Care Home: Meadow Grange

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What the care home does well People live in a homely, safe and comfortable environment. People who use the service generally report that they feel that staff provide good care and that the care that they receive is discussed and agreed with them. Before they are admitted to the home they are encouraged to visit and they feel that they receive suitable information about the service to help them make decisions about living there.People living at the home consider the staff to be enthusiastic and committed, and that they develop good relationships with the people who live there. They report that staff respect their rights to privacy and dignity. A person using the service that was spoken with said: `Staff do everything possible to make my stay comfortable.` People feel that if they raise any concerns or complaints, the management will genuinely listen to them and take any necessary steps to resolve any issues of concern. People enjoy the quality and the choice of food provided. A person who uses the service said: `I wouldn`t fault the food.` Comments from people living at the home indicate that most people feel that the range of activities provided meets their social and leisure needs. What has improved since the last inspection? The service has worked to address the requirements made at the last inspection, which took place on 3rd October 2007 and there are no outstanding requirements from that inspection. The approach to care planning has developed and there is a robust reassessment process for the review of individual plans of care. Medication procedures have been improved and there is periodic audit of the system to monitor against standards. The service has continued to look at ways that it can provide a varied activities programme to meet the individual needs of the people who live there. The home has improved the systems for dealing with any complaints and concerns and there has been further training for staff in the safeguarding of vulnerable adults, which promotes the protection of those living at the home. The staff training programme has been developed and a training matrix helps to ensure that staff receive ongoing and appropriate update training. The home has not had a manager registered with the Commission for some time. The acting manager confirmed at this inspection that she intends to apply to the Commission forthwith, and has completed the procedure for obtaining Criminal Records Bureau clearance through the Commission`s pathway. The Commission anticipates the receipt of a completed application. What the care home could do better: It has not been necessary to make requirements at this inspection. Recommendations have been made to further develop some aspects of the care planning systems, the processes for documenting the personal monies of people living at the home, and to develop the policies and procedures relating to the safeguarding of adults. Feedback from relatives is that they would appreciate more regular resident/relatives` meetings to discuss issues of interest to them, and a recommendation has been made for this. CARE HOMES FOR OLDER PEOPLE Meadow Grange Holmesfield Road Dronfield Woodhouse Sheffield Derbyshire S18 8WS Lead Inspector Andrew Bailey Unannounced Inspection 1st December 2008 09:50 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 Meadow Grange DS0000002063.V373379.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. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadow Grange Address Holmesfield Road Dronfield Woodhouse Sheffield Derbyshire S18 8WS 0114 2891110 0114 2891068 meadowgrange@heathcotes.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) Mr John Andrew Hill Mr Simon Cobb Manager post vacant Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider is registered to provide nursing and personal care for service users whose primary care needs fall within the following category: 1. Old age not falling within any other category (OP) 46. 2. The maximum number of persons to be accommodated at Meadow Grange is 46. 3 October 2007 Date of last inspection Brief Description of the Service: Meadow Grange currently provides personal care and support for up to 46 older persons. It is a converted building with a later extension and is close to the village centre, with access to local shops, church and other facilities. There is level access to extensive grounds, which provide a large patio area, together with a large car parking facility. The environment is well maintained and there is a choice of lounge and dining rooms for service users. There are thirty-eight single bedrooms, many with en-suite facilities and four double bedrooms. Bathrooms and toilets are suitably located and equipped. There is a large central kitchen and separate laundry facility. We were informed at this inspection that the range of weekly charges is as follows: £420.00 - £650.00 The home provides information about fees, how they are determined and what they cover. Fees are dependent on the type of room chosen, individual’s assessed care needs and funding contributions as may be determined by the local authority, where applicable. The home’s Statement of Purpose and a copy of the most recent inspection report for this service is available at the home. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and looks at any aspects of service provision that may need further development. The inspection was unannounced and took place over a period of seven hours. For the purposes of inspection we have taken into account information that we hold about this service. This includes our previous key inspection report of 3rd October 2007 and information provided in the Annual Quality Assurance Assessment (AQAA) questionnaire completed by the home. Resident survey information has been analysed and responses are incorporated within the report. At this inspection there were thirty-seven people using the service. We used case tracking as part of our methodology. This means that we looked more closely at the care and services that four of those people were receiving. Where possible, we did this by talking with those people, speaking with their relatives and by looking at written care plans and associated health and personal care records. We spoke with management and staff about the arrangements for matters such as recruitment, induction, training and the general running of the home, and we observed some of the staffs’ interactions and approaches with people who use the service. What the service does well: People live in a homely, safe and comfortable environment. People who use the service generally report that they feel that staff provide good care and that the care that they receive is discussed and agreed with them. Before they are admitted to the home they are encouraged to visit and they feel that they receive suitable information about the service to help them make decisions about living there. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 6 People living at the home consider the staff to be enthusiastic and committed, and that they develop good relationships with the people who live there. They report that staff respect their rights to privacy and dignity. A person using the service that was spoken with said: ‘Staff do everything possible to make my stay comfortable.’ People feel that if they raise any concerns or complaints, the management will genuinely listen to them and take any necessary steps to resolve any issues of concern. People enjoy the quality and the choice of food provided. A person who uses the service said: ‘I wouldn’t fault the food.’ Comments from people living at the home indicate that most people feel that the range of activities provided meets their social and leisure needs. What has improved since the last inspection? The service has worked to address the requirements made at the last inspection, which took place on 3rd October 2007 and there are no outstanding requirements from that inspection. The approach to care planning has developed and there is a robust reassessment process for the review of individual plans of care. Medication procedures have been improved and there is periodic audit of the system to monitor against standards. The service has continued to look at ways that it can provide a varied activities programme to meet the individual needs of the people who live there. The home has improved the systems for dealing with any complaints and concerns and there has been further training for staff in the safeguarding of vulnerable adults, which promotes the protection of those living at the home. The staff training programme has been developed and a training matrix helps to ensure that staff receive ongoing and appropriate update training. The home has not had a manager registered with the Commission for some time. The acting manager confirmed at this inspection that she intends to apply to the Commission forthwith, and has completed the procedure for obtaining Criminal Records Bureau clearance through the Commission’s pathway. The Commission anticipates the receipt of a completed application. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Meadow Grange DS0000002063.V373379.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 Meadow Grange DS0000002063.V373379.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service receive information to help them decide whether the service can meet their needs, and have the opportunity to visit the home before choosing to live there. EVIDENCE: In the Annual Quality Assurance Assessment (AQAA) document that we received before this visit the service said that they invite the person to visit the home before deciding to live there. They also told us that they undertake thorough pre-admission assessment visits for all planned admissions. They told us the home’s care plans are put in place within 48 hours of admission. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 10 We case tracked four of the people living at the home. This included looking at their care records and where possible speaking with them during the visit. We were able to speak directly with three of the people (or with their relatives) about the admission process. They felt that they had received suitable written and verbal information about the care home before deciding if it was the right place for them. In all cases, either a relative had visited the home prior to the admission or the person living there had undertaken a pre-admission visit. One of the surveys that we received before the visit contained information that the person would have liked to have had a trial period before deciding to live at the home, but had agreed to come to the home on the basis of the written information and the contract that they had read. People we spoke to at the inspection said that pre-admission visits had been offered to them. We noted that there was written information about the service on display in the entrance area of the home and in the bedrooms that we looked at during the inspection visit. The care records of the case tracked people that we examined contained assessments from which more detailed care plans had been developed. Where appropriate, social services assessments had been received prior to admission of the person to the home. Meadow Grange DS0000002063.V373379.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care needs of people living at the home are met and staff respect their rights to privacy and dignity. EVIDENCE: In the annual quality assurance assessment (AQAA) the service state that staff maintain respect and dignity for all residents. They told us that there are individualised, person centred plans of care and that appropriate risk assessments are carried out. They said that residents and/or relatives are encouraged to look at the care plans and be a part of the review processes. The service told us that medication practices had been improved and that monitoring of the medications system took place. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 12 When we spoke to people living at the home, or their relatives, they confirmed that staff are respectful of the privacy and dignity needs of people living at the home. For example, staff knock on the bedroom door before entering the room. They also felt involved in deciding what care they received. Relatives said that there was appropriate communication with them about any health changes of their relative. People living at the home that we spoke with (or their relatives) felt that care needs were generally met, but two of the relatives felt that there were times when more staff were needed, particularly to meet the needs of the less able bodied people at the home. One of the written surveys that we received also stated that this person usually received the care they needed, but they said: ‘ Because of the large number of residents and low number of staff this isn’t always possible’. Another relative said: ‘Meadow Grange is a very good care home; my mother is well looked after and tells me that the staff are very good to her. I think the staff are excellent, but there are not enough of them’. Overall feedback from this inspection visit was that care needs were being met most of the time. A relative we spoke with said that there usually seemed to be enough staff and also said that staff were polite and seemed to be good at their jobs. A person living at the home said: ‘Staff do everything possible to make my stay comfortable’. When we spoke to staff, one thought that there was enough staff and another thought that it was sometimes difficult to meet all the needs of the people at the home on current staffing levels, particularly in the morning. We discussed the feedback with the acting manager and she agreed to monitor the situation on an ongoing basis. We examined the care plan records of the four people that we case tracked. The care plans had been formulated from pre-admission information and from risk assessments undertaken at the home. In most cases the records were satisfactory, but in one case there was no continuity in the records when the community nursing service had become involved for aspects of pressure ulcer prevention care. Whilst the community nursing service has separate records, there was no information in the home’s records about the referral or the impact that subsequent prevention measures had for the care delivered by staff at the home. However, in another person’s care records there was clearly continuity and links in respect of where nursing services had been referred to for tissue viability advice and management. The home’s records in this case did detail the supportive and complementary care required by the home’s staff to ensure that the person was protected from undue risk of tissue damage. The records we looked at had been subject to regular review to ensure that the documented care needs had not changed and were still relevant. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 13 We looked for evidence within care plans that consideration had been given to the capacity of people to make some or all decisions for themselves. The acting manager told us that some of the staff had attended training to learn about the Mental Capacity Act 2005 and the implications it has for people living in a care home. Currently, there is little evidence in the care plans documenting that capacity has been considered. We discussed this with the acting manager at the inspection and she is aware that it is an area that for her attention. We looked at the medication systems and there were no apparent matters of concern to us. This was not an in-depth assessment, but there has been a recent external audit of the medication system carried out by the community pharmacy, with no outstanding matters for the home to address. The management also have an audit tool, which includes looking at the medication system and this was last utilised in May 2008, with actions taken where needed. The service has addressed the requirement from the last inspection, which related to the management of creams and lotions. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity programme and standard of food is good, which meets the needs of the people living at the home. EVIDENCE: The service told us in their annual self-assessment that they had reviewed the dining arrangements and had purchased a further hot trolley to transfer food to the first floor dining room, ensuring optimum food temperature. They also told us that they had looked at the activities and were placing more emphasis on participant activities. They are continuing to review the activities to provide a varied programme to meet the individual needs of the people who live at the home. The previous activities organiser has retired. There is now a new activities coordinator in post. Various outside entertainers visit the home. The service told us in the questionnaire that staff document the life histories and interests of people living at the home, with the help of relatives if appropriate. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 15 We spoke with people living at the home and with relatives and their feedback told us that they were generally satisfied with the catering. One person thought that the food quality was what they expected and overall good value for the fees paid. Another person said: ‘I wouldn’t fault the food’. A relative said that they food was good and varied and that their relative enjoyed their meals. People spoken with confirmed that a choice exists and that alternatives are available if they do not like the particular menu items. The cook told us that he knows the likes and dislikes of the residents and that he asks people what they prefer. We observed the midday mealtime on the day of the visit. Staff were on hand to support people who needed assistance with feeding. The mealtime was unhurried and people seemed to enjoy the food served. A programme of activities is displayed in the reception area and efforts are made to provide a variety of activities to meet the varying needs and abilities of the people living at the home. On the day of the inspection a range of activities took place, which included carpet bowls. Other regular activity includes beach ball exercise, musical memories, quizzes and dominoes. The coordinator keeps a record of the activities and the participation of the people at the home. One person who lives at the home told us that they go out to an art class. The November edition of the monthly newsletter produced at the home included mention of the ‘firework extravaganza’, concerts, and nights out to the Dronfield Civic Hall. People living at the home told us that visitors are made welcome. They also said that they are able to exercise choice in what they do and as far as possible can lead independent lives. One person described to us about going to church every week. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home responds appropriately to concerns and complaints and aims to protect people from harm. EVIDENCE: The AQAA self-assessment that we received prior to the inspection told us that any complaints are recorded and investigated, with actions recorded on file. The service told us that it had improved the system for handling complaints. The home has a complaints procedure and this is displayed in the home and contained in the written information available to current and prospective residents. The service told us that there have been seven complaints recorded in the last year, with all responded to within the twenty-eight day timescale. They told us that staff had completed safeguarding adults training. During discussion with staff at this visit, staff confirmed that they had received training in the protection of vulnerable adults (safeguarding adults). This training alerts staff to recognise abuse and respond to any allegations of abuse. When we looked at the policies and procedures, which are there to guide staff we found that they did not suitably describe how and when multiMeadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 17 agency safeguarding referrals would be made. However, the training materials used for staff instruction were more detailed and prescriptive in this respect. When we spoke to people using the service, or their relatives, they told us that they feel that management are approachable, will listen to them and take any issues of concern seriously. Feedback from the completed surveys indicated that relatives knew how to complain if they needed to. One person living at the home said: ‘I usually know who to speak with if not happy’. We looked at the complaints records and it was confirmed that complaints had been responded to in accordance with written procedures. One of the recorded complaints had been notified to the Commission and has now been resolved. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable, clean and suitably maintained care home. EVIDENCE: People that we spoke with were satisfied with the facilities at the home. One person commented: ‘My room has everything that I need’. We undertook a partial tour of the premises and found the home to be clean and tidy. One person told us that their room is always kept clean. The home had no apparent safety risks for the people living there. For example, the radiators are of the low-surface temperature type. There are shower and Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 19 assisted bath facilities for use by the people living at the home, and the showers are of the walk-in type, suited to those with mobility difficulties. Staff had undertaken infection control training and we observed that they used aprons and other protective measures during the time that we were observing during the inspection. The laundry is fit-for-purpose and feedback from the people living at the home indicated that they were generally satisfied with the service. There is seven day per week laundry and domestic staff cover. There is a handyman working for the home two days per week and the acting manager confirmed to us that there is no significant maintenance work outstanding. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training and recruitment practices promote the safety of people living at the home. EVIDENCE: The self-assessment completed by the home states that there is a good core of staff at the home and that the use of agency staff has reduced. The service tells us that they have increased the training that staff undertakes and that there is a better organised and efficient team working system. A skill matrix has been developed, which helps to ensure that there are no gaps in training and staff receive training updates when they are due. We sampled the recruitment files of two staff employed at the home. The records that we examined contained satisfactory evidence to support that the home is carrying out the appropriate pre-employment checks before staff commence working at the care home. Overall feedback from this inspection visit was that care needs were being met most of the time with the current staffing levels, but some staff and some Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 21 people that we spoke to who live at the home (or their relatives) felt that there were times when staff struggled to meet the needs of people. The acting manager stated the situation would be monitored on an ongoing basis. We spoke to the acting manager and to staff about the training programme at the home. Staff receive a range of training on a rolling programme, including mandatory training. The acting manager informed us that there are staff undertaking National Vocational Qualification (NVQ) Level 2 and 3 training. When these staff complete there will be more than fifty percent of the staff that hold this level of qualification. Induction and training records are held for each staff member. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, welfare and safety of people living at the home are promoted by the management systems in place. EVIDENCE: Safe working practices were examined on a sample basis, with consideration given to the information provided prior to the inspection in the AQAA selfassessment dataset. Staff receive mandatory training including fire safety, manual handling, and first aid. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 23 From our sampling of documentation, there was evidence that routine servicing and maintenance of equipment is taking place. We looked at the recording system for the management of personal money belonging to people living at the home (small amounts). The recording system was satisfactory, is backed up by annual company audit, but currently there is usually just one signatory to transactions and it may be in the interests of staff and people living at the home if a dual-signature system were adopted. The acting manager stated that they had been thinking about this and that they would give this further consideration. The home is currently managed by an acting manager, which means that she is not registered with the Commission for Social Care Inspection. The acting manager confirmed at this inspection that she intends to apply to the Commission forthwith, and has already completed the procedure for obtaining Criminal Records Bureau clearance through the Commission’s pathway. Feedback that we received from people who use the service and from staff indicates that they have confidence in the acting manager and that they feel that the home has developed in the time that she has been employed there. We looked at the quality assurance and quality monitoring systems in place at the home. We were able to confirm that mandatory monthly visits (Regulation 26 visits) were taking place, with reports compiled from each visit. These regulatory visits are part of the quality monitoring processes, which are meant to act in the interests of the people living at the home. The service uses a quality monitoring tool and the last report from this multifactorial assessment was in May 2008. The audit looks across the service at factors such as medication and care planning recording performance. The acting manager and staff confirmed to us that staff meetings take place. We spoke with some relatives and they felt that there should be regular resident/relative meetings with management and staff so that topics of interest could be discussed and debated. They felt that this would be one means of improving communications at the home. A monthly newsletter is produced with items of interest and relevance to the home included. A service user satisfaction survey had been completed and reported on in January 2008 and the acting manager confirmed that there were plans to repeat this again in the New Year. Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X 18 3 3 X X X X X X 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 X 3 X 3 X X 3 Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations There should be evidence within the home’s care plan documentation that the service considers people’s capacity to take decisions as part of the routine assessment process, in accordance with the Mental Capacity Act 2005. Care plans should always contain detail of actions taken, such as referral to nursing services, where tissue viability issues have been identified in the assessment of people living at the home. The home’s safeguarding adults procedure should describe how and when multi-agency safeguarding referrals are made. Meetings should be held for residents and relatives/representatives to meet with staff to periodically discuss issues of interest to them. A dual signature system should routinely be employed for documenting the personal money held on behalf of people living at the home. 2 OP8 3 4 5 OP18 OP33 OP35 Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Meadow Grange DS0000002063.V373379.R01.S.doc Version 5.2 Page 28 - 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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