Inspection on 04/01/07 for Levitt Mill

This inspection was carried out on 4th January 2007.

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 11 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 05/06/06

Levitt Mill 24/01/06

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 Key Unannounced Inspection 4 & 16th January 2007 09:00 th Levitt Mill DS0000041903.V319799.R01.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 Levitt Mill DS0000041903.V319799.R01.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. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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 NONE NONE Sapphire Care Services Limited ** Post Vacant *** Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th June 2006 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 lounges, dining rooms, bathrooms, kitchens and laundry facilities. The home is on the outskirts of Maltby near Rotherham with facilities nearby including pubs, shops, restaurants and leisure facilities. The fees at Levitt Mill range from £1999.26 to £2559.28 per week. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second key inspection in the year 2006/07 it was unannounced and took place over two days on 4th January 2007 at 09.00 and finished at 13.30 the second day was on 16th January 2007 started at 12.00 and finished at 17.15. The home has also had two random inspections in this inspection year, one on 13th September 2006 this was as part of an adult protection investigation. Another Random visit was carried out on 16th October 2006. A meeting was also held with the Responsible Individual and Area Manager on 23rd January 2007 to discuss the management structure of the home and staffing problems. As part of the inspection process the inspector spoke to 6 residents, 2 relatives 8 members of staff and the Acting Manager. A tour of the building took place, observing environment, staff and practices. A number of records were examined these included medication, two service users care plans, staff rotas, recruitment, training and quality assurance systems. Feedback was given to the Manager when the visit was complete What the service does well: What has improved since the last inspection? The Acting Manager had worked very hard on recruitment, during the last six months the home has had a very high staff turn over, once the new starters are in post and completed their induction training staff numbers will be sufficient to meet the needs of the seven service users currently living at Levitt Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 6 Mill. Staff training has also improved with most mandatory training carried out for all staff. The major renovations were complete and the environment was much improved, clean and well maintained. 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. Levitt Mill DS0000041903.V319799.R01.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 Levitt Mill DS0000041903.V319799.R01.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 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessments for each service user were very good. The statement of purpose and service users guide were available but required the updated staffing structure to be added once finalised. EVIDENCE: Two service users were case tracked and in their plans of care were detailed assessments, which gave a good overview of each individual and from this it could be determined if the needs of that individual could be met at the home. The care management assessments from social services were also seen in the care plans. The assessments showed the home was able to meet the needs of the service users. The statement of purpose and service users guide were available and up to date, however the staffing structure needed to be added once this was in place. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users changing needs were reflected in the plans of care and they were supported to take risks as part of an independent lifestyle and were able to make decisions however this had sometimes been restricted due to the staffing problems. EVIDENCE: Two service users were case tracked as part of the inspection process to determine if their needs were clearly identified and met. The care plans had been reviewed and updated regularly by the key worker and the acting manager. The plans clearly identified service users needs and give good actions to meet these. The plan clearly sets out any restrictions on choice and freedom for the safety of the service users. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 10 Risk assessments were well documented in all plans looked at, with service users able to take risks as part of an independent lifestyle supported by the staff. The key workers were carrying out health action plans and person centred plans to ensure their individual needs and choices were know and service users spoken to said they were involved in the plans and worked with their key workers to ensure their wishes were in the plans. However it has not always been possible to meet their needs and choices due to staffing problems. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users activities and access into local community and activities were limited. Service users rights were respected and a healthy diet is offered. EVIDENCE: Service users had appropriate personal and family relationships, family links were maintained and family and friends were always welcome at the home. Two service users families were spoken to and they confirmed they were always made welcome. The acting manager had developed a new menu promoting healthy eating and a choice was always available. Most service users chose each day what they wanted to eat and were helped by support workers to prepare their meals. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 12 Food shopping was carried out weekly with service users. Service users spoken to told the inspector that the food was good and they always had a choice. Daily routines in the home promoted independence and choice and service users rights were respected. Activities and education opportunities had improved since the last inspection however it still required further improvement. The activities were still limited due to staffing numbers and sickness. The home only had two vehicles for service users to use and this also limited the choice of activities available. Activity plans have been devised and were seen in the plans of care and staff tried to maintain these programmes, but this had not always been possible due to the constraints mentioned therefore service users needs were not always met. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health care needs were met. Medication management needed improving. EVIDENCE: Staff spoken to were aware of service users needs and the amount of personal support required to meet those needs. The support was given in a way the service users preferred. Staff were also knowledgeable of service users physical and emotional needs, this was documented in plans of care to ensure service users needs are met. Staff were observed providing flexible personal support, respecting service users and treating them with dignity. Staff interacted well with the service users using appropriate communication techniques. Medication policies and procedures were good there were good records of medication received and administrated, however there were no records of medications that were to be returned to the pharmacy. It was not clear what Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 14 was being returned and what was still in use. There was an over stock of most medication and a number of bottles and packets of the same medication were open and being used. Some medication had been dispensed months ago and it was not clear when it expired. Medication procedures observed did not safeguard the service users. All staff that administered medication had received accredited medication training. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were protected from abuse and their views were acted on. EVIDENCE: There is a clear and effective complaints procedure, which includes set timescales. The complaints procedure also states that the CSCI can be contacted at any time. The home had received no complaints since the last inspection. Some concerns had been raised with the acting manager, which had been documented and dealt with appropriately. The home had a good adult protection policy which clearly defines different types of abuse and staff were well aware of different types they were also aware of the importance of whistle blowing, the whistle blowing and POVA policies had recently been reviewed. A revised contact list was available which clearly states whom to contact, and the local procedure to be followed should an incident need reporting. The home has had two adult protection referrals since the last inspection these were reported correctly and all procedures followed to safeguard service users. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was maintained to a good standard and kept clean. EVIDENCE: The standard of cleanliness observed during the tour of the building and during the inspection was of a high standard. The home had been completely renovated since the last inspection and the environment throughout the home had been much improved. New floor coverings had been fitted throughout, new furniture for lounges, bedrooms and dining areas had been purchased and many rooms had been re-plastered and re-decorated. On the first day of the inspection it was observed that bedrooms and en-suite facilities were not personalised and many toiletries were kept in communal Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 17 cupboards unlocked. This had been addressed at the second day of the inspection. Toiletries were kept in individuals bedrooms with risk assessments in place and the key workers had started to personalise the bedrooms and ensuite facilities with the service users. The walk in shower had also been identified as requiring some work this had been carried out when the inspector went on the second day. Some items were identified as still requiring attention these were, the floor covering in the small lounge at the barn which was not fixed properly, there was no soap or hand towels in any communal bathroom to prevent cross infection. No sanitary arrangements were in place in the barn for female staff and the kitchen in the mill needed new curtains and re-painting. The relatives spoken to all said that the environment in the home had much improved and was cleaned regularly providing a comfortable and safe environment for the service users. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by an effective team and protected by the homes recruitment practices. EVIDENCE: A selection of staff training files were seen, records were good and most mandatory training had been carried out, the manager and acting deputy manager have worked hard to ensure the training was continued even when staffing was very low to ensure service users needs were met. A thorough recruitment procedure was in place, a selection of personnel files were looked at they all contained all the required information and checks to ensure the service users are protected. The acting manager had recruited a large number of staff over the past few months due to a high staff turn over. At this inspection the home was fully staffed for the seven service users living at the home. however the home had some vacancies and before another service user is assessed to move into the home more staff will be required. The Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 19 acting manager was continuing to recruiting to ensure staff were in place if any new service users move into the home. When the new staff have completed their induction training the manager will register support workers on the NVQ training to ensure the home reaches 50 of staff trained to NVQ level 2. There by ensuring staff are appropriately trained to meet service users needs. Staff supervision has recommenced to ensure staff receive support they need to carry out their jobs. The manager has not received adequate supervision, the last record of supervision was July 06. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new management structure has been put in place and health and safety is maintained. Infection control measures need improving. EVIDENCE: Since the meeting held with the Responsible Individual on January 23rd a new management structure has been implemented at the home. The acting manager Wayne Cocksedge is going to apply to the Commission for Social Care Inspection to be the registered manager and two deputy managers have been appointed. One is now in post the other is currently working her notice at another home and is due to start on 18th February 2007. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 21 The acting manager is also devising a different work rota for staff to improve the service at the home and ensuring service users needs are met Quality monitoring systems were in place some had lapsed however most had been recommenced, staff meetings had recommenced and are planned to be every six weeks. Service user meetings were due to start on 26th January 2006, regulation 26 visit reports had been carried out and reports sent to the inspector. Quality assurance questionnaires had been sent out from head office to service users families. The home was due to send out questionnaires in February to gather service users views the aim is to use these in the development in the home. Health, safety and welfare of service users was promoted, all the maintenance records for electrical safety, portable appliance testing, legionella, fire checks, water temperatures and safe environment including equipment and machinery were all available at the time of the inspection. These were up to date ensuring the safety of the service users. Infection control measures needed improving, there were insufficient measures in place to prevent spread of infection. There were no soap or paper towels in communal toilets and bathrooms for staff to wash their hand when they had assisted a service user and the staff toilet had no soap or towels. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 X 3 X X 2 x Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 23 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 YA14 Regulation 16 Requirement The service users activities must be re-commenced fully to meet service users needs. (Old timescales 01/04/06 01/09/06 and 01/12/01) This is still not fully implemented due to staff shortages. Written confirmation of the action taken to comply with this regulation must be sent to the local Commission for Social Care Inspection office by 5/3/07. Staff training in NVQ level 2 must be recommenced. The statement of purpose must be updated to include the new staff team. service users choices regarding decision-making must be able to be met by providing sufficient staff who are trained to support service users. Service users must be able to take part in peer and culturally appropriate activities both in the home and in the local community Medication must be documented when disposed of. All excess DS0000041903.V319799.R01.S.doc Timescale for action 01/03/07 2. 3. 4. YA32 YA1 YA7 18 4 12 01/03/07 01/03/07 01/03/07 5. YA12 16 01/03/07 6. YA20 13 01/03/07 Levitt Mill Version 5.2 Page 24 7. YA35 18 8. 9. YA36 YA37 18 8 10. YA42 13 11. YA24 23 stock must be sent back to the pharmacy. Stock control procedures must ensure that medication is used in date order. All mandatory training for staff must be updated. (Old timescales 01/04/06 01/09/06 and 01/12/06) Written confirmation of the action taken to comply with this regulation must be sent to the local Commission for Social Care Inspection office by 5/3/07. The acting manager needs to be appropriately supervised at least six times a year. A manager must be put forward to become registered manager with Commission for Social Care Inspection. Infection control measures must be improved by providing liquid soap and had drying facilities in communal toilets and bathrooms and the staff toilet. The floor covering in the small lounge in the barn must be repaired. 01/03/07 01/03/07 01/04/07 01/03/07 01/03/07 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. Refer to Standard YA24 YA13 Good Practice Recommendations It is recommended that the kitchen in the barn is repainted and new curtains are provided. It is recommended that additional transport be considered to meet the needs of the service users. Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Levitt Mill DS0000041903.V319799.R01.S.doc Version 5.2 Page 26 - 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. 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