Inspection on 09/08/05 for 22 Millcroft

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

22 Millcroft 20/11/07

22 Millcroft 03/11/06

22 Millcroft 03/02/06

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 08/07/2008.

CARE HOME ADULTS 18-65 22 Millcroft Warley Road Scunthorpe North Lincs DN16 1QL Lead Inspector Matun Wawryk Unnnounced 9 August 2005 th 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 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 Stationary 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 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 22 Millcroft Address 22 Millcroft Warley Road Scunthorpe North Lincs DN16 1QL 01724 282720 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) New Era Housing Association Ltd Kirsty Anne Neal Care Home 6 Category(ies) of LD(6), PD(3) registration, with number of places 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 have a physical disability. It is owned New Era Housing and Support and is situated close to two other homes owned by that 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 are single bedrooms with a wash hand basin. Bedrooms are decorated and furnished to meet individual service users requirements and preferences. Communal areas of the home are decorated and furnished in a domestic style. Aids and adaptation have been provided as required to meet service users needs. All the service users living in the home are female. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced took place on the 12th of August 2005 and lasted for 3 hours. A tour of the home took place and a number of service user care records were examined. In addition the inspector also looked at medication records and some procedures. The inspector spoke to the two members of staff who were working in the home at the time of the inspection. Five service users were at home on the day of the inspection. Four of the service users had very limited communication and the inspector spent time with service users observing activities instead of conducting formal interviews. What the service does well: At the time of the inspection the home was clean and tidy. Staff spoken to reported that they enjoyed working in the home. Staff stated that they felt the home was well managed and commented on the approachability of the manager. Staff reported that relatives are made to feel welcome when visiting the home, and records seen confirmed this thereby helping service users to maintain family contacts. Service users are encouraged and supported to access local facilities and amenities in the area. Individual care programmes for service users are comprehensive and reflect all areas of identified needs. These means staff have all necessary guidance to enable them to meet the needs of the service users. The meals in the home are good offering both choice and variety. There was evidence of good working relationships with social services and health staff. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 6 What has improved since the last inspection? 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. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 There had been no new admissions to the home in the last three years. Therefore none of these standards were assessed on this occasion. EVIDENCE: 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Individual care programmes are comprehensive and reflect all service users identified needs. Care programmes needs to be produced in a different format to improve the accessibility of these for service users. EVIDENCE: Case tracking of two service users was completed. This included talking to staff and looking at records held on the service users. Both the service users care plans were comprehensive and reflected all areas of need. Completed risk assessments were in evidence in both files examined. The home continues to use individual service user diaries to record events and support provided. Care plans are produced in standard written format. These need to be produced in a more accessible format for service users. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 15 & 17 Residents are encouraged to maintain family links and friendships. The meals in the home are good offering both choice and variety. EVIDENCE: Staff stated relatives and visitors are made welcome at any reasonable time and records seen confirmed this. Key workers helped service users to maintain family contact by sending cards at significant occasions such as birthdays and Christmas. Staff reported that service users are encouraged and supported to go out into the local community to use local facilities and amenities. Records of food provided showed service users were offered a variety of food. On the day of the inspection a service user requested an alternative to what was on the menu and this was provided. Food likes and dislikes were recorded. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 20 Service users receive care and support, which promotes and respects their rights to privacy and dignity. Staff need to be provided with formal medication training. This is needed to ensure staff develop necessary skills and competencies. EVIDENCE: Staff were observed to respond to service users in a respectful and sensitive manner. All the bedrooms are for single occupation and staff advised the inspector that all consultations and examinations were carried out in the service users bedrooms. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 12 Care workers administer medication. The home used the Nomad system for drug administration. There were no controlled drugs in the home at the time of the Inspection. Since the last inspection the manager had revised the procedure for medication. Staff reported that in-house training had been provided and records seen confirmed this. Staff had not been provided with accredited medication training. Examination of a sample of service users medication administration records showed staff had failed to record administration of medication for two service users on one occasion. The manager must ensure staff are aware of and understand the importance of ensuring records of medication administration are accurately maintained. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home had a satisfactory complaints procedure and staff were confident about making a complaint. EVIDENCE: A detailed complaints procedure was in place. The complaint procedure had been rewritten in a more suitable format for service users. The majority of service users had some communication difficulties therefore the inspector was not able to confirm service users fully aware of the complaints process. The care worker on duty at the time of the inspection stated that there had been no complaints made to the home in the last twelve months. Staff spoken to stated they would feel confident about raising any issues with the manager. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The home was clean and tidy. The standard of the décor within some parts of the home does the not provide service users with an attractive place to live in. EVIDENCE: The inspector carried out a tour of the home. The home was clean and tidy. No mal odours were noted. Two bedrooms carpets were in need cleaning or replacing. The sitting room carpet was marked and stained in places and some parts of the wall covering were marked. There was a broken bed and chair in the rear garden. Whilst this does not pose a health and safety risk to service users, it does not create a pleasing and welcoming environment for service users. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 &35 Roles and responsibilities were clearly defined. Training provided to staff was generally satisfactory however further improvement is needed with regards to the provision of service specific training EVIDENCE: Staff were very clear about their roles and responsibilities and understood the management and reporting structures for the home. Training records showed staff were up to date with all areas of mandatory training. There was some evidence that some staff had had specific learning disability training however this was not the case for all staff. This needs to be an area of development. Staff had not yet been provided with equal opportunities training, including disability training; race equality and anti-racism training. This remains an outstanding requirement from previous inspections 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The home is effectively managed. EVIDENCE: Staff reported that the manager was efficient and approachable. Systems were in place for the manager to brief staff and to receive feedback from staff for example staff meetings and handovers. 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 22 Millcroft Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x x x 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 18 no 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 20 Regulation 18(1)(c) Requirement The registered person must provide all staff dealing with service users medication with accredited training. Timescale of 16/10/03 not met The registered person must ensure that the gardens are safe, well maintained and accessible to all service users. Timescale of 16/10/03 not met The registered person must provide all staff with equal opportunities training, including disability training; race equality and anti-racism. Timescale of 16/10/03 not met The registered person must 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 planningaction-review, reflecting aims and outcomes for service users. Timescale of 19/2/04 not met The registered person should ensure that training is ongoing so that 50 of care staff in the home hold NVQ 2 or above by 2005. Timescale for action 31.10.05 2. 28 23(2)(o) 31.10.05 3. 35 18(1)(c), 12(4)(b) 31.10.05 4. 39 24(1)(a)( b)(2)(3) 31.11.05 5. 32 18 31.12.05 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 19 6. 7. 37 6 18 12(3) 8. 9. 10. 11. 26 24 24 20 16 16 23 19(1)(a)1 9(5)(a)17 (2) The registered manager should complete NVQ 4 in management by 2005. The responsible person must develop support plans in a more accessible format for service users. The registered person must have two bedroom carpets cleaned or replaced The registered person must have the sitting room carpet cleaned or replaced The registered person must have the broken chair and bed removed from the rear garden The registered person must ensure medication records sheets are accurately maintained 31.12.05 31.10.05 30.9.05 30.9.05 31.8.05 with immediate effect RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 14 Good Practice Recommendations The registered person should provide service users in long-term placements with the option of a minimum seven-day holiday outside the home as part of the basic contract price. The registered person should develop a tool to assess dependency levels to inform decision regarding staffing levels . 2. 33 22 Millcroft 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 20 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park, Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 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 22050809 22 Millcroft Inspection Repoprt s2873 v242557.doc Version 1.40 Page 21 - 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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