Inspection on 11/08/08 for Mill House

This inspection was carried out on 11th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mill House 04/06/10

Mill House 13/08/07

Mill House 31/08/06

Mill House 29/11/05

Mill House 21/04/05

Mill House 26/11/04

Mill House 07/07/04

Mill House 29/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Mill House 51 Mount Pleasant Bilston Wolverhampton West Midlands WV14 7LS Lead Inspector Bhag Jassal Unannounced Inspection 11th August 2008 09:15 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 Mill House DS0000030207.V369547.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. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mill House Address 51 Mount Pleasant Bilston Wolverhampton West Midlands WV14 7LS 01902 493436 01902 493436 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) Mr Ragavendrawo Ramdoo Mrs Bernadette Ameranmerion Ramdoo Janice Parker Care Home 24 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (24) of places Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th August 2007 Brief Description of the Service: Mill House care home is providing personal care and accommodation for 24 older people who have some form of Mental illness, but who are not in need of nursing care. The home is located on a main road with ease of access to the Bilston high street and all of its amenities. The home is a large detached two-storey building that was adapted as a residential care home in 2002. The accommodation consists of 24 single occupancy rooms with en suite and shower facilities with the exception of one bedroom without a shower facility. Communal facilities of sitting and dining areas are located on each floor. There is a quite room for people who use the service and a meeting room for visitors on the first floor. There are adequate communal toilets and assisted bathrooms facilities on each floor. There are gardens and a patio area at the rear of the building. There is ample car parking space at the rear of the building. The Registered Providers Mr Ragavendrawo Ramdoo and Mrs Bernadette Ramdoo have been operating this service since March 2002. The Registered Manager Mrs Janice Parker has been in post since May 2003. Mr and Mrs Ramdoo make their services known to prospective service users in The Statement of Purpose and Service Users’ Guide. The Inspection Report is mentioned in the Statement of Purpose and how a copy can be obtained. The care home rates are reviewed annually and service users are notified one month in advance. The only additional charges to service users are for hairdressing and chiropody. This is clearly laid out in the terms and conditions. Fees for Mill House as of 1st April 2008 are: £408.00 to £418.00. All service users pay monthly. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 Star. This means the people who use the service experience adequate quality outcomes. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 11th August 2007. This unannounced visit started at 9.15 am and lasted 7 hours and 45 minutes. The home had 21 places occupied and three beds remain vacant. The judgements made within this report are based upon information supplied by the home, and from interviews with staff, people who use the service and their relatives. During the course of inspection the assessments information and care plans were case tracked for 4 people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observation of care practices and interaction between staff and people using the service was also completed. Discussions took place with several members of staff and several people using the service and three visiting relatives were spoken to throughout the day of inspection. The Deputy Manager – Ms Linda Smith assisted in the inspection process until the Registered Manager – Mrs Janice Parker arrived at the home at midmorning and she remained present throughout the inspection process. All information received from the care home was considered and discussed with Mrs Parker. On this occasion all the key Standards of the National Minimum Standards were inspected. We received from the home Regulation 37 Notifications, concerns and complaints against the home, and Regulation 26 reports. In addition, we received an Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager on 5th August 2008, offering an overview of the home. All this information was considered and discussed with the Registered Manager. On site surveys were distributed during the inspection and completed by people living, working and visiting the home. The comments are included in this report. We wish to thank the Registered Manager, the staff, people who use the service and their relatives for their assistance and co-operation on the day of inspection. Mill House DS0000030207.V369547.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: Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 7 Those members of staff who as yet have not received mandatory training in safe working practice topics – for example, first–aid, food hygiene, infection control/COSHH, fire safety, health and safety, safe handling of medication, NVQ Level 2, and adult protection/safeguarding issues must do so as a matter of priority. This training would enable staff to improve further their care practices, knowledge and skills. Adequate staffing levels must be maintained at all times to ensure the delivery of ongoing good care for people using the service. The quality assurance monitoring systems must be appropriately implemented in order to ensure the feedback is sought from the service users, relatives, other stakeholders and visitors to home and action taken to improve the quality of service for people who use the service. There are two requirements related to the staffing levels and staff training at the home, which must be addressed promptly. 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. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 8 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 Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 9 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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mill House provides detailed and clear information to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Everyone receives full needs assessment prior to admission to the home to make sure that their needs can be met. EVIDENCE: Admissions are not made to the home until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self-funding and without a care management assessment, they always receive assessment by the Registered Manager. Four files/care plans of people who use the service were inspected, (including one service user admitted to the care home in late July 2008), which contained pre-admission assessments of their needs, both from assessments by the home and other relevant professionals, and initial risk assessments. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 10 Observations and discussions with people using the service, their visiting relatives, the Registered Manager and staff on duty indicated that the home continues to meet the needs of older people with mental health care needs in a satisfactory and sensitive manner. It was noted from the staff training records that 10 members of staff have received training in Dementia care needs. The Registered Manager stated that the remaining members of staff will receive this mode of training shortly. The home does not provide a service for those assessed and referred solely for intermediate care, who require help to maximise their independence and return home. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 11 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 and10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone who uses the service has an individual plan of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People using the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: People using the service undergo an assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Four care plans of people using the service were examined in detail. There was evidence to show that the short-term and long-term goals, aims and objectives were clearly identified and appropriate interventions required to put them into action to meet the individual needs of people using the service were also identified. The quality and details of daily care recordings have improved since the last inspection. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 12 Discussions with people who use the service showed that the home has a strong ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Information from the initial assessments had been written into the plan of care. The care plans are reviewed on a monthly basis by the Registered Manager and senior staff. Care plans demonstrated that staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Wherever possible continuity of care for the service users’ declining state of physical and mental health is assured. District nurses and CPNs are called upon to assist with clinical help, equipment and advice where necessary. The Registered Manager promotes the key worker system robustly so that relationships between key staff and individuals are enhanced. Visitors are able to meet people using the service in their bedrooms, in the lounges and visitors’ room on the first floor, which offers privacy when not being used. It was observed that people using the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. We spoke at some length with several people using the service and all of them commented positively about their care and they felt they have everything that they need. Six people who use the service stated that “the carers are very good and kind and they look after us very well”. Four other people using the service said “the carers are always there to help”. One visiting relative stated in the On-site Survey “the home provides good care to residents and promotes independence”, and further added “My wife is very happy, through the improvement of care and patience”. Another relative stated “ the home treated my sister well by the staff”. Generally people using the service appeared to be content, comfortable and happy. They were complimentary regarding the quality of their lives and the care they were receiving at Mill House care home. Discussions with the Registered Manager and the staff training records showed that all senior staff have completed their training in safe handling of medication. However, it is the home’s policy that only the senior members of staff would be responsible for the safe handling and administration of medication. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines have been given. Records seen included medication received, administered and leaving the home. It was also seen that the mobile medication trolley was securely and Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 13 safely stored after use in the Registered Manager’s office. The photographs of people using the service have been provided on medication sheets to avoid any risks of maladministration of medication. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are unable to exercise choice, because of lack of variety of social and recreational activities inside and outside of the home. Relatives and friends are encouraged and assisted to maintain contacts with people using the service. The food provided at Mill House is of good quality and choices are always available. EVIDENCE: The home provides an activities programme, which is limited in meeting everyone’s choices, preferences and capacities in relation to social, leisure and cultural interests. People using the service, who were able to give opinion, were complimentary about the activities provided, but added that there is lack of choice and variety. A record of activities participated in is not consistently kept but photographs of major events are displayed in the home. People using the service were seen sitting in the lounges chatting to staff and visitors and with each other. Three people using the service stated that they preferred to sometimes sit quietly in their bedrooms or in the quiet room on the first floor and the staff respected this. The home has a hairdressing room appropriately redecorated and equipped on the ground floor. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 15 Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. The people who use the service also keep contacts with the local community – for example, shops and park. Two visitors told us “the home provides a good service and staff are very caring and they are pleasant”. However, the records of social and leisure activities seen showed insufficient range and levels of activities provided for people using the service. Therefore, the home should consult with people using the service about as to what they would like the home to provide in terms of more outings and trips and/or a more varied programme of activities in the home. The AQAA completed by the Registered Manager states that “ We need to stimulate service users by offering a wider choice of activities and to encourage families to take part in activities with the service users”. The home’s improvement plans for the next 12 months are: • • • • To To To To provide more outside activities i.e. trips and outings, have more input from the families, continue with training to ensure good care is provided, and encourage service users with independence. The Registered Manager stated that the people using the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Registered Manager also stated that a close liaison is maintained with the relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of the Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people using the service told us “the food was very nice, well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was good and the home catered for those people using the service, who have individual preferences and medical needs. The Cook and the Registered Manager stated that the menu is changed on a regular basis in consultation with the people who use the service. The Registered Manager also stated that at next review a range of choices in the menu will be offered in accordance with the needs and requirements of people who use the service. The AQAA also states “our plans for improvement in the next 12 months is to ensure that our menus reflect the season – i.e. winter stews etc. summer salads and plenty of fresh fruit”. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 16 The kitchen is well equipped and kept clean and tidy. The catering staff are trained in food safety and hygiene matters. However, the First-Aid box needs checking and to be stocked with the required items and the disposable paper towel also needs to be provided in the kitchen. Mill House DS0000030207.V369547.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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a clear Complaints Procedure in place, a copy of which is made available to people who use the service and their relatives. This should ensure that any complaint made is listened to and acted upon. The home has an Adult Protection policy and procedure but formal training is required for all staff to ensure that people who use the service are appropriately protected from abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. The home’s records showed that the Commission for Social Care Inspection (CSCI) has not received any complaints about the care home. However, the home received one complaint and this was dealt with satisfactorily in accordance with the home’s complaints procedure. Two relatives of people using the service when asked were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff in-charge or the Manager. The Registered Manger stated that the home has not had to report any vulnerable adult protection issues. The home has good policy and procedure in place regarding restraint, dealing with aggressive behaviours and prevention of abuse, which includes a whistle blowing policy. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 18 However, the staff training records showed that four members of staff have received training in adult protection issues. The Registered Manager stated that the other members of staff who as yet have not undertaken this mode of training will do so shortly. People using the service were seen to speak easily to staff and were comfortable in their company. Several members of staff are trained in communicating with people with mental health and dementia care needs to ascertain their well- being. Mill House DS0000030207.V369547.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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained but needs some improvements to décor, fittings, furniture and safety matters. The home is clean and hygienic. EVIDENCE: A tour of the premises highlighted a number of issues that must be addressed to the internal environment. The Registered Manager stated that there is a planned programme for maintenance with timescales for specific jobs, including redecoration of bedrooms and communal areas and renewal of old furniture, fittings and floor covering. The AQAA states “ We have purchased a new washing machine/dryer, and now have two housekeepers to maintain a high standard of cleanliness and also have a full-time laundry assistant. W e also have a gardener on a fortnightly basis to ensure the gardens are kept tidy”. During our meetings with staff and three relatives who commented about the décor within the home and in particular the lounges and dining areas would Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 20 benefit from renewal. The carpets in the quite room and former smoke room on the first floor also need thorough cleaning/replacing. The home’s plan for improvement in the next 12 months is included in the AQAA - “Decoration is required within the home”. The self-closure mechanisms fitted on several bedroom doors and interconnecting doors should be checked regularly to ensure that they close properly to their rebate in the event of fire to ensure safety of people using the service. The majority of extractor fans in the bedroom en-suites were found to be not in working order and thus in need of repair/replacement. The hot water temperature in several bedrooms and bathrooms was found to be inconsistent and the temperature varied from 35 Degrees C to 41 Degrees C, which needs to be rectified promptly in order to ensure the people using the service enjoy a regular supply of hot water without the risk of scalding or not having the supply of sufficiently hot water at all. The home was found to be generally clean, tidy and free from any unpleasant odour. The home has good policies and procedures regarding infection control. It was noted from the staff training records that 9 members of staff have received training in infection control and those who have not yet received this mode of training must do so as a matter of priority. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 21 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff on duty on day and night shifts needs to be revised and improved sufficiently to meet the changing needs of people mental health problems/needs. The recruitment procedures have improved and now better protect people using the service from risks of employing unsuitable staff. The home continues to support staff to complete training, but not all staff are yet adequately trained to do their jobs. EVIDENCE: Information obtained through discussions with staff, the Registered Manager and the available staff rotas for the period of 21st July to 17th August 2008 on the day of inspection indicated that the home is not adequately staffed to fully meet the mental health care needs of 21 people currently using the service. It was noted that there are not always two carers on each floor. The Registered Manager or the Deputy Manager have to cover care duties in addition to their management duties. In case of emergency when additional member of staff is required to assist staff on both floors there is no floating member of staff available to assist and provide adequate care and supervision. The home employs a cook and two part-time cooks, two part-time cleaners and a laundry assistant to provide cover from Monday to Friday and thus the care staff are expected to provide cover for laundry at weekends in addition to their caring duties. It was also noted with some concern that there are only two night carers on duty at night instead of three. The Registered Manager stated that Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 22 currently there are vacancies of one night carer (35 hours per week) and two carers (35 hours per week each), which needs to be filled urgently. The Registered Manager’s hours should be in addition to the above required care and ancillary staff hours and supernumerary to allow Mrs Janice Parker to manage the care home effectively and efficiently. It was noted from the staff training records and discussions with staff and the Registered Manager that 7 members of staff have completed their NVQ Level 2 training and 4 members of staff also completed their NVQ Level 3. The Registered Manager stated that the remaining staff will undergo this mode of training shortly. It was also noted that a number of staff have undertaken their mandatory training in safe working practice topics. However, it was also clear that not all members of staff have received this mode of training. The Registered Manager stated that those members of staff who as yet have not undertaken training in safe working practice topics will do so shortly. They also will be nominated to undergo training in adult protection and safe guarding issues, dementia care, Mental Capacity Act 2005, mental health care, equality and diversity and behaviours that challenge. The home’s plan for improvement in the next 12 months is included in the AQAA - “To continue giving staff all training available relating to their job roles”. All new staff now receive their induction training in accordance with the Skills for Care standards and requirements. The staff confirmed that they are supported by the home for any training needs that they have. Since the last inspection, the home has operated an acceptable recruitment procedure. On inspecting four staff files, it was noted that now all staff are POVA and CRB checked. Two references are also obtained. There is evidence on file that staff receive statement of the terms and conditions of employment. There is now a staff training and development programme in place, which is being implemented. Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 23 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, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is trained and experienced to lead a team of staff. People who use the service can be assured that the home is run in their interests. Financial interests of people who use the service are safeguarded. The home generally promotes the health, safety and welfare of people using the service, but needs some further improvements. EVIDENCE: The Registered Manager – Mrs Janice Parker has completed her required qualification to meet the standards. She has achieved her NVQ Level 4 and RMA qualifications. Observations made and discussions with people who use the service, their relatives and staff indicated that the Registered Manager is very approachable and she operates an ‘open door’ policy. People using the service who could Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 24 express themselves stated that they are happy to approach the Manager and staff with any problems they might have and were confident that they would respond to them appropriately. Through discussions with the Registered Manager, she demonstrated that she is confident in her ability to lead a staff team whilst being fully aware of the individual needs of people using the service. Equality and diversity for people using the service were seen to be promoted throughout the home within the assessments, care plans, and activities. Equality for staff is promoted through the opportunities for training at all levels. Quality Assurance takes place throughout the service in both a formal and informal manner. Meetings, surveys, internal audits/checks, day to day contact, all provide records to show that the satisfaction of people who use the service is at the heart of the service. However, the questionnaires to people using the service and their relatives have been sent out in June 2007 to obtain their feedback on the quality of services and facilities provided by Mill House. The Registered Manager stated that she will analyse and prepare a report on the outcome of the feedback by the end of September 2007, and the report will be made available in the home and a copy to the CSCI. This report was not available in the home and for our inspection. The Registered Manager also stated that she was in the process of preparing the reports, including one for this year by the end of September 2008. The Registered Manager should also obtain feedback from other stakeholders and visitors to the home and analyse their response as well. In addition, the Registered Manager should consider developing systems for determining the views of people using the service with dementia/mental health needs/problems, who are unable to verbalise their needs. Financial records and administrative procedures relating to the handling of monies of four people who use the service were inspected and were found to be well ordered and maintained. The home has good health and safety policy and procedures, and staff were aware of their responsibilities regarding these issues and a number of staff have received training in these issues. Matters pertaining to fire safety and environmental health need to maintained to the required standards and all the outstanding issues identified in the recent inspection reports of the Fire Safety Officer, and the Environmental Health Officer should be addressed appropriately. All safety systems and equipment are regularly checked and well maintained and records of all tests/checks are kept up to date. However, the last test for legionnaires was undertaken in May 2007 and thus it should have been updated in May 2008. The safety test on wheelchairs were also due Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 25 to be undertaken. The Registered Manager stated that she will arrange with the appropriate contactors to undertake these tasks as a matter of priority. The staff training records indicated that there were many gaps in mandatory training for staff that includes fire safety, first aid, health and safety, moving and handling, infection control and food hygiene. The Registered Manager stated that the Registered Providers are aware of this deficiency and they both are taking appropriate steps to rectify this unsatisfactory situation shortly. Mill House DS0000030207.V369547.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 &16 Requirement Appropriate action must be taken to ensure that essential maintenance and repairs, such as those identified in this report are dealt with promptly. This is to ensure that people live in a comfortable and safe home. All staff must receive training appropriate to their work i.e. First-Aid Moving and Handling Health and Safety Fire Safety Infection control Food Hygiene Adult Protection/safeguarding issues A fully qualified member of staff in First-Aid on each shift – in order to ensure the safety of people using the service and protect them from harm, and ensure that first aid expertise is available on each shift (Previous timescale of 31/10/07 not met). There must be adequate numbers of staff on duty to meet service users’ needs at all times. DS0000030207.V369547.R01.S.doc Timescale for action 15/09/08 2. OP38 18 31/10/08 3. OP27 18 30/09/08 Mill House Version 5.2 Page 28 The Registered Providers must assess and identify safe staffing levels for the home and implement these. This is to ensure that there are sufficient staff on duty at all times to ensure that the care and support needs of people living at the home can be safely met at all times. 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 OP12 Good Practice Recommendations Records of all activities enjoyed by the people who use the service should be consistently maintained and also incorporated into the individual service user plans. The home should also consult with people who use the service about what they would like the home to provide in terms of a range of in-door and outdoor social and leisure activities. The Registered Manager should develop systems for determining the views of people using the service with Dementia/mental health needs/problems, who are unable to verbalise their needs. The Registered Manager should obtain feedback from stakeholders and visitors to the home on the quality of services and facilities provided to people who use the service, as part of the home’s Quality Assurance monitoring systems. The Registered Providers should consider providing staff training in Dementia care, mental illness/mental health care, Mental Capacity Act 2005, equality and diversity. 2. OP33 3. OP30 Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mill House DS0000030207.V369547.R01.S.doc Version 5.2 Page 30 - 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. 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