CARE HOMES FOR OLDER PEOPLE
Milford House Milford Mill Road Milford Salisbury Wiltshire SP1 1NJ Lead Inspector
Susie Stratton Key Unannounced Inspection 9:15 6 July and 10th 2007
th X10015.doc Version 1.40 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 Milford House DS0000069227.V338091.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 Older People. 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. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Milford House Address Milford Mill Road Milford Salisbury Wiltshire SP1 1NJ 01722 322737 01722 410339 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) Barchester Healthcare Homes Ltd Mrs Catherine Teresa Fountain Care Home 80 Category(ies) of Old age, not falling within any other category registration, with number (80), Physical disability (4), Terminally ill (7), of places Terminally ill over 65 years of age (7) Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The Maximum number of service users who may be accommodated in the home at any one time is 80. No more than a total of 7 service users with a terminal illness may be accommodated at any one time. No more than 4 service users with a physical disablement in the age range 18-64 years may be accommodated at any one time. The staffing levels set out in the Notice of Decision dated 4 July 2005 must be met at all times. Date of last inspection Brief Description of the Service: Milford House Nursing home is registered to provide nursing care for 80 older people. Much of the home is purpose built, providing a comfortable standard of accommodation. Services are provided over two floors and in a linked wing, called the Cathedral Wing, which is also over two floors. Passenger lifts are provided between ground and first floors. Part of the main building also has a second floor for support services such as the laundry and staff rooms. The home also provides large garden areas, which are accessible to wheelchair users. Many of the service users in Milford House are frail and have complex nursing and care needs. Any younger adults admitted to the home also have complex nursing and care needs. Prospective residents are issued with a service users’ guide at the time of admission. At the time of the first site visit, there were 71 persons resident in the home and the three beds regarded as empty were booked. Fees charged range from £668 to £965. Charges are also made for hairdressing, chiropody, taxis for personal transport, newspapers and sundries such as toiletries Milford House is situated on the outskirts of the city of Salisbury with pleasant views of the surrounding countryside. There is parking on site. The home is owned by Barchester Health Care Services Limited, a national provider. The Registered Manager is Mrs C Fountain and she leads a team of nursing and care staff. A full team of ancillary, support and administrative staff are also employed. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, 50 questionnaires were sent out to residents and their relatives and 30 were returned. Questionnaires were also sent out to social workers and GPs and twelve were returned. Comments made by residents, their relatives, social workers and GPs in questionnaires and during the inspection have been included when drawing up the report. The home provided an annual quality assurance assessment prior to the inspection, as required by the Commission. This was completed in detail by the manager and provided much information to inform the inspection. As Milford House is a larger registration, the site visits took place over two days, on Friday 6th July 2007 between 9:15am and 4:35pm and Tuesday 10th July 2007 between 11:40am and 3:30pm. The first site visit was unannounced. The registered manager, Mrs Cathy Fountain, was on duty for both site visits. As the home had produced such a detailed quality assurance assessment and so may people had responded in detail in questionnaires, the site visits concentrated on meeting with and observing care for people with communication difficulties and those who had complex nursing care needs. During the site visits, the inspector met with seven residents, two visitors and observed care for fifteen further residents for whom communication was difficult. The Inspector reviewed care provision and documentation in detail for eight residents, residents, three of whom had recently been admitted and reviewed documentation for certain specific areas for a further five residents who had specific personal or nursing care needs. As well as meeting with residents and visitors, the inspector met with five registered nurses, four carers, the training manager, the activities coordinator, two domestics, the senior laundress, the maintenance man and an administrator. The inspector toured all the building and observed three lunch-time meals and one activities session. Two medicines rounds were observed and systems for administration of medicines and the clinical rooms were inspected. A range of records were reviewed, including staff training records, staff employment records, maintenance records and financial records. What the service does well:
At 80 beds Milford House is a large and complex organisation. Despite this, there are effective management systems and the manager knows all the residents and many of their relatives individually. The manager is an experienced clinician and manager who takes effective action to ensure that
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 6 residents’ care needs are met. She investigated all complaints and concerns raised with her and takes action to rectify any matters. The parent company, Barchester Health Care is keen to make continued improvements to the home environment and equipment provided. There is a system for continuous quality audit of service provision and action is taken when issues are identified. The home has good working links with external professionals and there are safe systems for administration of medicines, which includes regular audit. Milford House presents a clean, well maintained atmosphere. Bedrooms are light and airy and most much exceed minimum standards for size. Residents and their relatives commented on the home, one reported “Having had some “experience” of 2 other homes in the area Milford House is in a “class of its own”, another “this home is outstanding in its care, compassion, understanding and tolerance” and another described the home as “clean well furnished and particularly sweet smelling. Many people commented on the staff, one reported “The staff are very responsive to mother’s slightest problems”, another “They seem also to give time to find out if there is a problem” and another “The staff are friendly positive and helpful”. What has improved since the last inspection?
Milford House has been newly registered by Barchester Health Care, therefore it is a new registration. However the home itself has been registered for many years. At the last inspection, thirteen requirements and thirteen recommendations were identified. All had been addressed by this inspection. Much work has been put into the development of person-centred care plans. Significant details such as the use of topical applications now are included on care plans, when needed. Where a person is at risk of pressure damage, care plans specify how often the person needs to be moved. Care plans relating to mental health care needs clearly specify actions to be taken by staff to meet such needs. Where a resident’s fluid intake is measured by use of a fluid intake chart, the amount of fluid taken in by the resident is totalled every 24 hours. Residents’ individual likes and dislikes for meals is documented in their records. Care plans have been developed in relation to residents’ recreational needs. Care plans are up-dated when a person’s condition changes. All relevant documentation is now dated and signed by the person drawing the record up. Systems for supervision of staff have been further developed, this includes ensuring that all staff comply with directions specified in care plans. Where a resident needs their condition to be monitored regularly, there was written evidence to show that they had received the care that they need, at the frequency indicated by their care plan. Frail residents’ records state what meals they were given. Audits of response times when call bells are used are undertaken regularly and if any deficiencies are observed, action is taken by management. Registered nurses no longer perform invasive procedures which have not been approved by the resident’s GP or are not part of the provider’s approved procedures. A new clinical room has been provided on the first floor
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 7 of the home, which includes storage for Controlled Drugs and a medicines refrigerator for that floor. The hours worked the activities coordinator have been increased. The home have further developed the activities programme, so that that residents who are unable, do not wish to leave their room or have additional complex needs, are more able to have their recreational needs met. Much emphasis has been put on further developing the meals service for residents. Improvements have been made to the home environment. New profiling beds have been provided in nearly all residents’ rooms. The laundry has been provided with intact wipable surfaces. This means that it is much easier to keep clean. If supplementary heaters are used in resident’s rooms, these are always secured and individual risk assessments for each person carried out. Wedges are no longer used to hold open fire doors. If a resident requests or is assessed as needing to have their door held open, a device which has been approved by the fire officer is used. An action plan detailing how residents are to be protected by the risks presented by the road outside the home has been drawn up. Recording systems have been developed. Staff do not commence employment until there is evidence that two satisfactory references have been obtained. References are only accepted from the person to whom they have been addressed and if prospective staff members do not put forward their current employer as a referee, there was written evidence as to the reason for this. All staff who have resident contact have been trained in abuse awareness. Night staff are trained in fire safety every three months. Records of residents’ valuables describe them clearly and do not use reference to any apparent value. What they could do better:
Two requirements and nine good practice recommendations were made at this inspection. As bed safety rails can present a risk to residents, where they are provided, there must always be a full risk assessment performed, in accordance with company policy and guidelines from the Health and Safety Executive. Where risk is identified, appropriate action must always be taken to reduce risk to the resident. Clear, measurable wording should always been used in residents’ documentation and the use on non-specific words such as “regularly” avoided. All staff should consistently document care given in line with the home’s documentation systems, to assist in audit of care provided. Where residents need thickening agent added to fluids, the actual amount needed by each individual resident should be documented, to make staff aware of individual specific needs. Care plans relating to medical conditions such as diabetes should be drawn up in every case. Responsibility for drawing up and evaluation of care plans should be delegated, to enable senior registered nurses to perform audit of care practice.
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 8 To prevent risk of hand contamination which can cause cross-infection, all clinical waste must always be placed in bins which are not operated by hand. As they cannot be properly cleaned, all deteriorated safety rail protectors should be taken out of use. Air cushions should be provided for residents who are at high risk of pressure damage, who wish to sit out of their beds for extended periods. Where air mattresses are provided, the resident’s weight should always be considered when setting the dial on the air mattress motor. The home’s statement of purpose should be revised to reflect that the home cares for persons who are terminally ill and how they ensure they meet such persons’ needs. It should also detail the numbers and skill mix of staff available throughout the 24 hour period. 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. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. The home does not provide intermediate care, so 6 is N/A. Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People admitted to Milford house have clear information provided to them and a full assessment completed. This ensures that the home can meet their needs. EVIDENCE: Residents and their supporters reported that the information they had received about the services offered by the home enabled them to make a decision on. Of the 28 people who responded to this section of the questionnaire, 25 stated that they had been given enough information before admission. One person reported “Our interview was good. The reputation of Milford House locally is also known and also good”. Another person described how their relative had been admitted in an emergency and how they were given information about the home after admission and that “Milford House responded to an immediate need with compassion and understanding”. The home’s statement of purpose
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 11 is clear and written in an approachable style. It was discussed that the information does not detail that the service offers terminal care and has links with appropriate supports to enable them to do this and it is advisable that this is included to full inform prospective residents and their supporters. The statement of purpose should also detail the numbers and skill mix of staff on duty at different times of day, to fully inform people of the supports offered. The manager reported to the C.S.C.I. in her annual quality audit assessment that the home aims to ensure an organised admission to the home, so as to provide minimal stress to the resident or their family. During the inspection, the Inspector met with three people who had been admitted during the past year. One reported that family members had visited the home on their behalf and another that they had known about the home, having been admitted for respite care on previous occasions. All residents hah had a full assessment of their need prior to admission. Records seen were clear and completed in detail. Where additional information was needed from healthcare professionals, for example the Community Psychiatric Nurse, this was obtained. All residents also have a full assessment of their needs at admission and if further information relating to their nursing or care needs was identified at this stage, this was sought. For example one record from the local hospital had not documented all of a residents’ needs and it was clear that the home were actively seeking more information on the person’s needs and circumstances, following their admission, to ensure that they could fully meet their needs. Registered nurses reported that they were informed both verbally and in writing of a prospective residents’ needs before admission, so that they could plan how they were going to provide nursing and care. One relative reported “The care home certainly meets my relative’s physical needs very well.” Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents’ health and personal care needs, including complex nursing care needs, are met by staff, who ensure that people are treated with respect. EVIDENCE: Milford House has nearly fully introduced a revised, person centred care planning system since the past inspection. This has been a complex process for staff and involved much hard work, however the new care planning system is much more resident-centred and is also in a format which is easier to evaluate and change if indicated by a resident’s condition. Care plans reviewed reflected what the resident reported and what was observed by the Inspector. Where residents were assessed as being at risk, for example, of pressure damage, falls or dietary needs, care plans were put in place to direct staff on how risk was to be reduced. The home are gradually ensuring that care plans give precise directions on how care is to be carried out, however some may need revision, so as to avoid imprecise wording such as “often” or
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 13 “regularly”. Several residents with swallowing difficulties were prescribed thickening agents and while this was documented in their care plans, it is advisable that the amount of thickening agent to be used is documented, as different residents will need their drinks thickening to a different consistency, depending on their individual needs. Currently care records are completed by the more senior staff, it was discussed with the manager, that now the new documentation system was nearly in place, that responsibility for completing records should be delegated to key workers, so that the senior staff on each floor could concentrate of auditing care plans, to ensure that they related to the individual, clearly directed actions to be taken and were followed by all staff. Milford House cares for some residents with highly complex nursing and care needs. Where residents were being artificially fed via PEG feeding systems, each resident had a detailed care plan, together with clear directions from appropriate healthcare professionals. Several residents had diabetic conditions and while this was referred to under their dietary needs, there were no overall care plans relating to their diabetic condition. Discussions with registered nurses showed that they were fully aware of actions to take to meet individual residents’ needs. It was discussed that care plans relating to medical needs were needed when indicated, to ensure a consistent approach by all registered nurses. GPs responded to questionnaires to state that they were satisfied by the service offered. Of the nineteen people who responded to this section of the questionnaire, thirteen reported that they always and five usually received the medical support that they needed. One person reported “The doctor is called whenever necessary.” Many of the residents in Milford House were frail and needed to be cared for in bed all or most of the time and to be given regular fluids. Such residents had clear care plans in place, which specified actions to be taken by staff to meet individual needs. All frail residents have individual monitoring records, which detail when they had their position changed, were offered fluids and given meals. These provided evidence that the staff in the home were meeting individual resident’s complex care needs. On one of the floors of the home, it appeared that some staff were completing records in an inconsistent way and while there was evidence that frail residents were having their needs met, lack of consistency in documentation would make it complex to audit. All residents’ care plans were regularly evaluated and plans changed when indicated. For example one residents’ condition had recently deteriorated and it was quite clear from their records as to where they now needed additional supports from staff. Registered nurses reported that they had begun to develop a system for regular meetings with residents’ relatives where individuals were not able to contribute to their care plans themselves. Of the 20 people who responded to that section of the questionnaire, 15 reported that the home always and 14 usually gave the person the care and
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 14 support that they needed. One person reported “Staff don’t mind what they do for you” and another “Carers do help me”. While one person felt that their relative was not bathed as often as they wanted, several other people reported on the flexibility of the service offered and that although the person had a designated day for a shower or a bath, this could be changed if needed or requested by the person. Each part of the home now has its own separate area for drugs, including a Controlled Drugs Cupboard and drugs refrigerator. There are clear systems for recording of drugs received by the home, administered to residents and disposed of from the home. All records, including Controlled Drugs records were completed in full. Where residents needed regular administration of medication by injection, records showed that correct procedure was used. There were clear systems for assessment and review where residents wished to self-medicate. Two medicines rounds were observed during the inspection. Both registered nurses performed the round in a safe and competent manner, in accordance with the home’s comprehensive medicines administration procedure. One of the registered nurses was very supportive of residents when giving out medication. She was observed to help residents in a kindly manner making sure that they were listened to and fully supported. The parent company, Barchester Health Care, performs regular quality reviews of systems for the administration of medication. All personal care was provided behind closed doors. Frail residents had their hair nicely brushed and had clean finger nails and mouths. Residents wore their own clothes. Discussions with the senior laundress indicated that she regarded correct and prompt return of residents’ personal clothing as a key part of her role. One resident reported “The laundry just happens, it’s not a problem.” Some residents had brief records in their room to indicate apparently small but significant matters, such as how many sugars they wished to have in their tea or how they liked their hair to be brushed. Where residents have limited communication skills, this useful document must support staff in ensuring that residents’ individual needs are met. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People who live in the home are supported in living their lives as they wish to, and have a range of activities and choice of different meals provided. EVIDENCE: The information provided by the home prior to this inspection showed that they had put much effort into improving services to residents across all of standards relating to daily life and activities. The activities person has increased her hours of work since the last inspection and has further developed the services offered. She is very enthusiastic in her role. She now attends staff meetings regularly, so that ideas can be shared across different staff groups. She has developed clear individual activities care plans for all residents and reviews them every month. One relative reported “There is a wide range of activities in the home – which is impressive”, another “Provides a great deal of stimulation with well thought out organised activities” and one external professional commented “They recognise the need for social interaction/activities”. Some comments related to the need for increased support for persons with disability,
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 16 such as people with visual or auditory needs. This had already been identified and plans are being developed to improve activities provision in this area. Residents who wish to are supported in going out of the home. The activities person books disabled transport for trips out. Several residents continue to go out of the home regularly, including attending local churches. Religious services, including communion, are held in the home for people who wish to attend. Residents reported that their visitors could come and go as they wished. Residents reported that they could choose when they got up and went to bed. They could also chose if they went to the dining room for their meals and if they attended activities or not. The maintenance man reported that he supported residents in personalising their bedrooms, particularly in putting up pictures. One relative commented that the home was particularly good at being “Responsive to client choice” and another relative commented on “the respect that residents are given.”. Since Barchester Health Care has taken over Milford House, much emphasis has been placed on further improving meals and mealtimes and ensuring that healthy options are available. As would be anticipated in any large care home, there were a range of comments made about the meals. Of the 20 people who responded to this part of the questionnaire, five reported they always, nine usually and five sometimes liked the meals. Comments varied from “Some things I don’t like” through “On the whole my relative enjoys the meals” to “It’s their best point.” Residents can eat in a choice of three different dining rooms. All dining rooms are attractively laid out. Staff were available to support residents throughout the mealtimes. Where residents needed assistance to eat their meals, staff sat with them encouraging and supporting them. A choice of drinks is offered with meals and residents who need nutritional supplements have them made available to them. Discussions with staff showed that they had a good appreciation of the importance of special diets. This was supported by full records and care plans. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. If people have issues that they wish to raise, they are listened to and action is taken to ensure their needs are met. EVIDENCE: Milford House has a clear complaints policy, which is made available to residents and their supporters. No complaints have been made to the C.S.C.I. about the home since the last inspection. Of the 26 people who answered this section of the questionnaire, 23 reported that they knew how to make a complaint. One relative commented, “I haven’t had to make one. On several occasions I’ve contacted the management directly about minor matters and they’re always helpful and things are quickly resolved” another “I will bring any problems to a member of staff if my relative mentions anything to me – it is then resolved” and another relative reported that they knew that their relative had complained and that staff took notice of what she said. The home’s complaints log was reviewed to assess if the home was aware of specific matters raised by people in questionnaires and it was noted that these had been documented and that appropriate action had been taken. It was observed that all matters, including concerns as well as complaints, had been documented. The manager regularly reviews complaints and assesses them for any trends, to further improve and develop service provision. She reported that she felt it was important for people to be able to raise any issues that
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 18 concerned them, so that appropriate actions could be taken, to ensure that their needs were being met and they felt safe. Staff spoken with were aware of the importance of safeguarding vulnerable adults. All staff are given a copy of the “No Secrets” booklet when they commence employment and receive training on the importance of the area during induction. Staff are then trained at regular intervals. This was fully supported by records. The administrator who handles residents’ finances showed a detailed awareness of the importance of the area. The manager has experience of working within local safeguarding adults procedures. One referral has been made since the last inspection, this was made by the home in support of a vulnerable person. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People in the home benefit from a hygienic, well-maintained environment, apart from one specific area relating to prevention of spread of infection. EVIDENCE: Milford House presents a well maintained environment. The quality audit submitted with the pre-inspection information showed that Barchester Healthcare have further improved the home environment across a range of areas during the past year, to make it more homely and attractive. There is a clear system for reporting of maintenance issues, this ensures that items needing maintenance are dealt with promptly and efficiently. One person described the environment of the home as “lovely”, another described it as “well furnished” and another as “a jolly nice place”.
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 20 Residents have a wide choice of communal rooms, which all vary in size. Several residents commented on how much they liked the garden areas. One person saying how they tried to get out there every day if it was fine and another how much they enjoyed going out into the garden. Barchester healthcare has provided a range of equipment to meet the needs of residents with a disability. Nearly all the bedrooms now have electrical profiling beds and more are on order and they will be available in all rooms shortly. One person who had recently been given one of these new beds reported “I do like my new bed.” A range of hoists are provided for residents who have manual handling needs. Where this is the case, residents are provided with their own lifting slings and do not share with other residents. A range of pressure relieving equipment is provided for residents who are at risk of pressure damage, however it was noted that no air chair cushions are provided and it is advisable that these are provided for residents who are at high risk of pressure damage who wish to sit out of bed for longer periods of time. The manager reported that she will put this in the next year’s budget. Two of the people met with who were provided with air mattresses did not have the dial on the motor set to their actual weight. Neither or these people were assessed as being at high risk of pressure damage, but as incorrect pressure for a person’s weight can cause pressure damage, the home needs to ensure that pressure relieving mattresses are always used correctly for all residents. The home presented a clean environment during the site visit. Of the 21 people who responded to this section of the questionnaire, twelve reported that it was always and nine usually fresh and clean. One person commented in their questionnaire that the cleaner in their area should be “commended” for her high standards. Another person reported that they were impressed that the atmosphere in the home was always fresh. Two cleaners were met with during the inspection, both reported that they had all the equipment and chemicals needed to enable them to do their job properly. One cleaner was observed to carefully clean small ornaments for a resident, taking care over the task. Staff were observed to correctly use protective clothing during the inspection and registered nurses reported that there was a ready supply of sterile gloves for aseptic procedures. Some of the protectors for safety rails had deteriorating surfaces and so could not be effectively wiped down. They need replacement, to prevent risk cross-infection. The manager reported that the home did have stocks of bed rail protectors. The laundress confirmed that staff handled laundry in accordance with the home’s infection control guidelines. The laundry has been upgraded since the previous inspection, to ensure that it complies with current guidelines for the prevention of spread of infection. It was noted that where relevant, residents are screened for infectious conditions on admission. One resident had a clinical waste bag for infected waste in their en-suite. This had not been placed in a foot-pedal or hands-free waste bin, so there was risk of spread of infection, as hand- Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 21 contamination could occur when items were placed in the bin. All other systems for the effective management of clinical waste were in place. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People are supported by a well staffed home, where staff are recruited in a safe manner and trained in the skills they need to perform their roles. EVIDENCE: Milford House have set standards relating to minimum staffing levels and skill mix, which they always comply with or exceed. As well as registered nursing and care staff, a range of ancillary staff are also employed. Of the 21 people who responded to this section of the questionnaire, eight reported there were always, twelve usually and one sometimes staff available when they needed them. A few residents commented on slow response times when call bells were used, but this was not generally echoed by other people. One person reported “If I ring my bell, they come and they are helpful when they do.” People commented on the low staff turnover. One person reported on the “stable staff base with very few changes”. One external professional also commented on this, reporting “They [i.e. Milford House] recognise the need for good staffing numbers.” Several people commented that the night staff were as supportive as the day staff. The files of three recently employed staff were reviewed at this inspection and they showed that the home were operating safe recruitment practice. All
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 23 prospective members of staff have police checks, at least two satisfactory references, proof of identify and evidence of their past working history obtained prior to employment. All staff are interviewed prior to employment and the manager is planning to introduce the Barchester Health Care interview assessment tool in the future. All newly employed staff are supported by a standard induction programme. All new staff are allocated to a mentor and supported by the home’s training manager throughout the period. The training manager maintains clear records of supports given during induction and has a flexible approach, depending on the person’s previous experience and skills base. On completion of induction, the home are keen to encourage staff in learning opportunities and developing their skills. NVQ training is supported. The range of courses offered to staff was detailed in their pre inspection information. This was fully reflected in staff training records. Recent training included tissue viability, diabetes, terminal care and dementia care. Staff spoken with showed an enthusiasm for developing their skills. The training manager has only recently taken up her role, she is keen to develop the service. She is able to work flexibly to support staff, including night shifts. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 22, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People receive a well managed service and are able to contribute their opinions on service delivery. Their health and safety is largely up-held, apart from one area where risk was identified. EVIDENCE: The manager of the home is experienced in her role as manager and registered nurse. She completed a very extensive annual quality assurance assessment of services provided by the home, as required by the C.S.C.I., to inform this inspection. The audit shows the amount of work put in by the manager to ensure that the home complies with standards and guidelines and provided a very useful tool for assessing the range of services offered by the home. The
Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 25 manager has ensured that all the requirements identified at the last inspection have been met. People spoken with reported on her approachability and supportiveness. Reviews of staff files shows that she has taken appropriate action, within Barchester Healthcare policies and procedures, to ensure improvements in individual member of staff’s performance when indicated. Barchester Healthcare has a system for reviewing quality of care. Residents are regularly surveyed for their opinions and the results made available. Where issues are identified, action is taken and the manager produces an improvement plan. The home also informs the parent company every month of key indicators, such as outbreaks of infections diseases or pressure ulcers. If matters are identified, the manager is asked to produce a report. The home also performs its own internal audits, for example, the manager regularly reviews response times when call bells are used. The audit showed that response times were nearly always under four minutes and on the few occasions when they were not, that appropriate action was taken to investigate reasons for slow response times. The home is visited regularly by a senior manager, who makes a report. These reports reflect the range of matters considered by this person and clearly identify if any actions are indicated. As part of Barchester’s policies, the home does not handle moneys for residents and all payments are by invoice. There are clear systems for monthly invoicing for services such as hairdressing or chiropody. All respondents have individual computerised accounts. All valuables handed in for safekeeping were correctly recorded. There are systems to ensure that staff are trained in areas relating to health and safety such as manual handling, fire safety and infection control. A range of training methods are used, including tutorials, taught sessions, distance learning and computer-aided learning. There is a comprehensive maintenance programme, to ensure that all equipment is regularly serviced and clear records are maintained by the maintenance man. Accidents are audited and there are three monthly health and safety committee meetings. Where residents need safety rails on their beds, the home has a standard assessment tool, which complies with advice from the Health and Safety Executive. These were generally completed in full. However for one person, this documentation had not been completed, although records showed that such rails had been placed on their bed about two months before the inspection. When inspected there were large gaps between the rails and bed sides, where the resident could have trapped a limb. This is a risk and ought to have been identified previously. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 3 3 x 3 x x x 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 3 Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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. Standard OP26 OP38 Regulation 13(3) 13(4)(a) (c) Requirement Timescale for action 31/07/07 All clinical waste must always be placed in bins which are not operated by hand. Where service users are provided 31/07/07 with bed safety rails, there must always be a full risk assessment performed, in accordance with company policy, for their use. Where risk is identified, appropriate action must always be taken to reduce risk. 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 OP1 Good Practice Recommendations The home’s statement of purpose should be revised to reflect that the home cares for persons who are terminally ill and how they ensure they can meet such persons’ needs. It should also detail the numbers and skill mix of staff available throughout the 24 hour period. Clear, measurable wording should always been used in
DS0000069227.V338091.R01.S.doc Version 5.2 Page 28 2. OP7 Milford House 3. 4. 5. 6. 7. 8. 9. OP7 OP7 OP7 OP8 OP22 OP22 OP26 service users’ documentation. All staff should consistently document care given in the same documentation. Where service users need thickening agent added to fluids, the actual amount needed by each individual resident should be documented. Responsibility for drawing up and evaluation of care plans should be delegated, to enable senior registered nurses to perform audit of care practice. Care plans relating to medical conditions such as diabetes should be drawn up in every case. Air cushions should be provided for service users who are at high risk of pressure damage, who wish to sit out of their beds for extended periods. Where air mattresses are provided, the service user’s weight should always be considered when setting the dial on the air mattress motor. All deteriorated safety rail protectors should be taken out of use. Milford House DS0000069227.V338091.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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
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