Inspection on 06/09/06 for Mill Green

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mill Green 09/03/07

Mill Green 15/09/05

Mill Green 04/05/05

Mill Green 21/07/04

Mill Green 13/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Mill Green Mill Green Mill Lane Felbridge East Grinstead West Sussex RH19 2PF Lead Inspector Vera Bulbeck Unannounced Inspection 6th September 2006 10:00 Mill Green DS0000013721.V311127.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 Mill Green DS0000013721.V311127.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. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mill Green 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) Mill Green Mill Lane Felbridge East Grinstead West Sussex RH19 2PF 01342 326105 Ashcroft Care Services Ltd To be confirmed. Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of persons for whom residential accommodation with both board and personal care is provided at any one time shall not exceed Six (6). The age/age range of the persons to be accommodated will be: 19 60 Years 15th September 2005 Date of last inspection Brief Description of the Service: Mill Green is a large detached house located in a quiet residential area in the village of Felbridge, East Grinstead. The home is registered to provide personal care for six younger adults with learning disabilities and is owned by Ashcroft Care Services Ltd, who own a number of care homes in the South East. The accommodation comprises of six single bedrooms, two sitting rooms, a kitchen/dining room, a utility room, toilets, and two bathrooms. The home has a large enclosed garden for the service users to enjoy, and ample parking in the front of the home. East Grinstead town centre is a short distance by car, and provides a good range of shopping and leisure facilities. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit to be undertaken by the Commission for Social Care Inspection as part of a key inspection. Mrs Vera Bulbeck, Regulation Inspector, carried out the inspection. The acting manager Ms J O’Brien for the home was present. The inspection took 7 hours 20 minutes commencing at 10.10am and finishing at 17.30. There are currently six service users living in the home, five service users have lived in the home for some time and one service user moved into the home within the last year. All six-service users were in the home on the day of the site visit at various times of the day. The inspector was able to speak with all of the service users during this time. Five service users are under the age of sixty years and the service users are mobile and able to undertake small jobs around the home. The four members of staff on duty on the day of the site visit were spoken to and one member of staff commented the home is operating an open management style and the staff team feel supported and work together as a stable team. However, the inspector was also informed staff morale is very low. The inspector was informed part of the problem lies with the many changes in the management of the home. A number of comment cards were sent to relatives at the time of the inspection to obtain their views regarding the service. A relative was spoken too on the day of the site visit and she confirmed that the current staff are very good. However, it has been necessary to discuss with the management of the home issues of concern and these issues have been addressed. Service users would not be able to complete comment cards even with staff support, as communication is difficult. However, staff has a good understanding of the service users and their needs. This is by talking, listening, body language and facial expression. A full tour of the premises was undertaken. Two care plans and two staff files were inspected. The fees range from £1249.66 per week to £1480.93 per week. The inspector would like to thank the service users and staff members for their time, assistance and hospitality during the inspection. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The management of the home need to ensure any requirements made must be addressed within the timescales given. If for any reason these are not achievable the provider must contact the Commission for Social Care Inspection (CSCI) to advise the reason for non-compliance. There were six requirements made at the time of the last inspection dated 15th September 2005. Three requirements were met and three requirements remain outstanding. There were also four recommendations made of good practice and four of these are still outstanding. A number of areas around the home are in need of attention in relation to the environment. The management of the home need to undertake a regular audit Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 7 of the premises to ensure all areas in the home are well maintained, equipment is working and that the environment is safe for service users. The acting manager is fully involved in the care and support provided to service users in addition to the management duties. The acting manager has been in post for a short time and is in the process of making a number of changes to the home. The acting manager is currently trying to work on the floor as well as undertake management duties. There are a number of areas that need addressing, as a matter of priority and therefore the acting manager must have more time to undertake management duties, and to address the areas, which fall short of meeting the required standards. The home has been operating without a registered manager for some considerable time. This has been partially because of the appointed manager registered being on maternity leave and more recently being dismissed from the home. The Registered Provider must ensure a manager is in post and must be registered with the Commission for Social Care Inspection (CSCI) within three months by 24th December 2006. 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. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 8 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 Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The records of the pre assessment of the last service user to enter the home were not available. EVIDENCE: The manager informed the inspector, the Behaviour Manager of Ashcroft Care Services Ltd undertakes the pre assessment for any new service user. However, there was no record of the last service user who entered the home having had a full needs pre assessment. There are currently no vacancies in the home but the placing of a new service user needs careful consideration, as the current service users are two age groups. There are three relatively young adults who are very mobile, and three service users who have mobility problems and two service users require a wheelchair when going out. Discussion with staff that two-service users walk very quickly around the home and observations made by the inspector it was noted one service user was worried by the quick movements of another service user. Therefore the inspector noted that the quick movements could be a potential risk for three of the service users being knocked over accidentally. The inspector was informed that one service users placement is under review. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 10 It was noted in one of the service users file that a number of risk assessments have been undertaken and some were in need of updating and signing. Documents are sent to head office for typing as the home is without the use of a computer. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 11 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 and 9. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The service users’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and include risk assessments. The staff are in the process of updating the care plans and risk assessments. EVIDENCE: Staff stated that service users are supported to make decisions affecting their lives in a number of ways. Each service user has an allocated key worker, who is trained to offer one to one support and who knows the service user well and understands his or her needs. This was observed at the time of the site visit. The majority of service users are unable to verbally communicate apart from one service user. Staff are experienced in communicating with the service users in a manner of ways, by talking, listening, body language and facial expression. Discussion with the staff members and comments made for example they know and understand the service users needs and actions, by body language and expression. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 12 Service users individual choices of meals were recorded on their weekly menu plan. Staff advised that information is provided to service users to assist with decision-making and this is in a format to suit their individual needs. All service users are involved with their care planning and should sign to indicate they agree with their care plan or a relative should sign. All service users who are unable to hold a key to their bedroom, information should be clearly documented in their care plans and should include the reasons for not holding a key. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that service users’ rights are respected. EVIDENCE: The acting manager and staff team are committed to providing a safe and homely environment for service users. Service users are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by the use of listening, sign and body language. The manager informed the inspector that questionnaires have been implemented and sent out to families on a yearly basis. There is a plan to send out questionnaires once again to families and friends. Staff stated that they actively encourage and support service users to be independent, to make Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 14 their own choices and to live their lives as they wish, as far as they are able. It was pleasing to note that service users and staff have a good rapport, service users were engaging with staff and it was very clear that staff have a good understanding of the service users needs. Household routines are kept to a minimum and are only in place to enable service users to share their home’s facilities and to maintain harmony within the household. It was observed, that staff knock before entering service users bedrooms and that personal care is offered discreetly. Service users are addressed in the way that they prefer and this is recorded in their individual plan. The acting manager informed the inspector that the weekly menu works well for the home and the majority of staff have completed a food hygiene course except for two staff members. Management of the home were advised that only staff that has completed the food hygiene training should be undertaking the cooking. A dietician is involved with one service user, who is not able to eat some foods, and has offered advice for the other service users and can be contacted when necessary. It was noted that the meat probe recording has been undertaken on a regular basis. All the service users go out on a daily basis, therefore the main meal is suppertime. The manager informed the inspector that various trips are organised, these include swimming, shopping, pub lunches and trips to the seaside. One service users goes to Church every Sunday with a member of staff. At the time of the site visit the inspector was informed that the annual holiday for two service users was scheduled to coincide with work to be carried out on the walk in shower room scheduled for 23/10/06. However, a number of day trips had been undertaken to various places including Littlehampton and picnics in Ashdown Forest. Ashcroft Care Services Ltd contributes £100.00 towards each service users holiday and the service user pays the balance including for a member of staff to accompany the service users. The home has a seven-seater vehicle, which is used on a daily basis, transporting service users to various locations including one service user who will be going back to college. The home has the use of a car, which is shared between two homes. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Personal support is provided appropriately and service users healthcare needs are well met. EVIDENCE: From the tour of the premises, it was clear that service users are provided with a variety of aids and equipment to assist with their independence. The inspector was informed service users are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. The manager stated that the administration of medication is carried out by A nominated, “key holder”, member of staff. These members of staff are detailed on a daily handover sheet, which specifies the staffing arrangements for each shift. It was noted that four service users have their medication tablets given on a spoon with jam. This practice has been in place for some considerable time. However, the inspector has contacted the pharmacy inspector to advise the management of the home the correct procedure for administering medication for those service users who find it difficult to swallow. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 16 From the individual plans and speaking to staff, it was evident that a number of healthcare professionals are involved in the support of the service users. These include general practitioners (G.P.), chiropodists, opticians, dentists and hospital specialists. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Policies are in place to protect service users from abuse and neglect. However, the policy and procedures need to be updated. EVIDENCE: The majority of staff except four has attended the safeguarding of vulnerable adults training the training has been arranged for two staff and a further two staff when the next course is available. When staff spoken to by the inspector it was clear that staff are aware of the whistle blowing policy. Service users and relatives should be provided with a copy of the complaints procedure. To enable service users to be clear of the procedure of making a complaint, the complaints procedure is available in picture form. The policies and procedures need updating. There were records of complaints received in the home; the acting manager informed the inspector the complaints have been dealt with, appropriate letters were seen on file. However, discussion with a relative stated she had found it necessary to make a recent complaint to the management of the home. The complaint was regarding the state of her son’s clothes. The complainant had made arrangements with the acting manager to go shopping to buy clothes for her son. There were no records available indicating that a complaint had been logged. The acting manager stated she was aware and would record the complaint as arrangements had been made with the relative and the problem had already been addressed on the day of the inspection. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 18 Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose EVIDENCE: The home is accessible, safe and generally well maintained. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. However, the kitchen is a number of years old and looking very tired and needs replacing. A drawer was seen to be broken. The kitchen is spacious and also used as a dining area. The lounge is a good size and comfortable for the service users to enjoy the surroundings. The radiator needs repairing or replacing as it was found to have the grill on the top broken and not fitting the casing of the radiator, as well as some evidence of rust. The use of a freestanding heater would indicate the heating in the lounge was not adequate or not working sufficiently at the time of the inspection. The use of free standing radiator can be a potential hazard to service users, particularly with trailing wires and the possibility of a service user getting burnt on the hot surface. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 20 Other areas around the home that require attention: Curtains were seen to be hanging off rails; the airing cupboard needs a lock. A chest of drawers was found to have a missing drawer, an armchair needs replacing and the carpet was badly stained in a service users bedroom. The carpet in the lounge was also badly stained and torn. In another service users bedroom it was noted that the sash cord had broken in the window and a restrictor needs to be fitted. One service user was without a headboard for her bed and the bedroom was in need of decorating. The majority of radiators are without protective covers, the management of the home to consider the health and safety of service users if the radiators are of low surface temperature radiators. The down stairs bathroom/shower room will be changed to a wet room to enable staff to assist service users who require support when showering. This was discussed with staff at the time of the site visit. Work is to commence in October 2006. The bathrooms and toilets need to be adequately equipped with toilet roll holders and toilet rolls. The inspector was informed the reason for this is because of a service user blocking the toilets. This practice must be addressed and a solution to the problem be rectified, it is not acceptable for service users and staff not to have the use of toilet paper and hand washing facilities. All communal areas should have paper hand towels; this is a health and safety requirement. The inspector appreciates that service users have challenging behaviour an observation made at the time of the site visit and this is reflected in the environment of the home. The garden is nicely laid out and service users are able to enjoy the garden, as observed on the day of the site visit. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 21 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): 34 and 35. Quality in this outcome area is POOR. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and service users evidenced a high degree of respect and skill in working with the individual service user at the home. Recruitment procedures must be followed at all times. EVIDENCE: The acting manager stated and staff confirmed, that supervision of staff has taken place. On the day of the site visit the staff files checked were without a criminal record bureau check (CRB). However, the acting manger did mention that records are held centrally; hence it was not possible to verify. There were no references or application forms available on staff files checked. Recruitment procedures need to be followed at all times as detailed in Schedule 2 of the Care Homes Regulations 2001. Staff spoken to on the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Verbal and written communication between staff was good and evidence was found in the handover book, cleaning rotas and communication book. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 22 The inspector appreciates that Ashcroft Care Services has a comprehensive induction package that all employers are required to complete. However, discussion with a relative indicated staff could benefit from further training in particular to specific training needs of some of the service users at Mill Green as well as taking into consideration diversity issues. There are a few staff that requires more training identified on the training plan. Staff training certificates should be available for inspection and copies should be kept on file. All staff should receive a copy of the General Social Council of Care, code of conduct document. The current staffing levels are four staff on duty throughout the day staff undertakes the cleaning, shopping, cooking and laundry duties. At night there is one waking night staff and one sleeping member of staff. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The systems in place for service users consultation are varied and have been devised specifically to enable the service users to make their views known in a manner of ways. EVIDENCE: The home is currently operating with an acting manager and being overseen and supported by a registered manager from another home. The registered manager has left the service and a new manager to be appointed. The inspector was informed that interviews are in process and a manager will hopefully be in post within the next three months. The new manager must apply for registration when appointed. All notifications must be sent to the Commission for Social Care Inspection (CSCI) within 24 hours. It was noted that a number of notifications have not been sent to CSCI as required since the last inspection dated 15/09/05. At the Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 24 time of the inspection it was noted that a total of 21 accidents/incidents were recorded with only three having been notified under Regulation 37 notices, this was up to 06/09/06. However, discussion with the acting manager lacks clarity of whether the missing Regulation 37 notices had been sent to the Commission for Social Care Inspection (CSCI). A number of records were checked and it was noted the majority are well documented and kept up to date. Management of the home needs to implement an emergency contingency plan and a copy of the plan to be held in the fire/health and safety folder. Relevant policies and procedures for health, safety and welfare of service users were in place and a number need to be updated. Systems existed to demonstrate these had been communicated to staff. Also those of relevance to service users had been shared with them. The majority of staff has received training in First Aid, Food Hygiene and other aspects of Health and Safety. Service users finances were not checked on this occasion as this area is currently under investigation. The inspector was informed the petty cash money is counted and signed for at each shift change. All money held in the home is audited on a monthly basis. The monthly visit to the home has been delegated by the Responsible Individual and is undertaken by a service manager or a registered manager from one of the other homes in the group of Ashcroft Care Services Ltd. Copies of the report were seen on file. Copies of these reports were requested to be sent to the Commission for Social Care Inspection (CSCI) on a monthly basis. This has been agreed by Ashcroft Care Services, (CSCI) are currently receiving these reports. The storage cupboard needs to be upgraded due to the fact of heavy wear and tear. The home to consider, under the present circumstances all food, needs to be in sealed containers. Potatoes need to be stored off the floor The COSHH cupboard in the laundry was not locked and a number of hazardous cleaning materials were inside. It was noted that the lock on one side of the cupboard was broken. It was also noted that the cupboard under the kitchen sink containing hazardous cleaning materials was not locked. This cupboard was locked at the time of informing the acting manager. A letter of serious concern has been sent to the Registered Responsible Individual for immediate action to be taken. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 25 Mill Green DS0000013721.V311127.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 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 X 2 2 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 1 35 2 36 X 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 2 X X 1 X Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 18 Requirement The manager must ensure that all staff has appropriate training in the protection of vulnerable adults procedures. (Timescale 15/09/05 not met). All staff files must be in accordance with the Care Homes Regulations 2001 Schedule 2. (Timescale 15/10/05 not met). A pre assessment must be undertaken on all perspective service users and must be kept in the home. The kitchen needs a re-vamp. Rusty radiator needs repairing or replacing. Trailing wires from freestanding heater need securing and a cover required for the heater. Carpets badly stained in service users bedrooms need deep cleaning or replacing. The lounge carpet is badly stained and torn needs attention. Headboard required for a service users bed. A service users bedroom window has a broken sash cord and must have a restrictor fitted. The walk in shower room must DS0000013721.V311127.R01.S.doc Timescale for action 13/10/06 2 YA34 7, 9, 19 13/10/06 3 YA2 12 13/10/06 4 5 6 7 8 9 10 11 Mill Green YA24 YA24 YA24 YA24 YA24 YA24 YA24 YA24 16 16 13 16 16 16 16 16 30/03/07 27/10/06 13/10/06 13/10/06 27/10/06 13/10/06 13/10/06 27/10/06 Page 28 Version 5.2 to be completed. 12 13 14 15 YA24 YA30 16 13 13 19 A service users bedroom needs decorating. All hand washing communal areas must have paper hand towels. All toilets must be fitted with a toilet roll holder and toilets rolls. The General Social Council and Care, code of conduct guidelines must be provided to all staff. (Carried forward from previous inspection) All staff must receive Equal opportunities training. (Carried forward from the previous inspection). A Registered Manager for Mill Green must be in post within 3 months. Notifications Regulation 37 to be sent to CSCI within 24 hours. To implement an emergency contingency plan. Dried food must be stored in sealed containers. The storage cupboard in the kitchen needs attention. 27/10/06 27/10/06 29/09/06 13/10/06 YA30 YA34 16 YA35 18 17/10/06 17 18 19 20 21 YA39 YA39 YA42 YA42 YA42 8 37 13 16 23 24/12/06 06/09/06 29/09/06 29/09/06 29/09/06 Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 29 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 3 4 Refer to Standard YA24 YA28 YA39 YA42 Good Practice Recommendations The service users wishes with regard to illness and death should be recorded on their care plan. (Carried forward from previous inspection). A risk assessment should be carried out on the staff sleeping-in room/office. (Carried forward from previous inspection). Policies and procedures need updating. Management to consider radiator covers being fitted. Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Mill Green DS0000013721.V311127.R01.S.doc Version 5.2 Page 31 - 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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