Inspection on 17/05/05 for Levitt Mill

This inspection was carried out on 17th May 2005.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Levitt Mill 26/09/08

Levitt Mill 28/01/08

Levitt Mill 04/01/07

Levitt Mill 05/06/06

Levitt Mill 24/01/06

Levitt Mill 02/02/05

Levitt Mill 19/08/04

Similar services:

Pennine Camphill

Muston Road (70)

Grayling

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 LEVITT MILL Levitt Mill, Wood Lee, Blyth Road Maltby Rotherham, S66 8NN Lead Inspector Sarah Powell Unnanounced 17 May 2005 at 12.15. 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. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Levitt Mill Address 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) Levitt Mill, Wood Lee, Blyth Road, Maltby, Rotherham, South Yorkshire, S66 8NN 01709 815565 None None Sapphire Care Service Limited Steven Light Care Home 10 Category(ies) of Learning disability (10) registration, with number of places LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One specific service user under the age of 18, named on variation application dated 14th May 2004, may reside at the home. When the individual service user reaches the age of 18 this condition will be removed. Date of last inspection 2-Feb-2005 Brief Description of the Service: Levitt Mill is a converted mill and barn set in extensive grounds providing accommodation for 10 service users with learning disabilities aged 18 to 65, There are six bedrooms all with en-suite in the mill and four bedrooms all ensuite in the barn, both units have communal areas, kitchens and laundry facilities. The home is on the outskirts of Maltby in Rotherham with plenty of facilities nearby including shops, pubs, resturants and leisure activities. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection in the year 2005/2006 and took place over one day the inspection commenced at 12.15 and finished at 17.45. The previous requirements were looked at with the manager. 5 Service users and 11 staff were spoken to. A tour of the building took place, observing staff and practices including activities. Two days following the inspection the company was purchased by Creagmoor and the responsible individual has now changed, however the company will still remain Sapphire Care Services and following a meeting with the new responsible individual and the Area Manager it has been confirmed that the staffing structure will remain the same. What the service does well: What has improved since the last inspection? There is a new Manager in post since the last inspection and staff confirmed that moral had improved. Staff told the inspector the new manager is much more approachable and listens to any concerns or questions raised by staff the atmospheres in the home has much improved and we all work well as a team. The Barn has been registered since the last inspection providing four more registered places two service users were already living in the barn with two vacancies still to fill. Since the building works have been completed the landscaping around the homes has been improved providing a large car park, a decked area for the service users and more level grassed areas. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 6 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. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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 LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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) 1,3 & 4 The home is able to meet the needs of the service users although they do not have up to date information in the statement of purpose and service users guide. EVIDENCE: The statement of purpose and service users guide were looked at and required updating with new manager details, company and staffing structure and all the details of the additional four registered beds and service provided to ensure service users have the relevant information to make an informed choice about where to live. The staff spoken to by the inspector had a detailed understanding of the service users. The home operates a key worker system which worked very well staff were seen to interact with service users and communicate appropriately enabling the needs of the service users to be met. Service users who were able to talk to the inspector said they liked living at Levitt Mill and the staff were all very good. All new service users are able to visit the home prior to admission and family are also invited numerous visits usually occur to determine if the prospective service users is able to get on with the existing service user group and the home is able to meet their needs. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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) 7 & 9 Service users were encouraged to make decisions and take risks as part of an independent lifestyle. EVIDENCE: Staff were observed encouraging service users to make decisions where they were able although in many cases they are very limited, this was seen detailed in the assessments Staff also enable service users to take responsible risks although most are supervised on a one to one basis and some on a two to one basis when they are taking part in activities outside the home, however service users are able to do this to enable them to lead a full life accessing the community and living as much as they are able an independent lifestyle. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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) 11,13,14 & 16 Service users have a full timetable of appropriate activities and access the local community. EVIDENCE: Each service user has an activity timetable suited to them this is drawn up by the key worker with the service users and enables the service users to access the local community. On the day of the inspection one service users had been to Morrisons, as she likes to have her breakfast in the restaurant, two had been to the day centre and another had been for a walk. Staff spoken to said the activity timetable are not rigid if the service users changes their mind then the activity is changed or they can stay at home if they so wish the choice is always theirs, service users also confirmed this. It was also evident on the day of the inspection as one service users was only getting up as the inspector arrived as he had chosen to spent the morning in bed this had left the home short staffed but the service users wishes had been respected. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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) none of these standards were assessed at thisinspection. EVIDENCE: LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 12 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 & 23 Service users are protected from abuse and their views are sought and acted on. EVIDENCE: The home has a comprehensive complaints procedure one complaint was currently being investigated and the procedure was being followed, an external advocate had also been involved to ensure the service user was protected and their best interests were upheld. The home has had two adult protection issues that have now been resolved and following on from these the staff have received more training to ensure service users are protected. The new manager also intends to cover this during staff supervision to ensure staff are fully aware of the policies and procedures to follow and that the training has been appropriate to protect the service users. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 13 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 standard of cleanliness in the home was excellent providing a homely, comfortable and safe environment for the service users. EVIDENCE: During the tour of the building it was observed that the standard of cleanliness was very good, the home was very homely with service users bedrooms being personalised while still providing a safe environment. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 14 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) 34,35 & 36 From the files seen it was not evident that the home operates a thorough recruitment process and it was also not evident that staff training was up to date. EVIDENCE: Since the last inspection there has been major changes at Levitt Mill the barn has been converted to accommodate four additional service users and has now been registered there is a new manager and many new support workers and a new staffing structure being implemented it was therefore very difficult to access standards 31, 32, and 33 although they were looked at during this inspection they will be assessed fully at the next inspection. The recruitment process was looked at not all the files were complete as the recruitment is carried out from head office it was very difficult to ascertain if the correct procedure had been followed as in many files references and CRB checks were missing and it was not clear if POVA checks had been sent for this could potentially put service users at risk. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 15 The new manager had implemented a staff supervision programme and this was due to commence at the time of the inspection and would be every two months covering all aspect required by this standard to ensure staff are able to meet the needs of the service users. Staff training and development is organised from head office and on looking at the files it was difficult to determine if staff training was up to date and it appeared that some mandatory training was only carried out every two years instead of every year this could put service users and staff at potential risk. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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) 37 & 38 The home is well run with leadership from the manager. EVIDENCE: The manager has many years experience looking after people with learning disabilities and the last three years as a manager and is well aware of the needs of this specific group. He has not yet commenced NVQ level 4 in management and care this is due to the company being unable to find a provider this needs to be addressed so as the manager is appropriately trained. The new manager has improved the ethos and leadership of the home the staff all commented it is so much better he is approachable will listen and take on board your views, he is much more in touch with what is happening in the home and as a result it is far better managed providing an improved environment for service users. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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 2 x 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 x 3 x Standard No 31 32 33 34 35 36 Score x x x 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 LEVITT MILL Score x x x x Standard No 37 38 39 40 41 42 43 Score 2 3 x x x x x J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 18 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation 4&5 Requirement the statement of purpose and service users guide needs updating with all the new information regarding manager, staffin structure and new extension. the recuitment process must be thorough obtaining two written refernces, CRB and POVA checks and details of thes should be kept in staff personal files in the home. (old timescale 1st April 2005) the staff trining must be up to date with mandatory trining being carried out yuearly not every two years. the home should provide an annula development plan (old timescale 1st April 2005) Timescale for action 1.8.05 2. OP34 19 1.7.05 3. OP35 18 1.7.05 4. OP39 17 1.7.05 LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 19 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 OP37 Good Practice Recommendations the registered manager should obtain NVQ level4 in management and care. LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster DN4 5HZ 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 LEVITT MILL J55-J07 S41903 Levitt Mill V190483 170505 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!