Inspection on 24/01/06 for Levitt Mill

This inspection was carried out on 24th January 2006.

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 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 17 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 17/05/05

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 South Yorkshire S66 8NN Lead Inspector Sarah Powell Unannounced Inspection 11:15 24 January 2006 th Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 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 Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 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. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Levitt Mill Address 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) Levitt Mill Wood Lee, Blyth Road Maltby Rotherham South Yorkshire S66 8NN 01709 815565 Sapphire Care Services Limited Steven Light Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2005 Brief Description of the Service: Levitt Mill is a converted mill and barn set in extensive grounds providing accommodation for ten 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, Rotherham with plenty of facilities nearby including pubs, shops, restaurants and leisure facilities. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection in the year 2005/2006 and took place over two days the inspection commenced on 24th January 2006 at 11.15 and finished at 16.30 the second day was 26th January commencing at 11.30 and finishing at 16.50. The registered manager was present on the first day and due to the concerns raised regarding the home the Area Manager and HR Manager also came to the home, an immediate requirement was served and this was discussed at length with the Area Manager. On the second day of the inspection the registered manager was on sick leave and had handed in a doctors certificate for 13 weeks. The Deputy manager has been given the job of acting manager and the inspection was carried out with him. Many of the immediate requirements were being addressed at the second day. 7 Service users and 14 staff were spoken to. A full tour of the building took place on both days observing the standard of the environment staff and practices. A complaint investigation was also carried out during the inspection as an anonymous complaint had been received by CSCI. What the service does well: What has improved since the last inspection? The service has failed to improve and had deteriorated since the last inspection. Resident care was maintained at a basic level. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 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 DS0000041903.V259666.R01.S.doc Version 5.0 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 Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 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 the following standard(s): 2&5 Full assessments were seen for service users and all service users had a contract. EVIDENCE: Each service users had a full assessment carried out prior to admission these were seen in service users files they were comprehensive and completed showing the service users needs. The contracts and terms and conditions were seen by the inspector these were very good the home was also in the process of drawing up service user agreements for all service users these were seen and covered all the items specified in the standard. They were signed by a company representative and the service user or if they are unable to sign by a relative or advocate to ensure the contract is understood and in the best interests of the service user. When completed these will be kept with the individual contracts in the service users files on site to ensure they are available to service users and representatives when required. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 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 the following standard(s): 6, 8 & 10. Plans of care did not show changing needs; it was not evident that service users were consulted. Service users confidences are kept. EVIDENCE: A selection of care plans were looked at by the inspector, two service users were found not to have a plan of care and they had been living in the home some time one since August 2005 and the other since the beginning of December 2005. It was therefore impossible to determine if service users changing need are reflected in the plans. The pre admission assessment of one of these service users stated they could not walk very well and were unsteady on their feet and need a hoist to access the bath, yet their room was on the top floor, there was no lift and his bath did not have a hoist, staff assured me he was not unsafe walking up stairs but nothing had been documented in a care plan to determine the home could meet his needs, staff said he did need assistance to access a bath, however they had not been trained and the service user had not been assessed as to what assistance was required therefore putting the service user and staff at risk of an injury. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 10 Other plans of care looked at did identify needs of service users but had not been regularly reviewed or updated. An immediate requirement was served on the first day of the inspection to ensure all service users had a plan of care to ensure their needs can be met. On the second day of the inspection staff had been working hard on plans of care and the two service users without any plans had been commenced and the personal assessment and life history had been completed these were very good containing good detail and showing the key workers had good knowledge of the service users. The risk assessments had been started and were good and the staff were hoping to finish all the plans within two weeks to ensure service users needs are reflected to ensure they are met. Talking to staff and observing practices it was not clear that service users are consulted on all aspects of life in the home, this has been due to staff changes and shortages, the acting manager is aware this needs to improve and it will be addressed to ensure all service users are fully consulted and participate In all aspects of life in the home. The home has a confidentiality policy that all staff were aware of when questioned, staff also told the inspector they were aware that information regarding service users is confidential and information is handled appropriately and confidences are kept. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 12, 14, 15 & 17. Appropriate activities are provided, service users have appropriate relationships. Service users diet is healthy. EVIDENCE: The acting Manager has drawn up new activity timetables with appropriate activities for all service users. It has been recognised that the activities have decreased over the last few months due to staff changes and shortages as most of the service users at Levitt Mill require a two to one ratio of staff when they leave the home for their safety. Some parents of service user have also raised concerns regarding lack of activities and these have been addressed by the Area Manager to ensure service users needs are met. The home has always been very activity focused for the service users and this is stated in the statement of purpose so the activities need to commence in full again to ensure service users needs are met. The Area Manager told the inspector a second vehicle is on order for the home to improve activities as each unit will then have its own vehicle rather than sharing this will increase outings for service users. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 12 Staff spoken to told the inspector that family links are maintained with family and friends always welcome at the home at any time. Staff said one service users had a birthday this week and the family were able to use a small lounge to have a party, which the service user thoroughly enjoyed, cards and decorations were seen in the lounge by the inspector. Various meals were observed during the inspection the service users were given choices not only of the food but times they wanted to eat, healthy food was also promoted and service users encouraged to eat healthily. Individual service users usually go shopping with their key worker to buy their food and most days’ service users eat different meals at different times and it was evident that this was the service users choice. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 18, 19, 20 & 21. Service users receive appropriate personal support, not clear if service users physical and emotional needs are being met. Medication policy and procedures safeguard the service user. Ageing and illness are not covered in plans of care. EVIDENCE: Staff spoken to were all aware of each service users needs and amount of personal support required to meet those needs and given in a way the service users prefers, staff were also aware of physical and emotional needs to ensure all healthcare needs are met, however it was not always evident in plans of care that these were being met, this needs to be addressed ensuring service users health care heeds are documented and reviewed. Medication polices and procedures in the home were very good all medication was documented on arrival, when administered and disposed of. Medication was appropriately stored. Controlled drugs were recorded clearly and checks carried out confirmed they were accurate to safeguard service users. All staff that administer medication have received accredited medication training. When the inspector arrived at the home there was no member of staff on duty who Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 14 was able to administer medication this needs to be addressed to ensure if an emergency arose and a service user required medication it could be administered. The inspector was told a staff member who was on a training course had come in early before he went to the training to give the morning medications and then the afternoon shift could give the other medication. The ageing, illness and death of service users has not been addressed this was discussed with the acting Manager and he will address this standard as the care plans are reviewed to ensure service users and their family requirements needs are met. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 15 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 the following standard(s): These standards were not covered during this inspection. EVIDENCE: Although this standard was not covered during the inspection a complaint had been received by CSCI and was investigated during the inspection, the complaint was regarding workers not recruited properly and putting service users at risk, poor practices and poor environment. Some of the complaint was upheld and other issues not up held as documented under the relevant standards. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 24, 25, 26, 27, 28 & 30. The environment and cleanliness of the home was poor. EVIDENCE: A full tour of the buildings took place during the inspection the standard of décor and cleanliness was extremely poor. Carpets, floor coverings, baths, toilets, sinks, wall tiles, skirtings and walls were encrusted in dirt and debris and all required a thorough clean. An immediate notice was served on the first inspection day to thoroughly clean the home and ensure there is a planned renewal programme for the fabric and decoration of the premises to ensure the service users live in a safe and well maintained environment. On the second day of the inspection it was observed the standard of cleanliness had improved, the staff had thoroughly cleaned the home and worked very hard. New vacum cleaners had been purchased a carpet cleaner was being borrowed from another home to ensure the environment was improved for the service users. Service users bedrooms suit their needs they were well personalised with sufficient space and all have en-suite facilities to meet service users needs and promote their independence. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 17 Adequate toilets and bathrooms are provided in the home to meet the needs of the service users. All bathrooms require redecorating, in one bathroom the wall plaster was damaged and the wall tiles are coming away from the wall these need fixing to ensure the environment is safe. Some floor coverings in en-suite facilities were badly stained these need replacing to provide a well-maintained environment. Each unit has a laundry facility and the home has policies and procedures in place for control of infection. Some offensive odours were noted during the tour of the building in en-suites and on stairs to third floor, on the second visit the en-suites had been cleaned and no foul odour was present however on the stairs the odour was still present this need to be addressed to ensure the home is clean and hygienic for the service users. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 & 36 Staff roles and responsibilities are not clear, staff are competent and qualified but the home is running without the full staff complement. Recruitment I procedures protect service users. Staff are not supervised. EVIDENCE: Staff do have clearly defined job descriptions however staff told the inspector that with shortages of senior support workers and management we have been confused as to what our roles are some shifts have no senior support staff as had happened on the day of the inspection, the Area manager and Acting Manager told the inspector that they were currently advertising for a Deputy Manager, Senior Support Staff and Support Staff and were hoping to interview and appoint very quickly to ensure service users needs are fully met. Staff on duty did know the service users very well and had developed good relationships with the service users they supported and were able to identify their needs. Staff are competent and qualified but with staff shortages there is not always the correct balance and skill mix on duty to ensure service users needs are met. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 19 The training provided by the company is very good and hopefully once there is a full complement of staff this can commence again to ensure all staff are up to date with all mandatory training to safeguard service users. Some staff files were looked at and thorough recruitment procedures are followed to protect service users. All staff personal files are in the process of being updated and all information will be kept at the home. With the changes in management staff supervision has not been carried out the Acting Manager and Area Manager are aware of this and ensured the inspector this will be addressed to ensure staff are appropriately supervised. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 41, 42 & 43. Homes policies and procedures are good; record keeping in the home needs improving. Health and safety procedures need reviewing. Management of the home has seen a lot of changes since the last inspection and is still to be resolved. EVIDENCE: The home has got good quality monitoring systems based on seeking views of service users and in the past have been carried, Regulation 26 visits have been carried out and an environmental audit had been carried out as part of quality assurance but other monitoring systems have lapsed recently due to staffing issues the Acting Manager is aware of the need to re-commence these to ensure service users needs are met. The home has good policies and procedures in place, which meet all the requirements of the standards. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 21 Record keeping in the home is not all maintained and up to date records not up to date have been identified under the appropriate standard and requirements made to ensure protection of the service users. The home has a good health and safety policy however staff training is not up to date although this is being addressed to ensure service users safety. The maintenance records for gas safety, electrical safety certificates including Pat testing, legionella and safe environment including equipment and machinery were not all available at the time of the inspection, change in company ownership had caused some of the problems these need to be rectified and ensure all the safety records are kept either on site or at an office where they can be made available to the inspector when requested. The PAT testing records could not be located so an inspection was organised at the time to be carried out on Friday 27th January to ensure the service users safety. Since the last inspection the home had changed ownership and had a complete change in external management, the management within the home is also changing which has caused staff to be unsettled and some have left, this is being addressed by the Area Manager and Acting Manager to ensure service users benefit from competent and accountable management. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 22 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 3 X X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X 2 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 2 3 X 1 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X X X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Levitt Mill Score 3 2 3 1 Standard No 37 38 39 40 41 42 43 Score X X 2 3 1 2 2 DS0000041903.V259666.R01.S.doc Version 5.0 Page 23 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 2 3 4 5 Standard YA6 YA8 YA14 YA19 YA21 Regulation 15 12 16 15 12 Requirement All service users must have a plan of care, which reflects their changing needs. Ensure service users are consulted on all aspects of life in the home. Ensure the service users activities are re-commenced fully. Ensure all service users physical and emotional health needs are identified and met. Service users needs regarding ageing, illness and death must be identified and documented in plans of care. A planned maintenance and renewal programme for the fabric and decoration of the home must be drawn up. A number of carpets and floor covering are badly stained these should be replaced. Wall plaster in the bathroom at the barn was damaged this needs repairing. Wall tiles in a bathroom at the barn had become loose these should be replaced. Timescale for action 01/03/06 01/04/06 01/04/06 01/03/06 01/04/06 6 YA24 23 01/04/06 7 8 9 YA24 YA24 YA24 23 23 23 01/05/06 01/03/06 01/03/06 Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 24 10 YA24 23 11 12 YA27 YA30 16 16 13 14 15 16 17 YA32 YA36 YA39 YA41 YA42 18 18 24 17 13 A number of walls in bedrooms, bathrooms and communal areas were badly marked and require re-painting. Ensure service users bathrooms met their needs by providing hoists if required. Ensure the home is clean and hygienic and free from offensive odour by implementing appropriate systems in the home. Ensure staff training is updated. Ensure staff are supervised at least six times a year. Ensure all quality-monitoring systems are carried out. Ensure all records in the home are up to date. Ensure all maintenance is carried out and records made available. 01/05/06 01/04/06 01/03/06 01/04/06 01/05/06 01/05/06 01/05/06 01/04/06 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 YA43 Good Practice Recommendations Ensure competent and accountable management of the service by re-instating a staffing structure in the home. Levitt Mill DS0000041903.V259666.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr 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. 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