Inspection on 20/11/07 for 22 Millcroft

This inspection was carried out on 20th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

22 Millcroft 03/11/06

22 Millcroft 03/02/06

22 Millcroft 09/08/05

22 Millcroft 14/02/05

22 Millcroft 21/09/04

22 Millcroft 19/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 16/12/2008.

CARE HOME ADULTS 18-65 22 Millcroft Warley Road Scunthorpe North Lincolnshire DN16 1QL Lead Inspector Stephen Robertshaw Unannounced Inspection 20th November 2007 09:00 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 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 22 Millcroft DS0000002873.V355443.R02.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 Adults 18-65. 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. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 22 Millcroft Address Warley Road Scunthorpe North Lincolnshire DN16 1QL 01724 282720 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) kirsty.neal@new-era.org.uk www.dimensions-uk.org Dimensions (UK) Ltd Kirsty Anne Neal Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2006 Brief Description of the Service: 22 Millcroft is a care home providing personal care and accommodation for six adults aged 18-65 years with learning disabilities. Three of these places are for service users who also may have a physical disability. It is owned by Dimensions (UK) Ltd and is situated close to two other homes owned by the same Company. The home is located in a residential area close to the centre of Scunthorpe. It is close to local shops, amenities and public transport. The home has its own transport. The home is a purpose built bungalow. All bedrooms are single and have wash hand basins fitted. Bedrooms are decorated and furnished to meet individual service user requirements and preferences. Communal areas of the home are decorated and furnished in a domestic style. Aids and adaptations have been provided as required to meet service users needs. All the service users living in the home are female. Information on fees can be obtained from the manager of the home. At the time of the site visit the current fees were £813.25 per week. Some of this is met through the income support claimed by the service users. All people that currently live in the home are funded through their local authority and any third party payments towards the fees have been agreed through the correct arrangements. Information on the service is made available to prospective and current people that live at the home through the services statement of purpose, service user guide and previous inspection reports. Copies of these documents can be obtained from the manager and several of them are available in the entrance to the home. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit took place on the 20th November 2007 and the visit was unannounced. The Commission were at the home for approximately six and a half hours and spoke with the management, four care staff, one visitor and three of the service users. What the service does well: What has improved since the last inspection? The gardens have been improved and are more accessible to the people that live in the home and the fences have been made higher to try and stop people using the grounds if they do not have permission. Two bedrooms have had new carpets fitted because the old ones were marked and did not make the rooms look like a nice place to be. Everybody has an annual health care check to make sure that they are in good health. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 6 Staff training has improved to make sure that the staff have all the knowledge and skills to be able to safely care for the people that live at the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that live in the home are given the opportunity to visit the service before they make a decision to move there on a more permanent basis. EVIDENCE: The home has an up to date statement of purpose and service user guide. These have recently been revised to include pictorial images to make the documents more accessible to the people that live in the home. An area of these records that needed amendment was the reference to the National Care Standards Commission in the complaints section. This must be replaced with the Commission for Social Care Inspection. The inspector observed the care files for two of the five people that were living in the home. These both included an assessment of the individual’s needs and there was evidence that these assessments had been completed through gathering information from different sources including external social workers and family members. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 9 The home is fit for its purpose and several of the areas including the garden have been improved since the last inspection. Individuals are assessed to determine if they require any aides or equipment to support their care at the home. The inspector spoke with four support workers who were working in the home at the time of the visit. They were all very knowledgeable about the care and support needs of the people that lived there and were able to fully describe individual care needs and routines for the way care should be offered. None of the service users were able to tell the inspector about their care needs and the input they required from staff due to their individual communication problems. Two professionals that are involved in the care of two people that were case tracked were also contacted and they were very positive in relation to the level of care that is provided in the home and they were also very positive in relation to the skills and knowledge of the staff team. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that live in the home are supported and encouraged to live as independently as possible within a safe environment. EVIDENCE: The Commission case tracked two people that were living at the home. This included observation of care plans and direct observation on the day of the site visit. The care plans that were looked at were very detailed and person centred and included pictorial information to help the individual that they concerned understand them. The individual support plans were in place supported the health and personal care needs identified for each person. The care plans had been regularly reviewed to make sure that they were still relevant to the individual that they 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 11 concerned and any changing needs had been identified through a new plan of care. Staff spoken to be the inspector were aware of the needs of individuals living in the home and could identify when any of the needs changed and how this affected the daily lives of the individuals that they involved. Risk assessments supported mobility, tissue viability, bed rail provision, medication, nutrition and other more general issues. Records in the home supported that regular care reviews were held with the responsible funding authority for individuals. A visitor to the service stated that they are always invited to their family members reviews at the home and commented that the care provided in the home was ‘exceptional’ and said that they were ‘very satisfied with the care provided’ and stated that ‘the staff have mostly been here for a long time and understand the needs of everyone that lives here’. All of the records in the home were stored in accordance with the Data Protection Act and supported the confidentiality of the people that they concerned. Care plans and other records must include full signatures of the people that complete them so that if necessary they can be identified at a later date. The records also included photographs of people that use the service, there was no evidence to support that appropriate authority had been obtained from the service users or their representatives to use these photos. New care plans are being introduced for all of the people using the service. Not all of them have been fully completed yet, however when this has been achieved they will all be more accessible to the people that they concern. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that live in the home are encouraged and supported to maintain and develop their personal lifestyles at the home. EVIDENCE: The people that live at the home are unable to maintain employment due to their abilities, however the staff encourage them to join in activities that interest them and to access any adult education or training that is appropriate to the individuals that live in the home. The home is in the middle of a housing estate. The manager stated that the neighbours to the home are very supportive of the service users and their relationships are good. Some local residents used to use the grounds of the home as a short cut so the management have now included a high fence with 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 13 anti vandal paint to try and dissuade people from using the gardens of the home as access to the estate. The home helps to support the people that live there to have an annual holiday, however they have to make a financial contribution towards this. National Minimum Standard 14.4 states that ‘service users in long term placements have as part of their basic contract price the option of a minimum seven-day annual holiday outside the home, which they help to choose and plan. The service also rent a vehicle to transport people that live in the home to access activities in the wider community. Each of the service users is charged £43 per month for the use of the vehicle. This fee is not believed to be included in the individuals contracts with the home, however the inspector was not able to verify this, as the individual contracts were not available at the home as these are maintained centrally by the parent company. Support workers are responsible for organising and arranging activity programmes for the group of people that live at the home and for individuals. Records did not evidence that staff had been provided with training in planning and delivering activity programmes for people with complex needs. The inspector advises that consideration should be given to providing staff with relevant training in this area. Activities available at the home included; hands massage and nail care, outings, visits to public houses and shopping trips. Meetings with service users or their representatives to identify the activities that they are interested in are not held on any regular basis, however a visitor spoken to by the inspector confirmed that they are consulted in the events that the home are involved in at the service itself and in the community. The manager and staff also supported that more informal contact is made with service people that live in the home or their families to determine how the service needs to develop. This needs to be developed in a more formal way and this would then support the quality assurance programme for the home. Several of the people living at the home also attended day services provided by the local authority. Recently the Local Authority and changed their policies towards day care provision for people that access residential care. This has meant that the support staff at the home have had to develop more regular activities though the home itself. This needs to be kept under review to ensure individuals social, recreational and personal development needs continue to be met in an appropriate manner. Interviews with management and support staff supported the evidence that most people living at the home had good contact with their families and friends. Staff stated relatives and visitors are made welcome at any 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 14 reasonable time. A relative visiting the home at the time of the site visit confirmed that ‘we visit at any time and are always made to feel welcome’. Individual’s are encouraged and supported to maintain contact with their families and friends by sending cards at significant occasions such as birthdays and Christmas. Meals that are provided are presented well and the people living at the home were observed to be happy with the meals that were presented to them. A visitor to the home stated that their relative nutritional needs were met and the staff were ‘very patient’ in encouraging them to eat their meals. Three meals are provided each day and records showed that a varied and nutritional menu was available. Food likes and dislikes were recorded on individual care plans. The inspector spent time in the dining area observing the lunchtime meal. Staff interviewed by the Commission had a good knowledge of the individual’s food preferences, the preferred portion size and manner of eating. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service supports all of the personal and healthcare needs of the people that live in the home. EVIDENCE: The home does not provide nursing care, however the records observed in the home supported that where appropriate the health care needs of the people that live there are supported by health care professionals that are based in the community. This included GP’s. Dentists, chiropodists and district nurses. All the bedrooms in the home are for single occupation. This means that medical treatments and examinations can always be carried out in private and people can see their families and friends in private. Individual support plans detail how personal care should be provided and this helps to uphold the dignity, privacy and respect of the people involved. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 16 The home uses the Nomad system for drug administration. Management of medication systems in the home was observed to be good. None of the service users living in the home at the time inspection visit had been prescribed controlled medication. All of the records had been maintained accurately and were up to date. The records for one person’s PRN was recorded on a separate sheet of paper, the inspector advised that this should be included on the medication record sheet. Medication storage in the home is very limited; following previous requirements the care staff now monitor the temperatures in these areas to ensure they do not exceed the manufacturers guidelines. All of the prescribed medication in the home is provided through a local pharmacy. The chemists continue to provide the home with a full medication audit on a six monthly basis. Staff training files and interviews with management and staff supported that medication training had been introduced and this included assessment of competence in the delivery and storage of medication. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the people that live at the home are protected form abuse and have the right information to help them make a complaint if they wish to. EVIDENCE: There had been one complaint made to the home since the last inspection. The proprietors investigated the complaint and the complaints were not upheld following their research in to the matter. The inspector observed the records for the investigation and advised the manager of the service that the safe guarding adults team should have been consulted before the investigation took place as there were areas that could have been identified as safeguarding issues. The homes complaints procedure includes pictorial guidance to help the people that live at the home understand them. The procedure seen by the inspector still referred to the National Care Standards Commission, this could be misleading and must be updated to include the appropriate Commission. None of the residents had the ability to confirm to the inspector that they understood the complaints process, however a visitor to the home stated that they were ‘confident’ that any concerns that they raised would be ‘dealt with appropriately’. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 18 No referrals had been made to the local safeguarding adults team. Staff spoken to by the inspector stated that they had received safeguarding adults training and this was supported through the staff training records that were observed by the Commission. However the safeguarding adults training did not appear to be effective in light of the investigation of the previous complaint. The manager of the home was not available when the complaint was ‘investigated’ and therefore the senior management of the service carried out the investigation. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the environment of the home is suitable to the people that live there. EVIDENCE: The inspector made a tour of the premises and found them to be very well cared for and was free of any offensive odours. A visitor to the home stated to the inspector that the ‘hygiene was particularly good’ at the home. The home was well decorated and was furnished in a homely manner. Since the last inspection two of the bedrooms had been decorated and new carpets had been fitted. The inspector observed the rooms of three of people that live in the home and these had all been personalised to their own tastes and preferences. This included small items of furniture, ornaments, photos, posters and lighting. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 20 The dining room table looked very old and was at different levels where tables had been pushed together to make a bigger area. This did not look good and could have made difficulties for people if they placed hot drinks or food on the uneven area causing a possibility of injuries to themselves or others. The bathrooms were clean and were close to the bedroom areas. People that live at the home have the opportunity to choose between a shower and a bath. Individual assessments help to identify any aides and adaptation s the individual need to support their lives at the home. Staff spoken to by the inspector confirmed that they had access to all required specialist equipment needed to ensure that individual’s needs could be met at the home. This included a hoist, additional moving and handling and specialist bathing equipment. The home’s washing machines were programmable to sluicing and disinfection standards. However the laundry area was left unlocked and this could mean that people that shouldn’t have access to this area could enter the room and come in to contact with caustic materials and hot water outlets. The maintenance and refurbishment records identified that the kitchen in the home is due to be re-furbished including new cupboards and fittings being put in. It would also be beneficial if the floor covering was also replaced. The floor is beginning to show wear and is becoming more difficult to keep clean. Since the last inspection the garden area of the home had been improved and is a pleasant area for people to use in good weather. Recently some of the garden equipment including a garden swing was stolen from the grounds of the home. As a result of this a new high fence with anti vandal coating has been added around the property, this has also reduced problems with local youths using the grounds of the home as a short cut. The grounds do not include safe parking areas for the staff group and one member of staff has recently had several serious incidents with their car including car windows being broken and fuel lines being cut. The local police were made aware of these issues. The management of the service could consider some other choices to act as a detriment to possible vandals and to improve the safety of staff, visitors to the home and their property. This could include either a secure parking area and/ or external CCTV coverage of the parking area. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the staff have the appropriate knowledge and skills to be able to care for the people that live at the home and to protect them from harm. EVIDENCE: The inspector observed the staff personnel and training files for four of the staff that were working at the home. And spoke with the same four staff. All of the staff understood their own roles in the home and those of their colleagues. A agency carer who covers some shifts at the home stated to the inspector that ‘Mill Croft is the best place that I go to’. The training records and discussions with the homes manager confirmed that three out of the homes care staff have achieved NVQ2 or equivalent in care. This equates to 30 of the staff that have achieved this award. The management of the service must make sure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 22 The staff rotas and interviews with management, care staff and visitors to the service confirmed that there are always appropriate numbers of staff available to the people that live at the home. The staff were observed in their interactions with individuals and it was evident that they clearly understood the needs of all of the individuals that they were involved with. Recent rotas identified that additional hours had been added due to difficulties that ine specific service user was experiencing. The staff files, interviews with management and care staff all supported the evidence that the home uses equal opportunities in the services employment procedures. This included appropriate safety vetting before the staff were allowed to have any access to the people that live at the home. Staff induction records seen by the inspector appeared to conform to the sector skills training targets. Staff stated that they are provided with specialist training in relation to learning disabilities and challenging behaviours. The training records in the home also supported this. Staff meetings are held at the home usually once every month. This gives the staff an opportunity to give their views in relation to the services being made available to the people that are living at the home. It also allows them to be able to identify any training needs that they may have either as individuals or as a group. Formal supervision of the staff group also takes place on a regular basis. This also helps to identify how well they are completing their tasks and also identifies ant individual training needs. This has improved since the manager has returned from leave. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42,and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that in general the management of the home understands and supports the needs of the people that live at the home and the staff group. EVIDENCE: The registered manager of the home has worked in the home for five years. She has a combined studies BA and a BTEC National Diploma-Caring Services (Social Care). She also takes part in the mandatory and specialist training with the remainder of the staff. The manager is also registered on the Registered Managers Award, however only one unit has been completed. This qualification should be completed as soon as possible. The manager stated to the Commission that recently the providers of this training had recently been changed by the home’s management and stated that hopefully this would 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 24 mean that more support would be made available to help her complete the award. Visitors to the home and the care staff both supported that the management approach to the home is open and inclusive. They said that the manager was always ‘approachable’. The home did not have a formal quality assurance and monitoring system, but it was evident that families and professionals were important to the home in the development of the service. It is very important that this system needs to be implemented as soon as possible to formally identify other people’s opinions in relation to their views on the running and development of the service. All of the records in the home were stored in accordance with the Data Protection Act 1998. An area for improvement in the records was that staff completing records should sign their full names and not just include their initials. The home charges a flat fee of £43 a month for use of the home’s vehicle. This must be identified in the homes statement of purpose and service user guide and the fee should be proportionate to the amount of times that individuals use the transport and should not be a flat fee as this could be disproportionate to the actual use by individuals. These fees should be clearly identified so individuals are able to make a choice. The service contributes towards annual holidays for the people that live at the home. It does not cover the full cost. The homes statement of purpose and service user guide should identify the amount of contribution that the service will provide for individuals to go on holiday. The management of the service ensure that as far as is reasonably practicable the health, safety and welfare of the people that live at the home and the staff that work there are upheld. This included safety records for the fire fighting equipment, fire alarm testing and fire drills, appropriate gas safety certificates and there were clear records for the maintenance and serving for most of the equipment in the home. The manager could not provide a safety certificate for to ensure the safe hard wiring of the electrical systems in the home. As identified in the protection section of this report the senior management of the service must take notice of their Safeguarding Adults policies and procedures and report any concerns to the appropriate agencies. 22 Millcroft DS0000002873.V355443.R02.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 Adults 18-65 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 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 2 2 X 3 3 2 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 YA1 Regulation 4,5 and 6 Requirement The registered person must update the home’s statement of purpose and service user guide to include the contributions towards annual holidays and to identify a proportional fee for the use of the services vehicles. This will allow the people that live at the home or their representatives to be able to clearly identify why any individual charges are made. The registered person must ensure that all staff including senior management of the service are fully aware of the home’s policies and procedures for safeguarding adults. This is essential to provide the correct protection for everyone that lives in the home. The registered person must make sure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent to identify that they have the right knowledge and skills to care for the people that live at DS0000002873.V355443.R02.S.doc Timescale for action 31/12/07 2. YA23 YA43 13(6) 31/12/07 3. YA32 19 (5b) 30/03/08 22 Millcroft Version 5.2 Page 27 the home. 4. YA39 24(1ab)(2&3) The registered person must 29/02/08 develop a quality assurance and monitoring system that meets the requirements of this standard and produce an annual development plan based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. (Timescales of 19.2.04, 31.12.05 and 30.4.06 and 31/07/07 were not met). This must also include regular service user or their representatives meetings to give them an opportunity to air their views. 13(4 b, c) The registered person must 31/01/08 make sure that when service user photographs are used they have obtained the correct authority to do so otherwise the individuals confidentiality may be compromised. This authority should also be formally recorded. 5. YA41 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 Good Practice Recommendations The registered person should make sure that ll of the homes care plans are updated and include the services new paperwork. The registered person should make sure that the laundry door is kept locked to ensure that only people with the right permission can enter it. The registered person should consider changing the dining room furniture in the home to make a more comfortable and homely atmosphere. DS0000002873.V355443.R02.S.doc Version 5.2 Page 28 YA24 YA24 22 Millcroft 4. 5. YA24 YA35 6. YA37 The registered person should consider how the staff, visitors, and people who live at the home could be made safer, giving particular attention to the car parking area. The registered person should make sure that all records completed in the home contain full signatures of the people that complete them so that they can be identified at a later date. The manager should continue with their Registered Managers Award and complete it as soon as possible to demonstrate their ability to safely manage the service. 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 22 Millcroft DS0000002873.V355443.R02.S.doc Version 5.2 Page 30 - 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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