Inspection on 05/06/06 for Levitt Mill

This inspection was carried out on 5th June 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 19 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 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 5th June 2006 09:10 Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 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.V293049.R01.S.doc Version 5.1 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.V293049.R01.S.doc Version 5.1 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 ** Post Vacant *** Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 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 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. The fees at Levitt Mill range from £1999.26 to £2559.28 per week. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection in the year 2006/2007 was unannounced and took place over two days the inspection commenced on 5th June 2006 at 09.10 and finished at 14.45 the second day was 8th June commencing at 09.20 and finishing at 15.00. The Area Manager was at the home on the first day of the inspection and the Deputy manager who has been promoted to Manager but has yet to be registered with CSCI. As part of the inspection process the inspector spoke to 7 Service users and 13 staff. A full tour of the building took place observing the standard of the environment staff and practices. A number of records were examined these included medication, three service users care plans, activities, staff rotas, recruitment, service users finances and quality assurance systems. Feedback was given to the Manager when the visit was completed. What the service does well: What has improved since the last inspection? The care plans have greatly improved since the last inspection with good detailed assessments in place and the needs of the service users identified and actions well documented. Risk assessments are now in place and all areas of risk are identified and service users are encouraged to take risks as part of an independent lifestyle. The major renovation works were due to start on 10th June 2006 with the builders working round the clock to get the work completed within seven days. The service users were going on holiday during this period to enable this to take place. The standard of cleanliness observed during the visit was much improved. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 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.V293049.R01.S.doc Version 5.1 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.V293049.R01.S.doc Version 5.1 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): 1&2 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The assessments for each service user were very good. The statement of purpose and service users guide were not available. EVIDENCE: Three service users were case tracked and in each plan of care was a detailed assessment, which gave a good overview of each individual and was a tool to determine if the needs of that individual could be met at Levitt Mill. 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. Since the home changed ownership and management structure there is not an updated statement of purpose or service users guide the manager is aware of the need to devise these but has asked for assistance from the Area Manager. This was discussed at length with the Manager and they need to be implemented to ensure perspective service users and their families are given adequate information to make an informed choice about where to live. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 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, 7 & 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users changing needs are reflected in the plans of care and are supported to take risks as part of an independent lifestyle. EVIDENCE: Three service users were case tracked as part of the inspection process to determine if their needs were clearly identified and met. The care plans have been reviewed and updated up by the Manager and Deputy Manager since the last inspection. The plans clearly identify 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. One service user had been assessed by the occupational therapist and some recommendations had been made these had not all been carried out this needs to be assessed and clearly documented to ensure the service users needs are met. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 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. It was not clear in the plans if the service users had any input into them, or if they were unable if relatives or advocates were involved. This needs to be addressed to ensure service users best interests are upheld. Health action plans were discussed with the manager and if these were implemented it would show input from service users. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 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, 13, 14, 15, 16 & 17. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users activities and access into local community is limited due to staffing numbers. Service users rights are respected and a healthy diet is offered. EVIDENCE: No activity plans were seen in the plan of care and staff spoken to said it depended on staffing numbers if activities off site took place as most service users required two staff for this and this was not always possible with staffing numbers and sickness. Service users were not getting the opportunity to maintain and develop social skills or fulfilling activities. Staff tried to stimulate service users with games and activities in the home and some went for walks in the ground as these are extensive, but staff told the inspector that some service users get very frustrated when they are not able to go out and they can then present with challenging behaviour. Activities need to be addressed to ensure service users needs are met. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 12 Service users activities was discussed with the Manager who is in the process of developing activity programmes that are flexible but meet the needs of each service user. Staff sickness is being dealt with and should be remedied and recruitment is ongoing to fill the vacant positions this should then enable service users needs to be met Staff spoken to told the inspector that family links are maintained with family and friends always welcome at the home at any time. It was a service users birthday on the day of the inspection a party was organised which was thoroughly enjoyed by all service users. The Key worker for the service users organised a birthday present, which was appropriate and the service users was very happy. 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 were 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.V293049.R01.S.doc Version 5.1 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users health needs are met and receive appropriate support. Medication policies and procedures are good. 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, this was also now well documented in plans of care to ensure service users needs are met. Staff were observed by the inspector providing flexible personal support, respecting service users and treating them with dignity. Staff interacted well with the service users using appropriate communication techniques. 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 administers medication have received accredited medication training. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 14 A medication error had occurred the week prior to the inspection this had been reported to CSCI and procedure followed to protect service users. A manager from another home was investigating this on the day of the inspection. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 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): 22 & 23. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Not clear if service users are protected from abuse or listened to. EVIDENCE: The home has a complaints procedure but it needs updating as many staff on the policy no longer work for the company. The home had a complaints book for relatives or visitors to document any concerns however, this was not confidential a different procedure was discussed with the Manager and he was going to implement this to ensure confidentiality and that any views received are acted on. The manager told the inspector the home had not received any complaints since the last inspection there had been concerns raised but these have not been documented. This was discussed with the manager and concerns are to be documented. CSCI had received a number of anonymous concerns regarding staffing problems and this was discussed with the manager. These same issues were also raised by the staff spoken to at the home and are detailed under the relevant standard. The home has a good adult protection policy but not all staff have received training on protection of vulnerable adults this needs to be addressed to ensure service users are protected from abuse. Staff spoken to during the inspection were aware of adult protection different types of abuse and the need to report. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 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 & 30 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The environment is due to have major renovation and this was due to start on 10th June 2006. The standard of cleanliness throughout the home was good. EVIDENCE: The standard of cleanliness observed during the tour of the building and during the inspection was to a high standard and had much improved since the last inspection ensuring service users live in a clean and hygienic environment. Major renovation works were due to start on 10th June 2006 and all the previous requirements were still outstanding but should be complied with once the work is complete this will be looked at in detail at the next site visit. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 17 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): 32, 33, 34, 35 & 36. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Staff training is not up to date recruitment files not up to date. The home is still short staffed. EVIDENCE: All mandatory training is out of date with all staff requiring updates. The home had just received training files and staff were due to commence the training this needs to be addressed urgently, it was a requirement from the previous inspection to ensure service users are supported by appropriately trained staff. Staff numbers are maintained on the duty rota but on many occasions there are no extra staff for the 2 to 1 staffing which allows service users to participate in off site activities, sickness levels are also high and shifts regularly run short staffed. Recruitment files were in the process of being re-organised in the new company format one file was complete and contained all the required information to safeguard service users. The Manager needs to ensure all other files are organised and contain all the relevant information. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 18 Although not looked at in detail supervision was discussed with the manager, as this was still not being carried out, this needs to be addressed to ensure staff are appropriately supported. The Manager also told the inspector he has also not received any supervision this needs to be addressed by the area Manager. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 19 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): 37, 39 & 42. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The home does not have a registered Manager; quality assurance systems are not in place. Health and safety is promoted. EVIDENCE: The Manager has yet to apply to be registered with CSCI this was discussed at the time of the inspection and the process explained to the Manager, as he has not previously managed a home although he has been a deputy and a senior support worker. The Area Manager needs to support him during this process. Quality monitoring systems are in place but have not been carried out, the manager and deputy are aware of the need to implement these again but have only been in post since January and have been ensuring care plans are up to date. The quality monitoring systems need to be implemented to ensure service users views underpin development in the home. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 20 Regulation 26 visit reports had not been sent into the inspector this was discussed with the Area Manager who sent these into the office the next day these have now been requested to be sent in monthly. The home has a good health and safety policy however not all staff are familiar with the new policies and procedures this needs to be addressed to safeguard service users. The maintenance records for gas safety, electrical safety certificates including Pat testing, legionella and safe environment including equipment and machinery were all available at the time of the inspection. Risk assessments for safe working practices were seen by the inspector they cover all areas and were very comprehensive. Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 21 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 1 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 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 1 X 2 X X 3 X Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 22 Yes Are there any outstanding requirements from the last inspection? Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 23 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 YA12 Regulation 16 Requirement Ensure the service users activities are re-commenced fully to meet service users needs. (Old timescale 01/04/06) A planned maintenance and renewal programme for the fabric and decoration of the home must be drawn up. (Old timescale 01/04/06) A number of carpets and floor covering are badly stained these should be replaced. (Old timescale 01/05/06) Wall plaster in the bathroom at the barn was damaged this needs repairing. (Old timescale 01/03/06) Wall tiles in a bathroom at the barn had become loose these should be replaced. (Old timescale 01/03/06) A number of walls in bedrooms, bathrooms and communal areas were badly marked and require re-painting. (Old timescale 01/04/06) Timescale for action 01/09/06 2. YA24 23 01/09/06 3. YA24 23 01/09/06 4. YA24 23 01/09/06 5. YA24 23 01/09/06 6. YA24 23 01/09/06 Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 24 7. YA27 16 Ensure service users bathrooms met their needs by providing hoists if required. (Old timescale 01/04/06) Ensure staff training is updated. (Old timescale 01/04/06) Ensure staff are supervised at least six times a year. (Old timescale 01/05/06) Ensure all quality-monitoring systems are carried out. (Old timescale 01/05/06) The manager must ensure the statement of purpose and service users guide is amended and updated and made available to all service users. The manager must ensure when recommendations are received by professionals that they are acted upon. The manager must ensure all staff receive protection of vulnerable adult training. The complaint procedure must be updated and made available in the home. 01/09/06 8. YA35 18 01/09/06 9. YA36 18 01/09/06 10. YA39 24 01/09/06 11. YA1 4 01/09/06 12. YA19 12 01/07/06 13. YA23 18 01/09/06 14. YA22 22 01/07/06 Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 25 15. YA34 19 The staff personal files must be updated in line with the new policy. The manager must start the process to become registered with CSCI. Ensure service users are able to access the local community to meet their needs as part of their activity programme. Ensure adequate staff are on duty to meet all needs of service users. 01/09/06 16 YA37 8 01/07/06 17 YA13 16 01/09/06 18 YA33 18 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Levitt Mill DS0000041903.V293049.R01.S.doc Version 5.1 Page 27 - 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!