Care Home: The Meadows

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What the care home does well The service has continued to support the lifestyle of permanent residents whilst simultaneously establishing a rehabilitation/intermediate care service. The integration of the health and social care teams was now well established and working well. The model provided a rapid response for rehabilitation service users to enable them to undertake a goal centred short period of intensive support and treatment with the aim of them returning home and being able to look after themselves either independently or with domiciliary support. What has improved since the last inspection? All recommendations made by the Fire Officer have been implemented. Exposed pipework in a toilet area has been covered to ensure the health and safety of service users. Care plans are reviewed monthly and signed by reviewer and manager. Furniture has been re-sited so that it no long obstructs the alarm call system for service users. CARE HOMES FOR OLDER PEOPLE The Meadows Wrenbury Crescent Berryhill Stoke on Trent Staffordshire ST2 9JZ Lead Inspector Linda Clowes Key Unannounced Inspection 5th December 2007 09:00 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 The Meadows DS0000032500.V352217.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.V352217.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 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 33 Category(ies) of Dementia (5), Mental disorder, excluding registration, with number learning disability or dementia (5), Old age, not of places falling within any other category (33), Physical disability (33) The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 33 Physical disability (PD) 33 Dementia (DE) 5 Mental Disorder (MD) 5 The maximum number of service users to be accommodated is 33. 2. Date of last inspection 28th June 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 33 older people and/or 33 adults with physical disability, five may be adults with dementia care needs and five may be adults with mental disorder. The total number who may be accommodated at any one time is 33. The Meadows is described as a Centre of Excellence and, therefore, raises expectations that it is an excellent, high quality service and this is what the service says it provides. The home’s Statement of Purpose states that the minimum age of adults admitted to this service will be 55 years. People are admitted for a six-week period following a full needs assessment by the multi-agency team of health and social care professionals. The prime aim of the service is to promote independence and develop life skills in order that people may return to their own homes. There are 22 bedrooms situated on the first floor that are now being used for The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 5 people on rehabilitation/intermediate care programmes. There are 11 bedrooms situated on the ground floor, 9 of which are being used to accommodate long-standing service users. All bedrooms are for single occupancy. There are none with en suite facilities. However, there are adequate toilet and bathing facilities conveniently situated throughout the home. Small lounges/dining areas have been introduced several with their own kitchenette areas to promote a ‘homely’ feel. Service users on rehabilitation programmes are encouraged and assisted to prepare their own meals in the kitchenettes. The home provides all meals for long-standing service users and a main lunchtime meal is also available for people who are on rehabilitation programmes. Another section of the building accommodates a team of social care and a team of health care professionals. This ensures that people on rehabilitation programmes have prompt access to community health and social care workers. The home has links with a local GP Practice that provides support to service users whilst they are in residence at The Meadows. A Healthy Living Centre that accommodates 24 day-care service users. People who are under rehabilitation programmes and people in the community are able to access this facility, following a needs assessments by an appropriate professional, to promote independent living and life skills, e.g. to provide instruction and support to enable a person with diabetes to take their own blood/sugar readings; to promote good nutrition and cooking skills; mobility techniques. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection carried out by one inspection and took place over 9 hours. The inspection was carried out under the Care Standards Act 2000, the Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People. All of the core standards have been assessed during this visit. Statistical information regarding the service has been provided by the Manager in the Annual Quality Assurance Assessment (AQAA). The Service Manager and Registered Manager were present for the inspection and impressed as dedicated and enthusiastic regarding the change from a residential care facility to a Rehabilitation/Intermediate Care Unit. The Meadows is presently in transition from a residential care home to a Centre of Excellence for Rehabilitation. Nine permanent service users remain in the service and are situated on the ground floor of the building. On the first floor there is accommodation for 22 rehabilitation service users and this was fully occupied on the day of this inspection. No new permanent admissions will be made to this service. This inspection found that a very good service was being provided to both permanent and rehabilitation service users. Without exception all service users spoken with were complimentary and positive about their stay at The Meadows. Staff spoken with were enthusiastic and committed to providing a good service. There was a positive attitude to training and development that benefited both staff and service users. The refurbishment of the building is almost complete and is approaching its final stage which includes upgrading the laundry area. Eight service users returned questionnaires and all expressed satisfaction with the care they received at The Meadows. Several added comments such as “I am happy at the Meadows and enjoy the food and drinks.” ”I was made very welcome. I press the nurse call and someone is knocking on my door in no time. We have meetings to discuss things.” “Excellent staff. The home is clean and fresh. On the whole I am satisfied all round.” Two requirements and three recommendations have been made as part of this report. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Ensure that service users have information about the service and its fees prior to admission. To ensure that monies held on behalf of service users are regularly audited. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 8 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. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 9 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.V352217.R01.S.doc Version 5.2 Page 10 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): 1,2,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users must be provided with the information they need to make an informed choice about whether the service is suitable for them prior to admission to the service. Comprehensive needs assessments are undertaken by health and social care professionals to determine whether the rehabilitation service can meet individual needs. EVIDENCE: There were no requirements in this outcome area in the last inspection report. The home had a Statement of Purpose and Service Users Guide that was currently being reviewed and updated. It is understood that these documents are located in a welcome pack in bedrooms in the rehabilitation unit. It is imperative, however, that service users should have access to this information prior to being admitted in the rehabilitation unit in order that they may make an informed choice regarding whether the service is suitable for them, whether The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 11 the terms of residency and any fees are acceptable. A requirement has been made as part of this report regarding this issue. (Requirement 1) It is acknowledged that no fees are charged for the assessed rehabilitation service, which may last up to six week. However, should a person’s stay extend beyond this time then fees/charges will be liable. These circumstances and charges must be explicit and in writing to clearly inform service users and their relatives what to expect. Four service users who responded to surveys indicated that they had not received a contract and two said they had not received enough information about the service before they moved in. Often service users are admitted directly from hospital following an assessment by the nursing/hospital team. However, the registered manager takes responsibility for individuals admitted to the home and she would undertake an assessment if it is not clear whether the individual’s needs can be met. Under these circumstances it is unusual for a person entering the service to visit the unit to see whether they would like to stay there prior to admission. It is imperative, therefore, that as much written information and any other advertising material e.g. DVD’s, Videos are readily available at point of contact. The alterations and refurbishment are almost complete with areas such as kitchens and laundry awaiting upgrades shortly. Rehabilitation services are located on the first floor only so that this intensive service does not impact on the daily lives of long-stay residents. Occupational and Physiotherapists are located on site to meet the assessed needs of service users admitted for short-term rehabilitation. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 12 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 using available evidence including a visit to this service. The service users social, health and personal care needs are recorded in an individual plan of care that is drawn up with the service user and/or their representatives. Service users were treated with respect and sensitivity. The service’s medication procedures protected service users. EVIDENCE: One requirement was made in this outcome area in the last inspection report that care plans must be reviewed monthly, dated and signed by reviewer and manager. This has now been complied with. A small random sample of care plans was sampled for both rehabilitation and permanent service users. Person Centred planning ensured that the health and personal care provided was based on individual needs. Care staff spoken with were aware of individual needs. Individual service user files were dynamic documents that were used as active working tools by support staff from all agencies. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 13 Regular reviews of care needs were undertaken throughout the person’s stay and any alterations/amendments were recorded in the file. Collaborative Goal Sheets were in place and Daily Progress Sheets provided detail of the individual’s daily activities and whether goals had been attained. All staff had received rehabilitation training and were aware of the change of focus from provision of permanent residential care to the rehabilitation model. Service users spoken with knew that they were on a rehabilitation programme and that the common aim was to work towards getting them back home and independent as soon as possible. Local General Practitioners provide their medical support to the service. They attend The Meadows twice a week, or when requested. This arrangement cuts down on any delays that might be experienced when individuals are outside their own GP’s area. Service users are encouraged to self-medicate where they are able. There was a lockable facility in their bedrooms to ensure security of medication. An inspection of the medication round found that the process was complex consisting of a combination of sealed monitored dose containers, bottles and packets of medication for each service user. Only Senior Staff were responsible for the recording, handling and administration of medication. All had received training. In view of the complexity, medication rounds were quite lengthy. Discussions took place with the manager regarding the need to monitor this situation to ensure that there was sufficient time allocated between each medication administration session. An inspection of the Medication Administration Records (MAR) found accurate and satisfactory recording. Controlled drugs were appropriately stored and signed off. The Medication trolley was securely stored when not in use. All service users who returned surveys and those spoken with on the day indicated that staff respected their right to privacy. The inspector observed kindly and sensitive interaction between staff and service users and it was apparent that service users were confident and at ease when making approaches to care staff. The Meadows DS0000032500.V352217.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): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are helped to exercise choice and control over their lives. Family and community links were promoted. Service users were provided with and encouraged to maintain a wholesome, balanced diet. Rehabilitation service users were assisted and encouraged to prepare their own meals. EVIDENCE: No requirements were made in this outcome area in the last inspection report. The refurbishment that has taken place has affected the in-house Activities Programme as there has been limited space to provide entertainment for all service users. However, a ‘Memory Lane’ singer visited on 04/12/07 and everyone said how much they had enjoyed this. On 12/12/07 Richard Layton would visit to take the lead with Christmas Carols. The Christmas Party was arranged for 20/12/07 with family and friends included. On Christmas Eve there was Christmas Bingo with special seasonal prizes. In the rehabilitation setting many of the planned daily activities were focussed on targeted input from physiotherapists and care staff. They were included in any entertainment which took place in the home. Entertainment was now able to take place in the Health Living Centre that had recently been reopened. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 15 Two service users who responded to surveys stated that there were arranged activities they could take part in “sometimes” with one adding ‘usually bingo’ Three said there were never any activities arranged with one adding “I do not know of any activities being arranged during my stay at the home” One senior member of staff was responsible for the Entertainment Programme and now that there was accommodation available to use she was arranging events for 2008. Service users on the day were seen chatting to one another, receiving visitors, attending medical appointments, watching television, knitting, reading and ‘people watching’. Staff were observed playing cards and chatting with service users. A high number retired to their bedrooms after lunch. One visitor spoken with confirmed that they were always made welcome by managers and staff. The surveys returned by service users/relatives showed that one liked the meals ‘always’, four ‘usually’, two ‘sometimes’ and one did not answer. In the main, people spoken with on the day said they enjoyed the food, its variety and quantity. Two people said that they did not. Discussions took place with the manager regarding this issue. There was a scheduled Residents Meeting on 6th December 2007 and she said she would raise this as an agenda item to see if she could address any concerns. On the day of this visit there was a choice on the main menu, but discussions with cook identified that she had also provided a jacket potato for one person and hot snacks for two others who did not want the main menu items. Other specialist diets were catered for, e.g. gluten free and liquefied meals. The Meadows DS0000032500.V352217.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to ensure that service users are protected from abuse. The service has a complaints procedure that is included in its service users guide. EVIDENCE: No requirements were made in this outcome area in the last inspection report. There was a comprehensive complaints procedure in place that was readily accessible to service users and relatives and was available in other languages and formats on request. One formal complaint had been received regarding the service that was being investigated through the corporate complaints procedure and was not yet complete. The CSCI had not investigated any formal complaints regarding the service since the last inspection. Copies of compliments were held on file but these often were not dated and so it was difficult to identify when they had been received. A recommendation was made that the date of receipt be recorded. (Recommendation 1) Service users spoken with confirmed that they would be confident to raise any matters of concern with any of the staff team and managers. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 17 An inspection of the training file found that the majority of staff had attended Protection of Vulnerable Adults from Abuse training since the last inspection. Staff spoken with were aware of the various forms of abuse and what procedures they must undertake should they suspect this. There had been no safeguarding referrals since the last inspection. The Meadows DS0000032500.V352217.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): 19, 20, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lived in a safe, well-maintained environment that was suitable for their needs. EVIDENCE: One requirement was made in this outcome area in the last inspection report for the call system to be relocated to make it accessible to service users. This has now been complied with. The home had been upgraded and refurbished and presented a clean, bright, ‘homely’ environment. The security of the building was protected with digital locks. The service requested that service users meet with their visitors in their bedrooms. Bedrooms were not large and in those visited by the inspector the The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 19 only space to sit was on the commode or the bed. This has obvious hygiene implications for visitors. As visitors are expected to meet with service users in bedrooms, it is recommended that consideration be given to providing suitable seating. (Recommendation 2) The home was warm, clean and attractively decorated. It was equipped with specialist equipment to maximise service users independence. Aids to daily living were provided to enable service users to access all areas of the service. There was a passenger lift to aid easy access. The home had a dedicated laundry area with appropriate equipment. There were plans in hand to upgrade the laundry in the near future. Rehabilitation service users were able to access the service’s laundry facilities or, if this was part of their rehabilitation programme, they could use the domestic style washing facilities provided on the first floor. Alternatively, family could take laundry home. There was a dedicated smoking room on the ground floor for the benefit of service users. Visitors were requested not to smoke in the building. The Meadows DS0000032500.V352217.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): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skills-mix are appropriate to the assessed needs of service users and the geography of the building. EVIDENCE: No requirements were made in this outcome area in the last inspection report. An inspection of the rotas found that there was adequate staffing to meet the assessed needs of the two groups of service users that are accommodated. Care staff were supported by domestic staff. Service users and visitors commented that the home was ‘always’ clean and tidy and that there were no malodours. One added “there are cleaners on the go all the time, plus hand wash dispensers all around the building”. Managers and staff spoken with on the day confirmed that the integrated model of working between health and social care teams was very successful and benefited service users and improved communication. Of the 33 permanent care staff employed by the service 13 had attained National Vocational Qualification (NVQ) in Care Level 2 and 6 were working towards this award. Two care staff were working towards NVQ level 3 Allied Health Profession Support/General and had been allowed a weekly study day to attend college over the last twelve months. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 21 The training matrix showed that staff had attended training for dementia care and mental health awareness. There were plans to provide Mental Capacity Act training to all staff when spaces on the training courses were available. There was sufficient staffing to meet the assessed needs of service users. The manager’s hours were supernumerary to the staff team. In addition support was provided by the Intermediate Care Team which comprised Social Worker, Nurse, Occupational Therapist, Physiotherapist and 2 health care assistants. A small random sample of staff files was inspected. Robust recruitment procedures were in place that included taking up Criminal Records Bureau Enhanced Disclosures (Police Checks) and two references. Proof of ID, references and medical information was held centrally by the Human Resources Department but there were e.mails on file to confirm that these had been obtained and were satisfactory. All staff undertook thorough induction training and a wide range of job related on-going training. Care staff spoken with said they were encouraged to take up any training available. All statutory training was in hand. The Meadows DS0000032500.V352217.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): 31,32,33,35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefited from a competent, experienced and qualified manager who ran the home in their best interests. EVIDENCE: Two requirements were made in this outcome area in the last inspection report – for fire safety improvements to be implemented and for pipework to be covered. Both have now been complied with. The Registered Manager has the required qualifications and experience, is competent to the run the home and strives to meet its stated aims and objectives. She provides a clear sense of leadership and direction that staff and service users understand. She has a clear vision of the service based on the values and priorities of the Local Authority. Good, professional relationships throughout the team are promoted and encouraged. She is The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 23 provided with support and direction from her Service Manager who demonstrates an equally positive and enthusiastic commitment to ensuring that the Rehabilitation Service is truly a Centre of Excellence. Service users spoken with confirmed that they felt ‘safe’. One service user who responded to the survey stated “the lady in charge, Diane, is always happy to listen”. There were policies and procedures in place and the manager ensured that staff followed these. Supervision was held regularly to monitor staff competence and training needs. Staff meetings were held to ensure that staff were kept informed of any issues relating to the home and changes in policies or procedures. Staff were encouraged to raise any practice issues in this forum. An inspection of finances found small discrepancies that were sorted on the day. However, it was identified that in some instances it was a considerable time lapse since cash had been checked e.g. 21/9/06 and 07/07/07. A requirement has been made for this situation to be addressed in order to provide a clear and timely audit trail. (Requirement 2) Health and safety systems were regularly reviewed and updated and the manager ensured that all staff received training from Induction onwards in health and safety matters. The following random sample of health and safety records was inspected and found to be satisfactory: Accident Records Fire Training Fire equipment testing and maintenance Boiler Maintenance Refrigerator and Freezer Records Food Temperature Records Individual Fire Risk Assessments. The records for cleaning of the kitchen area and equipment were not clear and in two instances were not completed on Sundays. A recommendation is made as part of this report for the Cleaning Record Sheet to be reviewed so that it clearly demonstrates what equipment and surfaces have been cleaned and when. (Recommendation 3) No Service User Satisfaction Surveys were provided. The manager was aware of the need to introduce a system to obtain the views of service users who may only use the service for up to six weeks. This area will be monitored at the time of the next inspection. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 24 The Certificate of Registration was displayed in the home as required by regulation. The current Certificate of Insurance was displayed. Personal and confidential records were securely stored and were accessible only to staff with authorisation to see them. Computers were protected by passwords. The manager ensured that risk assessments were completed for all areas of the business to ensure safe working practices throughout. The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 25 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 2 2 3 X x 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 3 X X 3 3 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 4 4 3 X 2 X X 3 The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 4(1)(b), 5(1)(b)(c) Requirement Each service user must be provided with a statement as to the facilities and services that are to be provided by the service and the terms and conditions in respect of accommodation to be provided including the amount and method of payment of fees, as appropriate prior to their admission. This will ensure that service users and their relatives have full knowledge of the terms of residency and fees and will enable them to determine whether the service is suitable for them. Regular monitoring of monies held on behalf of service users must take place to ensure that there is a clear audit trail. This will ensure that service users financial interests are safeguarded. Timescale for action 29/02/08 2 OP35 17(2) Sch 4.3 31/12/07 The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 27 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 OP16 Good Practice Recommendations It is recommended that any compliments received by the service should be date stamped in order to be able to determine how many have been received within a specified timescale. As the service requests that visitors meet with service users in their bedrooms, it is recommended that consideration be given to providing suitable seating. This will go some way to demonstrating that visitors are welcome. It is recommended that the record sheet for cleaning the kitchen and equipment is reviewed and amended to identify how often and when this takes place. 2 OP23 3 OP38 The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 77 Paradise Circus Queensway Birmingham B1 2TD 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 The Meadows DS0000032500.V352217.R01.S.doc Version 5.2 Page 29 - 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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