Care Home: Meadowbrook Manor

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What the care home does well The staff are committed to training and the home exceeds targets that have been set for the numbers that should have a National Vocational Qualification (NVQ). This helps to make sure staff can meet the needs of people living in the home. There is a welcoming atmosphere throughout the home. Peoples` needs are met in a way that appears to respect their privacy and dignity. People have a pleasant environment to live in. The home has outdoor space with seating area which is accessible to all including those with mobility problems. With the exception of the laundry area the home was clean and fresh and there were no offensive odours. What has improved since the last inspection? The manager have introduced a checklist for carrying out regular routine checks of the building to ensure everything in the home is working properly so that repairs can be carried out speedily. The registered manager has undertaken random checks on medications to ensure all staff involved are following policies and procedures. The home has introduced a more varied programme of activities, which includes craft, baking, exercising to music and gardening. The aim is to make sure there is some activity for everyone to enjoy. The home has updated its policies on complaints and all appropriate employees have had training with regards to the protection of vulnerable adults. This helps to make people living in the home is safe. The redecoration of four bedrooms and the lounge/dining room has taken place. This has help to make the environment more pleasant for the people living there. The home has updated its quality questionnaire in order to gain a more advanced understanding of how the service is meeting the needs of the people living there. Peoples care plans are signed and agreed by people living in the home or their relatives. This shows they are involved in planning the care they receive. What the care home could do better: People`s changing needs must always be documented and followed through when a care need had been identified. This would ensure people needs are not over looked. Windows were very difficult to close and the same windows had "broken double-glazing" seals. This makes it difficult for people living the home to open and close their window at will. A number of the kitchen units are showing signs of wear and tear. If not address there is the potential for the home to look worn. However the manager said this is programmed for refurbishing soon. The steps leading to the laundry and the laundry area itself are dirty and require cleaning. Otherwise the quality of the environment for the people living there will become poor. There should be a notice in the lift explaining what to do in the case of an emergency. This will help to make people feel at ease and not panic whilst in the lift. All staff must have regular supervision at least six times a year. This would enable them to discuss any concerns and manager can use that opportunity to inform them of any changes in the home. CARE HOMES FOR OLDER PEOPLE Meadowbrook Manor 147/149 Wakefield Road Garforth Leeds West Yorkshire LS25 1NE Lead Inspector Hebrew Rawlins Key Unannounced Inspection 13th February 2008 08:55 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 Meadowbrook Manor DS0000001481.V359886.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. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadowbrook Manor Address 147/149 Wakefield Road Garforth Leeds West Yorkshire LS25 1NE 0113 232 0054 F-P 0113 2320054 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) Mrs Beverley McHale Mrs Beverley McHale Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2007 Brief Description of the Service: Meadowbrook Manor is a purpose built home set in a half acre of landscaped gardens, which are accessible to wheelchair users. The home is just outside the village of Garforth with a parade of shops and a pub within a short walking distance. The home offers care to a total of 23 older people, male and female with low to medium dependency needs. The home does not provide nursing care. The home has three floors; there are 19 single and 2 double rooms with en-suite facilities provided in 19 rooms. The home has a large dining room and three lounge/day areas. There is a ramp at the front door for wheelchair access and inside a passenger lift provides access to all floors. Car parking is provided at the front of the home. The current fees range from £398.00 per week to £420.00 per week with additional charges for hairdressing and chiropodist. The manager provided this information at the time of the visit. Meadowbrook Manor DS0000001481.V359886.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 Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. Information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and carried out by one inspector who was at the home from 8.55 until 16.30 on 13th February 2008. The inspector was accompanied on the day by an “expert by experience” from the organisation Choices and Rights. An “expert by experience” is a person who, because of their shared experience of using services, is able to help us get a better picture of what it is actually like for people using services. The “expert” who came during the visit looked around the home, had lunch and spoke to some of the people living there. The feedback she gave us has been incorporated into this report. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who use the service and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. During the visit a number of documents were looked at and areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and staff. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information about the home. Survey forms were sent out to the people who use the service, relatives, carers, general practitioners (GPs) and other healthcare professionals. Several were returned and information provided in this way will be reflected in the report. Feedback at the end of this inspection was given to the manager. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 6 Thanks are extended to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: What has improved since the last inspection? The manager have introduced a checklist for carrying out regular routine checks of the building to ensure everything in the home is working properly so that repairs can be carried out speedily. The registered manager has undertaken random checks on medications to ensure all staff involved are following policies and procedures. The home has introduced a more varied programme of activities, which includes craft, baking, exercising to music and gardening. The aim is to make sure there is some activity for everyone to enjoy. The home has updated its policies on complaints and all appropriate employees have had training with regards to the protection of vulnerable adults. This helps to make people living in the home is safe. The redecoration of four bedrooms and the lounge/dining room has taken place. This has help to make the environment more pleasant for the people living there. The home has updated its quality questionnaire in order to gain a more advanced understanding of how the service is meeting the needs of the people living there. Peoples care plans are signed and agreed by people living in the home or their relatives. This shows they are involved in planning the care they receive. Meadowbrook Manor DS0000001481.V359886.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. Meadowbrook Manor DS0000001481.V359886.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 Meadowbrook Manor DS0000001481.V359886.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): 1, 3 and 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The information provided about the service is good and gives people that are considering using the service the opportunity to decide whether or not the home can meet their needs. The assessment procedure is thorough and people can be sure that the home will not offer to provide a service unless the staff are able to meet their needs. EVIDENCE: The Statement of Purpose provides good information about the service, which helps people decide whether or not the home can meet their needs. People spoken with said they were given the opportunity to visit and assess the facilities and suitability of Meadowbrook Manor. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 10 In people case files looked at there was evidence of comprehensive preadmission assessments. This provides details of peoples condition, health and other professional’s involvement with the individual. From all of the information collected, if the home believes it can meet the person’s needs, a plan of the care needed is written. Meadowbrook Manor DS0000001481.V359886.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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are aware of the specific needs of people living in the home. Their privacy and dignity is respected. People’s health care needs are met, and medication practices are safe. EVIDENCE: The recording of information to assist staff care for the people living in the home was fairly good. However people’s changing needs must always be documented and followed through. When a care need had been identified there was not always clear instruction to staff on how to manage the change. People’s care plans are reviewed regularly. There was evidence of signatures by people agreeing to their plans of care and end of life documentation is within the care plans to ensure fulfilment of individual wishes. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 12 From discussion with staff it was clear that they knew the precise needs of the people living in the home and provided care based on individual needs and preferences. The home has a comprehensive medication policy that covers all aspects of recording and administering medication. Medication is stored in a safe environment. Meadowbrook Manor DS0000001481.V359886.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a relaxed and informal atmosphere that promotes flexibility and visitors are made to feel welcome. People are encouraged to take part in social and leisure activities. A good and varied diet is provided. EVIDENCE: Religious services are held once per month in the home, which everyone could attend if they required. I understood that there is a different denomination in sequence. Trips out take place, but due to the age group and disabilities of most of the people, because they require one-to one and wheelchairs, only four people could go out at one time. Hire transport is not available to take more people/wheelchairs. The eldest person is almost one hundred, but is blind and deaf, as is another elderly person living in the home. These are great difficulties for staff to Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 14 overcome when providing enhanced social lives for everyone, but I believe the staff do their utmost to please everyone, and are always on the lookout for alternative hobbies/entertainment. A large patio area has been arranged so that wheelchair access and Zimmeraccess in better weather, is made easier for both people in the home and staff. The usual: birthday parties, Xmas parties, Bingo, and painting are available. The home also has a piano and electric organ available. One person used to play occasionally and is hoping to start again. The “expert by experience” had lunch with people living in the home, which she said was good and had a variety of colour on the plate. Frozen vegetables are used, and on this occasion were suitable for the meal. People in the home said they enjoyed their food and were “well fed”. Staff were attentive to people during the mealtime, zooming in on people who they knew may have difficulties, but only when required. Meadowbrook Manor DS0000001481.V359886.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People and their representatives can be confident that their concerns will be listened to and dealt with. The home has the necessary systems in place to make sure that people are protected from abuse. EVIDENCE: The home records all complaints they receive. No complaints have been made either to the home or the Commission For Social Care Inspection since the last inspection in February 2007. The home has a comprehensive policy and procedure on the action staff should take if abuse is suspected or reported. In discussion with staff they all appeared confident in the action to be taken. People spoken with said information on how to make a complaint was made available to them and all said they know how to complain. The manager was aware of the need to report any suspected or alleged abuse to the local authority and other relevant authorities. Meadowbrook Manor DS0000001481.V359886.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. People live in a homely environment that is clean, comfortable. There are signs of wear and tear, however it is generally well maintained making it a nice place to live. EVIDENCE: The home is welcoming and provides a homely atmosphere. All bedrooms seen were tastefully decorated and have en-suites facilities All the people living in the home and relatives spoken with said the home was always clean and free from offensive odours. Gloves, aprons and alcohol gel is provided and used by all staff and infection control procedures and policy are in place. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 17 The expert by experience said, ‘Meadowbrook, has a warm and friendly environment, and I felt very welcome by staff and residents’. ‘There was a choice of lounges, which anyone could choose to sit in’. ‘I would choose the picture window in the upstairs lounge’. ‘This made one feel very much part of the outside world’. Some people’s rooms had similar beautiful views and were very much appreciated by the people living there. Two people said they would not change their room with their view for anything. One person who cleaned her own room, because she preferred to, had her own furniture and “heirlooms”. I admired her embroidered framed pictures, which she had completed herself some years ago. She was very proud of her room and bathroom (en suite). Other rooms were of varying degrees and obviously reflected different personalities. Everyone seemed happy in his or her own domain. The downstairs and some of the top floor doors were being revarnished. Some staff acquired some of the varnish on their clothes. It was difficult to tell which doors had been painted. As this is a one-off exercise, perhaps the next time painting downstairs takes place it could be done late evening when people are making their way back to their rooms. Two people’s windows were very difficult to close and the same windows had “broken double-glazing” seals. The kitchen was clean and tidy however a number of the units are showing signs of wear and tear. However the manager said this is programmed for refurbishing soon. The steps leading to the laundry and the laundry area itself are dirty and require cleaning. There should be a notice in the lift explaining what to do in the case of an emergency. This will help to make people feel at ease and not panic. The training of staff in fire safety matters is up to date ensuring people are not put at risk. Meadowbrook Manor DS0000001481.V359886.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. It appears the numbers of staff employed is sufficient to meet the needs of people in the home. They have received sufficient training to ensure peoples needs are met in a satisfactory way. The recruitment procedure is robust so that people can be confident that they are protected from potential harm. EVIDENCE: Staff files included necessary documentation such as two references; Criminal Record Bureau enhanced disclosures, contract, application forms and interview information records. There is an ongoing programme of NVQ (National Vocational Qualification) training over 60 of care staff have achieved an NVQ. Staff have received up to date training in mandatory requirements such as fire safety, health and safety, moving and assisting, food hygiene and infection control. The comments made by people living in the home were very positive about the staff and they complimented their care and kindness in meeting their personal needs. ‘They always there when you need them’ ‘I have only got good things to say about them’. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 19 Meadowbrook Manor DS0000001481.V359886.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager has extensive experience to manage the home so that people living there can be confident the home is well run. The health and safety of people is promoted and protected. This makes it a safe and good place to live in. EVIDENCE: The manager of the home has 20 years management experience in a care setting and is working towards the National Vocational Qualification level 4 qualifications in management and care. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 21 She is aware of areas that need to be improved to make the lives of people in the home better. There is a quality assurance system, which helps to determine the standard of care for people in the home. If a person living in the home does not want to manage their finances, or does not have the capacity to do so the home manage finances in the best interests of that person, or encourage them to appoint a lasting power of attorney. The home provides a safe place for people to keep valuables and money. A record of anything kept within this area is maintained. Training for staff in health and safety, infection control, fire awareness, food hygiene, first aid and handling and assisting are all up to date. However staff supervision has fallen behind which the manager has agreed to address. The home has up to date policies and procedures to promote and protect employee’s health and safety. There is full and clearly written recording of all safety checks and accidents, including analyses. Meadowbrook Manor DS0000001481.V359886.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 x 3 x 3 N/a 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 x 18 3 2 3 x x x 3 x 2 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 2 x 3 Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 People’s changing needs must always be documented and followed through when a care need had been identified. This would ensure people needs are not over looked. Windows must be made easy to open and close and “broken double-glazing” seals repaired. The steps leading to the laundry and the laundry area itself are dirty and require cleaning. All staff must have regular supervision at least six times a year. This would enable them to discuss any concerns and manager can use that opportunity to inform them of any changes in the home. Timescale for action 07/04/08 2. 3. 4 OP19 23 13 18 07/04/08 07/04/08 07/04/08 OP26 OP36 Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP19 OP22 Good Practice Recommendations The kitchen is now showing sign of wear and tear. There should be a notice in the lift explaining what to do in the case of an emergency. This will help to make people feel at ease and not panic whilst in the lift. Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Meadowbrook Manor DS0000001481.V359886.R01.S.doc Version 5.2 Page 26 - 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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