooms. With the exception of one bedroom all rooms are single occupancy. The home is situated in a rural setting near to the Licky Hills and is also only five minutes from the motorway. Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this inspection. The inspection was unannounced and commenced at 10am. It took place over a period of five hours. The main focus of this inspection was to assess care and medication practice and to review progress on requirements from the last inspection report. What the service does well: What has improved since the last inspection? 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. Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 6 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 Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 7 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): None of the standards in this section of the report were inspected; refer to previous report for further information. EVIDENCE: The requirement from the last visit for a Service User Guide to be updated and contain accurate information was not inspected at this time; the inspector is therefore unable to comment if this has been addressed. Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 8 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, 8, 9, & 10 Individual care plans and risk assessments are of a poor quality and do not reflect the current care needs of residents. Medication is not administered on time, which places residents at risk. EVIDENCE: Care plans were of a poor quality, and care instructions did not reflect current care needs, a number of documents in the care plans inspected were unsigned and did not contain specific dates. One care plan had not been updated since September. Nutritional care plans seen had not been updated, it was noted in one care plan a resident had lost weight and was now deemed at risk however a specific care plan had not been implemented to address this risk. Nursing tools used to identify residents at risk of developing pressure sores had been added up incorrectly, placing residents at risk by not identifying Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 9 those most vulnerable. Pressure sores were not being managed within the agreed care plan documentation. Risk assessments from various residents care files were inspected these included, a resident who smoked, a resident at risk of leaving the building and a resident at risk of falling these had not been reviewed within the past month and up dated and therefore placed these vulnerable residents at unacceptable risk. Records seen of residents requiring regular blood sugar monitoring for diabetes were not consistent with the care plan. There were a number of signature gaps on the medication records seen and general medication recording was of a poor quality. Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 10 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): None of the standards in this section of the report were inspected; refer to previous report for further information. EVIDENCE: Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 11 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): None of the standards in this section of the report were inspected; refer to previous report for further information. EVIDENCE: Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 12 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): None of the standards in this section of the report were inspected; refer to previous report for further information. EVIDENCE: Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 13 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): 29 None of the standards in this section of the report were inspected; refer to the previous report for further information. EVIDENCE: Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 14 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): 38 None of the standards in this section of the report were inspected; refer to previous report for further information. EVIDENCE: Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 15 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 16 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 OP7 Regulation 15 Requirement Care plans must be reviewed at least once a month or as soon as care needs change. Outstanding requirement from inspections, 10/07/04 07/12/04 & 6/07/05 Blood sugar monitoring for those residents with diabetes must be carried out if this is stated in the agreed plan of care. Details of normal blood sugar ranges and treatment/action in the event levels are recorded above or below normal levels must be available to staff. Immediate requirement left with the home 21/11/05 Care plans must in place for all residents which identify any social and emotional needs and details action to be taken by staff to support / care for the resident concerned. Outstanding requirement from 6/07/05 Monitor and record the weight of all residents on a monthly basis and ensure appropriate action is taken when significant weight DS0000004124.V265758.R02.S.doc Timescale for action 21/11/05 2 OP7 12 (1) (b) 21/11/05 3 OP7 15 21/11/05 4 OP8 12 (1) & 15 21/11/05 Meadows Nursing Home, The Version 5.0 Page 17 5 OP7 12 (1) & 15 6 OP7 12 (1) 13 15 7 OP8 12 (1) 13 15 8 OP12 16 9 OP38 23 loss or gain is evident. Outstanding requirement from 07/12/04 & 06/07/05 Monitor and record the weight of all residents on a monthly basis and ensure appropriate action is taken when significant weight loss or gain is evident. Outstanding requirement from 07/12/04 & 06/07/05 Risk assessments must be reviewed at least once a month for each resident in relation to skin viability, nutrition, moving and handling, falls and other identified and significant risks. Action to minimise risk identified must be included in each individual care plan. Outstanding requirement from 6/07/05 Risk assessments must be reviewed at least once a month for each resident in relation to skin viability, nutrition, moving and handling, falls and other identified and significant risks. Action to minimise risk identified must be included in each individual care plan. Outstanding requirement from 6/07/05 A regular programme of social and recreational opportunities must be made available to all residents in accordance with individual needs and preferences. Residents should be made aware of planned activities and additional information displayed around the home. Outstanding requirement from 6/07/05 The fire risk assessment must be reviewed 21/11/05 21/11/05 21/11/05 21/11/05 21/11/05 Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Meadows Nursing Home, The DS0000004124.V265758.R02.S.doc Version 5.0 Page 20 - 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!