Inspection on 21/10/09 for Milner House

This is the latest available inspection report for this service, carried out on 21st October 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milner House 22/06/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for older people Name: Address: Milner House Ermyn Way Leatherhead Surrey KT22 8TX     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jane Jewell     Date: 2 1 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Milner House Ermyn Way Leatherhead Surrey KT22 8TX 01372278922 01372278046 milnerhouse@ashbournesl.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ashbourne Homes Ltd care home 58 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 58. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home Milner House is a large late Victorian detached property that has been converted and extended over the yeas to provide nursing accommodation for up to for fifty-eight older people many of whom have dementia. Parts of the home have maintained some of its orginal features and is a member of the Surrey Historical homes. The home has been owned by Ashbourne Homes Ltd since 1996, which is part of Southern Cross, who are a large national provider of registered care services. The home is located in a rural location on the outskirts of leatherhead. Access to local Care Homes for Older People Page 4 of 37 58 0 Over 65 0 58 Brief description of the care home services such as shops, churches, public transport are a distance away. The home has access to private transport ( mini bus). The home is presented across four levels with residents accommodation across three floors with level access provided by a passenger lift. The vast majority of bedrooms are for single occupancy with some facility to provided shared bedrooms. All bedrooms provide en suite accommodation. Communal areas are available throughout the home, compromising of lounges and dining rooms on each floor, as well as a number of quiet areas and a large entrance hall. The home is set in its own large grounds which includes patio areas, lawns, flower beds and a large fountain. The homes literature states that the homes objective is to provide a high standard of individualised care to all its service users. The manager confirmed that the current fees are from £575 to £850 per week, depending on the services and facilities provided. Extra such as: newspapers, hairdressing, chiropody, toiletries are additional costs. Refer to the homes literature for the actual amounts charged for any additional costs. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is Two star. This means the people who use the service experience Good quality outcomes. The information contained in this report has been comprised from an unannounced inspection undertaken over nine hours, from 10am to 7pm and information gathered about the home before and after the inspection. The manager had completed an Annual Quality Assurance Assessment (AQAA) within the date requested. This provided a good standard of information about the home which was used to inform the inspection process. The inspection was undertaken by regulation inspector Jane Jewell and facilitated by Toshwaite Latchman (registered manager). The focus of the inspection was to look at the experiences of life at the home for people living there. The inspection consisted of being shown the communal areas, and being invited to view some residents bedrooms, Care Homes for Older People Page 6 of 37 examination of the homes documentation and observations of residents daily routines and in their interactions with staff, during lunch time and over the morning and afternoon period. Fifteen residents, ten staff and five relatives were consulted as part of the inspection process. Feedback surveys were sent to the home for distribution, in order to obtain the views on the quality of the services and facilities being provided. Twenty one were returned in total, seven from residents who were supported to complete the form, one from a resident, seven from staff and six from health care professionals. Their feedback is included in this report. There were forty five residents living at the home at the time of the inspection. An expert by experience accompanied the inspector for three hours as part of the inspection process. An expert by experiences a person who, because of their shared experience of using care services, supports the inspector to look at the quality of the outcomes for the people who use the service. They did this by focusing on specific outcomes for residents including activities and occupation, privacy and dignity and the environment. They obtained this information by observation, discussion with residents, staff and a tour of the premises. Their outcomes are included in this report. Care Homes for Older People Page 7 of 37 What the care home does well: Residents continue to live in an historic, well maintained, homely and spacious environment with their private accommodation able to be personalised according to their individual preferences. A relative said environment is friendly and warm, they often play music in the entrance hall which is very welcoming. A resident said that they choose the home due to the large size of the bedroom so they could bring in all of their furniture. The home provides both prospective and existing residents, with a range of information about the home and what to expect when living there. A recently admitted resident said that they had been given lots of information about the home when they initially looked around and felt that it was clearly the best home that they viewed. The vast majority of people consulted spoke positively about their experiences at the home and a sample of their comments included is very homely staff are very co operate and understanding very family oriented and flexible it is very relaxing here by and large very nice amazing service they have been very good at helping me sort things out appointments bank accounts. They have been very flexible and accommodating and I think it is a very caring relaxing and friendly community and I would recommend it to anyone. A health care professional fedback I have recently reviewed four clients currently at the home. Relatives and family members were all very satisfied by the care their loves ones were receiving. They have all commented that they could not have made a better choice. Residents receive a good standard of health care support with prompt medical intervention and advice being sought. A residents said they know if I am not feeling very well and will just get the nurse or call the Dr. Personal support is offered in ways, which generally promotes and protect residents privacy and dignity. A resident said always knock on the door always incredible polite. A relative commented my relation looks beautifully turned out. Residents lives are enriched when the home provides opportunities for occupation and stimulation. A sample of comments about activities provided included we are very pleased with the activities lady there is good activities and trips available and there is always something going on. Links with families and friends are highly valued and supported by the home. A relative said I can visit any time of day and always made to feel very welcome I have a good relationship with all the staff, it is like my second home. Residents are able to exercise some choice over their daily routine. Residents fedback I can get up and go to sleep when I want I have choice of what to do during the day and I am asked each morning what time I would like breakfast. There is a complaints system with evidence that residents and relatives feel that their views would be listened to. A relative commented we would go straight to the manager, she is very quick to respond. They are often aware of any problem before we bring it up. Care Homes for Older People Page 8 of 37 Some of the meal time experiences for residents were positive and their comments included the cooking is very good food it is excellent they always asks her what she wants to eat and their vegetables are very nice. Consistent feedback was received regarding the kindness of staff and their respectful nature. Comments included the staff are all very nice and respectable they are friendly and look after me well always smiling nothing is too much trouble staff very helpful and responsive, excellent and very approachable. First rate carers and we have got so many male carers. I am used to being washed by them, they are pretty tactful. What has improved since the last inspection? What they could do better: In order to promote consistency for all residents to receive good experiences a more individualised care planning system needs to be fully implemented that guides staff in all aspects of personal and health care needs of each residents so they can receive individualised but consistent care. Residents would benefit from a more individualised approach to some care practises including continence management and are able to make appropriate decisions about their lives to ensure that they are treated as individuals and that their rights to make decision are protected and any restrictions on their freedom is fully assessed or removed. One resident said it is difficult sometimes to move to the lounge in my chair, as the door in the corridor is now closed and has a code. Further training in dementia, Parkinsons and challenging behaviour would enable staff to provide residents with improved practises which should further enhance residents lives and their safety. Residents needs would be further met by improvements to staff skills to be able to engage more frequently and positively with residents. A health care professional said Milliner House is a large establishment and it is important that staff engage with residents frequently check them out and talk to them. A relative said although the staff do a wonderful job caring for her physical health, she longs for conversations about everyday sort of things and female staff do her nails not sure how much of the male staff are able to talk to her about everyday things. A review of the current meal time arrangements and practises would benefit residents to ensure that all residents received the same good standard of meal time experiences, Care Homes for Older People Page 9 of 37 choices and support. Although there is a comprehensive assessment process in place to ensure that the needs of any prospective residents are fully assessed prior to any admission, this had not always been followed in the past. This resulted in staff not being provided with the information they needed to be able to meet residents needs. To further promote good practises when supporting residents to make choices it is recommended that menus be presented in a format more suitable for all residents to access. Standards of cleanliness were generally noted to be satisfactory with areas in need of attention being addressed throughout the course of the inspection. A relative said the home is usually clean does not always look as though it has been hovered sometimes some unpleasant odours but not persistent . A resident said very good standard of housekeeping my bedroom is always kept tidy. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides both prospective and existing residents, with a range of information about the home and what to expect when living there, which helps make informed choices. There is a comprehensive assessment process in place to ensure that the needs of any prospective residents are fully assessed prior to any admission, however this has not always been followed in the past. The home is able to demonstrate that it can meet most needs of the wide range of residents needs being accommodated with further work needed to ensure the individual needs of people how have Parkinsons and dementia are able to be met. Evidence: The homes statement of purpose, which is a book that tells people who the home is for and the service users guide, which is the book that tells people how the home works, provides a range of information about the home. These are made available at the home and given to prospective residents, representatives and other interested Care Homes for Older People Page 12 of 37 Evidence: parties. The manager agreed to ensure that a copy of the homes terms and conditions are included in the homes literature to ensure that prospective residents were aware of them in advance to help them make informed choices. The manager reported that the service user guide is available in an audio format as well. A recently admitted resident said that they had been given lots of information about the home when they initially looked around and felt that it was clearly the best home that they viewed. The homes admission procedure is that prospective residents are assessed by a manager or deputy with information about their needs gathered from a variety of sources including the resident, their representative and health care professional. This also includes an assessment by any placement authority. In the majority of admissions this procedure was followed, however one significant example was noted whereby a needs assessment did not take place and therefore staff did not have all the information they needed to be able to address an individuals complex needs upon admission. The operations director external to the inspection confirmed that this failure to follow the homes admission procedures has now been fully addressed and no future planned admissions will occur without a full needs assessment being undertaken. This is necessary in order to establish that an individuals needs can be safely met at the home prior to any admission. The manager said that each new resident admitted receives a welcome gift of bathrobe and personal toiletries. A resident said that this was a nice way of being welcomed to the home. Residents, once admitted, are provided with a written contract of terms and conditions of residency with the home. This can be used with residents and their families to make explicit the placement arrangements and clarify mutual expectations around rights and responsibilities. A newly admitted resident said I am very happy with the terms and conditions they are very thorough. There is a wide range of residents needs being accommodated at the home with all residents primary needs being related to their older age and include residents who have complex nursing, physical and dementia needs, needs associated with Parkinsons disease, visual impairment, mental health needs and residents who live an independent lifestyle. Although the home is able to evidence that it can meet most needs of residents further work is needed to the care planning process and in the skills and training of staff to be able to meet the individualised needs of people who have dementia, Parkinsons disease and challenging behaviour. This is discussed further in this report. Care Homes for Older People Page 13 of 37 Evidence: Consistent feedback was received from those consulted about the quiet, relaxed calm nature of the home, which for some was a positive experience but for others this was a sign that not much was going on or not enough staff engagement. The vast majority of people consulted spoke positively about their experiences at the home and a sample of comments included is very homely staff are very co operate and understanding very family oriented and flexible it is very relaxing here by and large very nice lovely here well looked after everything is good amazing service they have been very good at helping me sort things out appointments bank accounts. They have been very flexible and accommodating life can be a bit of a drag sometimes as it is so quiet and I think it is a very caring relaxing and friendly community and I would recommend it to anyone. Residents and their relatives spoke of being provided with the opportunity to visit the home in advance to assess the quality, facilities and suitability of the home as many times as they liked. The manager confirmed that the first six weeks of occupancy is looked upon as a trail period. Following this, placements that are funded by social services are reviewed, to establish whether the home is meeting a residents needs. A formal process is also in place for privately funded residents to have a say whether they wish to remain at the home and become a permanent resident. Intermediate care is not offered at the home therefore this standard is not assessed. Care Homes for Older People Page 14 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents would benefit from a more individualised and comprehensive care planning system that would guide staff in all aspects of personal and health care needs of residents in order residents receive individualised consistent care. Residents receive a good standard of health care support with prompt medical intervention and advice being sought. Medication practises are well managed promoting good health. Personal support is offered in ways, which promotes and protect residents privacy and dignity. Evidence: Plans of care are available for each resident and seven were sampled. These contained some information about the needs of residents, however were largely standardised and in some cases did not reflect the support being undertaken by staff or include the range of residents needs. This is with particular reference to the needs of residents Care Homes for Older People Page 15 of 37 Evidence: with Parkinsons disease, dementia, managing challenging behaviour and continence needs. There was no evidence of how residents capacity is assessed and how residents are enabled to make choices, which is necessary to help ensure that residents rights are being protected. Individual risk assessments were in place, which covered core and some specialist areas of risks, and recorded the actions to manage any identified risks. Variable standards were evident in the staffs understanding of the contents of care plans. Examples of this included the use of body maps to record any marks or changes to a resident body which had not been updated. Staff were unclear of how to manage the behaviour presented by some residents who had dementia and Parkinsons. The manager confirmed that they had previously identified shortfalls in the care planning process and had recently introduced a person centred approach to care planning for all new residents admitted. It has been required that the care plans provide guidance on all aspects of the health, personal and social care needs of residents to enable staff to then provide support in an individual and consistent way. The home maintains a daily record for each resident on events and occurrences. The standard of daily recording was noted to be good with an account of actions and events that had occurred which was written in a respectful tone. The regular review of care plans helped to ensure that most changes in residents needs and preferences can be promptly identified. Annual placement reviews are also held with the placement authorities and residents families. This helps to identify whether the home can continue to meet a residents needs. A health care professional fedback I have recently reviewed four clients currently at the home. Relatives and family members were all very satisfied by the care their loves ones were receiving. They have all commented that they could not have made a better choice. Records show that prompt action is taken to address any medical concerns, including the involving of any additional specialist services including dietitians, speech therapist and specialist nurses. A residents said they know if I am not feeling very well and will just get the nurse or call the Dr. A relative spoke of the very prompt medical intervention that their relation received when they expressed some concern over their relatives health. A health care professional fedback when asked to comment on what the home could improve upon to reduce the urge to consult a GP for every minor Care Homes for Older People Page 16 of 37 Evidence: ailment, staff nurses should take initiative for some responsibilities. A resident fedback that some new glasses had been arranged by the home after a visit from an optician. A nurse confirmed that they have undergone tissue viability training and reported that currently no residents have any areas of significant tissue breakdown. One resident is assessed in order to be able to administer their own medication. Medication profiles are in place which provides information on how much medication is provided, how medication should be administered and when it is administered. Only nursing staff dispense medication. Medicines were well organised and stored. Good practises were noted in the dispensing nurse wearing a high visibility tabard which asked not to be disturbed during the administration of medication. This helped to maintain their concentration and focus. During the inspection staff were seen to be generally respectful towards residents. A resident fedback always knock on the door always incredible polite. A staff member was however observed referring to a resident as he/she in their presence rather than by their name. Staff consulted with did show an understanding of good practises in preserving residents rights to privacy and dignity. Staff were able to give examples of how they promote these rights in their every day care practises. Residents were observed to be dressed in well laundered clothing and residents enjoyed the regular input from the visiting hairdresser. A relative fedback my relation looks beautifully turned out. Another relative spoke of the sensitive and discrete actions of staff when dealing with incontinence episodes. Care Homes for Older People Page 17 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents lives are enriched when the home provides opportunities for occupation and stimulation. Links with families and friends are highly valued and supported by the home. Residents are able to exercise some choices over their daily lives, however further work is needed to ensure that residents are enabled to make decisions about their lives based on individual level of capacities. Not all of the homes practises treat residents as individuals with particular reference to the management of continence. Residents received variable meal time experiences. Evidence: Residents views regarding activities varied between those who enjoy socialising and others who were not so interested, however all residents confirmed that their preferences was respected by staff. A full time activities coordinator is employed who Care Homes for Older People Page 18 of 37 Evidence: undertakes a flexible range of activities including craft sessions, painting, board games, visiting pat dogs and nail care. The home has its own mini bus to enable outings to be undertaken to local shopping and gardening centres, theatres and exhibitions. A relative spoke of them also going on the trips with their relative. There is visiting clergy who provides ecumenical services and personal visits. A resident said that they liked going to the church services at the home, as they liked to be with the other people. Other residents spoke of the recent harvest festival at the home with local school children and having their newspaper delivered each day. A sample of comments about activities provided included we are very pleased with the activities lady there is good activities and trips available and there is always something going on On the day of the inspection the activities coordinator was not on duty instead they were working the weekend. The activities programme for the day did however indicate one to ones were supposed to be undertaken. A resident did feedback that occasionally the activities coordinator is called away to help undertake care duties. An example was noted whereby a resident clearly enjoyed drawing and painting, however their materials for doing this was not put within their reach so they could independently do this, or recorded in their care plan. This was fedback to the manager to address immediately and ensure that clear guidance is provided in the care plan. On the afternoon of the inspection there was musical entertainer which was clearly enjoyed by those residents participating. A travelling clothing company visits the home in order that residents can buy personal items. Feedback was received that it would be helpful to also provide a small shop selling personal items and toiletries. This was fedback to the manager. Relatives fedback upon how welcomed they are made to feel when they visit, this included being offered beverages or meals and how they can visit at any reasonable time. A relative said I can visit any time of day and always made to feel very welcome I have a good relationship with all the staff, it is like my second home. Several residents spoke of the importance of having their own telephone in their bedroom which enabled them to keep in regular contact with their family. During the inspection the majority of residents were observed to move around the home freely choosing which room to be in and what level of company they wanted to enjoy. However one resident said it is difficult sometimes to move to the lounge in my chair, as the door in the corridor is now closed and has a code. Any restrictions on individual movements around the home must be supported by a comprehensive risk assessment or the restrictions removed in order to preserve residents rights. Care Homes for Older People Page 19 of 37 Evidence: Through observation and discussion with residents and staff, staff try and accommodate residents individual preferences with regard to rising, meals and going to bed. A sample of residents comments included I can get up and go to sleep when I want I have choice of what to do during the day I am asked each morning what time I would like breakfast and I like to go to bed at 6pm and watch TV and I can get up whenever I call for help. The home was sensitive to the gender preferences of female residents as the vast majority of care staff are male. A resident said we have got so many male carers. I am used to being washed by them, they are pretty tactful. Although residents have continence assessments as part of their care plan this was not individualised or contained sufficient detail for staff on how to support individuals. Instead continence management appeared to be standardised with a high use of continence aids with all put a few resident reported to use pads to manage continence. These practises are not considered good practise and the manager agreed to ensure that this was reviewed as a matter of urgency. The manager reported that in line with the previously required staff have undertaken training in new Mental Capacity legislation. However this was in the process of being translated fully into practises at the home. For example including capacity assessments and guidance for staff on the decision making for some residents in care plans. The manager confirmed that as part of the new care planning documentation this would now be included. The manager reported two residents are supported by advocates to make decisions in their lives and represent their views and choices. The lunch time meal was observed which was presented well and showed that a varied diet is offered. The assistant chef said that the menus are developed based on the likes of residents. A computing system is used to breakdown the calorific value of the meals on the weekly menu which is then displayed. Specialised diets were catered for which included diabetic and pureed meals. The food is delivered to each unit and stored in heated trolleys where residents are then asked what they would like to each from the choices available. Residents preferences were respected with some residents having larger portions or additional vegetables. A sample of comments about the food included the cooking is very good food it is excellent they always asks her what she wants to eat their vegetables are very nice. Two residents left some of their meat saying that it was too hard to eat. A resident spoke of how they are provided with a cooked breakfast in accordance with their personal preferences. Although residents were offered a choice of drinks on one Care Homes for Older People Page 20 of 37 Evidence: unit on another unit one resident had to ask for a drink during the course of their meal. Printed menus were displayed on each table which contained all of the days menu in small print. Orientation white boards were in each unit, however in one unit it was empty in another unit this contained details of the day the staff on duty and the menu. It is recommended that in order to further promote choice that menus are presented in a format that is more accessible to all residents. The majority of residents eat their meals in the pleasantly decorated and set dining rooms. Some residents preferred to eat their meals in their bedrooms. Lunch time was clearly a busy time as many residents required assistance to eat and drink and although this was done in a gentle manner staff were interchanging their support between residents which did not promote continuity or orientation. This was feedback to the manager for addressing. In additions to meals, drinks and snacks are available including the provision of fresh fruit being on display around the home. Residents are provided with water jugs, however one relative fedback that these were not always in reach of their relative to be able to independently drink. There was insufficient cups to enable all residents to have a hot drink after their meal and instead had to wait until they had been rewashed. The manager said that they were aware of this and new cups had been ordered. The homes literature states that alcoholic drinks are available however when this was asked for by a resident the staff member did not realise that wine was available. In order to address the number of concerns around meal times observed it has been required that the meal time practises make proper provision for all residents to receive the appropriate level of services and support as indicated in the homes statement of purpose and in accordance with individual needs and good practise guidelines. Care Homes for Older People Page 21 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a complaints system with evidence that residents and relatives feel that their views would be listened to. Staff have the guidance and training necessary to show them what to do if abuse is suspected. Evidence: There is an accessible complaints procedure for residents, their representatives, and staff to follow should they be unhappy with any aspect of the service. All but one resident and all relatives consulted with said that they felt able to share any concerns they had with the manager and where they have raised minor issues, this has been addressed promptly. A relative commented we would go straight to the manager, she is very quick to respond. They are often aware of any problem before we bring it up. The home has written policies covering safeguarding adults and whistle blowing. These make clear the vulnerability of people in residential care, and the duty of staff to report any concerns they may have to a responsible authority for investigation. The majority of staff has received formal training in safeguarding adults and prevention of abuse and the staff consulted with showed an understanding of their roles and responsibilities under safeguarding adults guidelines. At the time of the inspection a safeguarding referral had been made relating to two Care Homes for Older People Page 22 of 37 Evidence: complaints by relatives in regard to their poor experiences with the home. The organisation had been asked to undertake an investigation into these concerns, but had not provide evidence of a thorough investigation having been undertaken and were asked by social services to re address some of the issues. This issue was forwarded on to the Commissions link person for this particular organisation. Care Homes for Older People Page 23 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in an historic, well maintained, homely and spacious environment with their private accommodation able to be personalised according to their individual preferences. Parts of the home is decorated and furnished to a high standard. Residents have a range of specialist equipment and adaptations to aid mobility and independence around the home and includes a call bell system which enables them to call for assistance if needed. Standards of cleanliness were noted to be variable but were largely addressed throughout he course of the inspection. Evidence: The home is a large period property which has been extended over the years and retains some original features. This includes the grand entrance hall and stairway. The entrance hall is often used for musical entertainment as it contains a grand piano. A relative said environment is friendly and warm, they often play music in the entrance hall which is very welcoming. Two health care professional expressed concern over the size of the home and how this could be potentially isolating for residents. No residents or staff consulted felt that currently this was an issue as staff regularly pop in to residents bedrooms and each staff is allocated the care of particular residents each shift. A resident said they check on me every two hours at night. They do not Care Homes for Older People Page 24 of 37 Evidence: mind me calling them for anything. They are down in a flash at night. The home is presented across three floors with each floor presented differently. The top floor has recently been reopened following its refurbishment. This has been completed to a high standard with residents living on this floor saying how nice it was. Standards of decor were variable throughout the rest of the home with the manager reporting that further decorating was due to be undertaken in the immediate future. This included work to some ground floor bedrooms and corridors. Standards of maintenance were generally good with much praise reserved for the homes maintenance staff. A newly admitted resident spoke of how helpful the maintenance staff had been in helping to organise their bedroom, putting up shelves and pictures and sorting out the locks on their furniture. Communal space is spacious and is spread out throughout the home, which includes lounges and dining areas on each unit, there is also an activities area on the ground floor. As previously noted some internal doors now have a key pad entry system, which inhibited a residents free movement around the home which must be addressed. Much effort is made to create a homely feel. Many historical pictures are displayed of the home over the years, including royal visits. The home is in a semi rural location set in is own well maintained grounds. Level access is provided to the garden through ramps. The gardens have flower beds, a fountain and seating areas with many residents and their relatives speaking of their enjoyment in sitting and admiring the gardens. Residents consulted with said that their bedrooms provided everything they needed. Residents bedrooms had been individualised with residents confirming that they are able to bring in items of furniture and personal possessions. A resident said that they choose the home due to the large size of the bedroom so they could bring in all of their furniture. There is sufficient number of toilets and assisted bathrooms located around the home, including all bedrooms provide toilet en suite facilities. Variable feedback was received regarding the temperature of the home with several residents and relatives saying how hot the home is and others saying that it felt chilly. No current problems were reported with the boiler and the manager agreed to monitor individual levels of comfort. Care Homes for Older People Page 25 of 37 Evidence: There is a range of individual aids and adaptations to assist residents mobility and independence including walking aids, height adjustable beds, raised toilet seats, grab rails and hoists. The manager reported that a new call system has been fitted throughout the home, which enables assistance to be summoned when pressed. Residents consulted in their bedrooms had their call points placed within easy reach. The call bell system is attached to all external doors as well as all bedrooms and communal areas and throughout the course of the inspection sounded almost continuously. No residents said that this was distracting by this noise. The manager confirmed that the volume is adjusted at night. All residents consulted felt that staff answer their calls for assistance fairly promptly. A resident said they come fairly soon afterwards, when I ring the bell. If they are very busy, they will pop in and say they are just finishing another job. Upon arrival at inspection there was a malodorous odour in the entrance hall and some parts of the home were in need of hovering. The manager stated that the main cleaning of the home did not start until the majority of residents were up and hovering was done over the lunch time period, in order to cause minimum disruption to residents. During the afternoon period it was noted that odours had been managed and hovering had largely addressed those areas earlier identified. A regular visitor also commented home usually clean does not always look as though it has been hovered sometimes some unpleasant odours but not persistent. A resident said very good standard of housekeeping my bedroom is always kept tidy. Some bedrooms were noted to have some variable standard of deep cleanliness including some carpets and bathroom floors. Staff confirmed that they have undertaken training in infection control and were observed to be working in ways that minimised the risk of infection through the use of protective clothing with all staff confirming that they had easy access to protective clothing. Care Homes for Older People Page 26 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff make a positive contribution towards meeting the physical needs of residents, however some further training is needed to ensure they have the skills and competencies to be able to also meet the more specialised needs of residents. Residents are being protected by the homes recruitment policy and practises which helps to ensure that only people who are safe are employed. Evidence: Staff, relatives and residents felt that there was usually sufficient numbers of staff on duty for staff to undertake their roles in a timely manner and for residents to receive the support they needed. The manager spoke of their flexibility to increase staffing in line with any new admission due to the re opened top floor. There is a core group of staff who have worked at the home for a number of years. The staff team was described as close knit with little staff turnover. Staff fun days are organised to further promote team work. Consistent feedback was received by staff regarding how nice it is to work at the home Consistent feedback was received regarding the kindness of staff and their respectful nature. A sample of comments included the staff are all very nice and respectable they are friendly and look after me well staff are quite nice they all seem very nice Care Homes for Older People Page 27 of 37 Evidence: people all members of staff are respectful and professional always smiling nothing is too much trouble and staff very helpful and responsive excellent and very approachable. First rate carers The vast majority of care staff are male and were originally employed from oversees. Feedback from relatives included my wife has not expressed any preference of the gender of carers she is more than happy with any of them and female staff do her nails not sure how much of the male staff are able to talk to her about everyday things. Variable feedback was received regarding standards of communication where English is not a staff members first language, with particular reference made that due to the softly spoken nature of many staff coupled with an accent this often made it difficult to hear what was being said. Through observation and feedback it was evident that sometimes there was little initiated engagement between staff and residents. This was particularly noticeable for some residents who had dementia who were not able to initiate conversations but once engaged became more orientated and animated. Examples were also noted whereby staff spoke very little to residents whilst assisting them to eat, during one to one supervision with a resident and undertaking practical support. A health care professional said Milliner House is a large establishment and it is important that staff engage with residents frequently check them out and talk to them. A relative said although the staff do a wonderful job caring for her physical health, she longs for conversations about everyday sort of things. It has been required that staff have the experience and skills to be able to meet the health and welfare needs of residents. The personal files of four staff were inspected and these showed that the previous shortfalls have been addressed with a robust recruitment process now being followed which includes the use of an application form, interviews, Nursing checks, Criminal Records Bureau (CRB) checks and written references prior to employment commencing. This helps to ensure that only staff who are suitable to work with vulnerable people are employed. The manager reported that due to the semi rural location of the home has made it sometimes difficult to recruit staff as there are no close public transport links, but they been innovative in developing lift clubs between staff. The home has been proactive in ensuring that more than half the staff have completed a National Vocational Qualification (NVQ) in care. Staff consulted with confirmed that they have undertaken all of the areas of mandatory training needed for them to work safely with residents. This includes manual handling, first aid and food hygiene. The home has two staff who have completed training to become trainers themselves and Care Homes for Older People Page 28 of 37 Evidence: who now facilitate most of the mandatory areas of training in house. Some areas of specialist training is also undertaken, staff spoke of completing the organisations dementia care course, equality and diversity and mental capacity training. As a result of some poor practises observed by the inspector it was identified that not all staff showed an understanding of Parkinsons disease, challenging behaviour and aspects of dementia. Although the practises were rectified immediately further staff training is needed in these areas to help improve staffs understanding. Care Homes for Older People Page 29 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from an open, approachable and experienced manager who ensures that they are well informed about residents, stakeholders and staffs viewpoints. A range of regular health and safety checks helps to promote the health and safety of residents and staff. Evidence: The manager has been the registered manager since late 2008, prior to this they were the deputy manager for many years. They are a registered nurse with twenty three years experience and have also undertaken the recommended management qualifications. They confirmed that they have kept themselves updated in changes in legislation and good practises guidance by regularly attending further training. The manager demonstrated a good understanding of the areas in need of improvement at the home and was open in their dialogue with the inspector and expert by experience. Consistent feedback was received regarding their approachability and hands on Care Homes for Older People Page 30 of 37 Evidence: nature. A sample of comments included very supportive to all staff manager always makes herself available and is often out on the floor so is easily accessible and the manager is lovely. The manager is supported by a deputy manager and administrator along with operations managers. The operations managers undertakes the required monthly audit of the services and facilities and completes a comprehensive written report on their visit. This helps the provider to monitor practises at the home. There are several mechanisms in place for the home to obtain feedback on the quality of the services provided and whether it is achieving its aims and objectives. This includes annual fedback surveys, internal audits, yearly placement reviews and direct discussion with residents, staff and stakeholders involved in residents care. As a result of this feedback changes to menus have been undertaken. It was evident that there is a good standard of communication between the manager, staff and stakeholders with residents consistently saying that they could tell the manager of anything they wanted to improve. A resident said during my first week one of the senior staff came to ask, is there anything we are not doing that we should be. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible person external to the home. The manager confirmed that they do not act as appointee for anyone. Small amounts of cash are held on behalf of some residents for personal expenditure, which are managed by the homes administrator. Care staff spoke of receiving formal supervision and direct supervision through working alongside nursing staff and felt well supported by them to undertake their role. Due to some of the concerns noted regarding the skills of staff and some poor practises observed closure practical supervision of staff may be needed in the interim to ensure these areas are being addressed. Written guidance is available on issues related to health and safety. Records submitted by the manager prior to the inspection stated that all of the necessary servicing and testing of health and safety equipment has been undertaken. The manager reported that recommendations made from the last visit by Environmental Health have been implemented. Systems are in place to support fire safety, which include regular fire alarms and emergency lighting checks, staff training and maintenance of fire equipment and fire drills were reported to have been undertaken. The manager reported that a fire risk Care Homes for Older People Page 31 of 37 Evidence: assessment has recently been completed in light of the reopening of the top floor. This records any significant findings and the actions taken to ensure adequate fire safety precautions in the home. There is a robust system in place to record and monitor accidents will the manager reviewing all accidents Care Homes for Older People Page 32 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 33 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 That care plans provide clear 15/01/2010 guidance for staff on all aspects of the health, personal and social care needs of service users and which make explicit the actions needed to meet these needs in an individual way. To ensure that staff have the guidance they need to be able to meet residents needs in an individual and consistent way. 2 14 12 That the homes practises promote autonomy and enable residents to make decision with respect to the care they are to received with particular reference to the management of continence and freedom of movement 17/12/2009 Care Homes for Older People Page 34 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To help ensure that service users are treated as individuals and that their rights to make decision 3 15 12 That the meal time practises 17/12/2009 make proper provision for service users to receive the appropriate level of services and support as indicated in the homes statement of purpose and in accordance with individual needs and good practise guidelines. To ensure that all service users receive the same standard of meal time experience and standards of support. 4 27 18 That at all times there are 17/12/2009 suitable skilled and experienced staff on duty to be able to meet service users health and welfare needs and in accordance with the homes statement of purpose and the aims of the service. To ensure that the staff on duty have the skills to be able to further enhance the quality of life of people living at the home through 5 30 18 That staff receive the specialist training they need 15/01/2010 Care Homes for Older People Page 35 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action to be able to meet the needs of the service users being accommodated at the home with particular reference to dementia, Parkinsons disease and challenging behaviour training. To improves staffs understanding of the needs of people who have dementia, Parkinsons disease and challenging behaviour. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 15 That menus are presented in a format for ease of understanding recognising in order to further promote choice for residents. Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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