Inspection on 08/11/05 for Mill House

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mill House 07/06/07

Mill House 07/06/06

Mill House 25/05/05

Mill House 04/10/04

Mill House 06/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mill House 15 Mill Road Gt. Ryburgh Fakenham Norfolk NR21 0ED Lead Inspector Mrs Dorothy Binns Announced Inspection 8th November 2005 09:30 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 DS0000015661.V254764.R01.S.doc Version 5.0 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 DS0000015661.V254764.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mill House Address 15 Mill Road Gt. Ryburgh Fakenham Norfolk NR21 0ED 01328 829323 01328 829554 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) Prime Life Limited Mrs Thandiwe Ziro Care Home 44 Category(ies) of Dementia - over 65 years of age (44), Old age, registration, with number not falling within any other category (44) of places Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No Service Users who need to use a wheelchair are to be accommodated in rooms 22, 23, 24 and 25. 25th May 2005 Date of last inspection Brief Description of the Service: Mill House accommodates 44 service users in a large extended country house. The main house is on two floors, with a single storey extension. Nine terraced bungalows also provide semi independent accommodation comprising, bedroom, sitting room and kitchen and a bathroom. The Home provides personal care to older people who are mentally frail except for those service users admitted to the bungalows. A new manager was recruited in April 2005.The Home is situated in a rural position at the end of a country lane in the village of Gt Ryburgh and overlooking the river. Most of the rooms are single and several have lovely views. The Home has a large garden and patio which has recently been redesigned and made safe. There is a bus service to Fakenham from the village. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine announced inspection lasting eight hours. Discussions were held with the manager about the progress of the Home and how the requirements of the last inspection had been met. Policies and records were examined. In addition seven service users were seen in private and three staff were interviewed. Some of the premises were toured. The Commission also sent out survey forms to be distributed by the Home to the service users and their relatives. Fifteen service users and seven relatives returned the form and their views have been taken into account in this report. The GP and district nurses attending the home were also surveyed for their views. What the service does well: The new manager who inherited staffing and other difficulties in the Home, is continuing to make positive changes in the service offered and is taking the staff group with her. There are still things to do but good progress is being made. Although staff have a lot to do and there is a question about the numbers of staff, service users think the staff are good and treat them well. They also speak well of the manager and feel she will listen to them. There is good documentation in the Home ensuring staff and service users are protected. Medication is dealt with properly and safely. Health and safety policies and training are in place. The recruitment of staff is rigorous ensuring service users have good people to look after them and staff are well supported by training and meetings with their manager. The food is good and varied and service users enjoy it. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 7 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 DS0000015661.V254764.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 A needs assessment is carried out on all service users entering the home to make sure they can be properly looked after. EVIDENCE: Sample care records were read and found to contain a detailed assessment document outlining the needs and abilities of the service users. All aspects of health and social care were covered allowing staff to have plenty of information to assist the service users appropriately. Where a service user had been admitted with the help of social services then information was also provided by that agency. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The service user’s health and personal care needs are well set out in an individual care plan providing staff with the information they need to care appropriately for the service users. The home has much improved systems in place for ensuring that service users’ health is monitored and attended to. Improvements need to continue however especially in regard to liaison and cooperation with the community nurses. Procedures are in place to ensure that service users are assisted safely with medication. Service users feel their privacy is respected and they are treated well by staff but there are improvements to be made in how personal care is delivered to the male service users. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 10 EVIDENCE: The care plans of four service users were examined. As stated earlier, a full assessment is carried out on each service user and the care plans were developed from this information. The plans were clear and detailed about how staff were to assist the service users and covered all areas of personal care and mobility. Where there were specific areas of assistance required, this was noted, for instance the cleaning of glasses. Another care plan showed how staff were to assist with feeding. Plans were reviewed on a regular basis to ensure that they were still appropriate. In addition staff write good daily reports on each service user including how they were during the night and what kind of day they have had. Problems are noted with actions taken but also whether service users have enjoyed any activities or visitors. A personal hygiene chart is also used where staff have to assist with washing and bathing and accidents were cross referenced to the accident book and found to be satisfactorily recorded. Risk assessments were in place for specific areas. Overall these records are very good with helpful information and clear recording. From the records provided, the evidence showed that service users had good access to doctors and community health professionals when that service was required. On the files seen, doctors’ visits were recorded, hospital appointments were shown, eyes were tested and district nurses visited for specific tasks. Access to NHS entitlements like flu jabs was also recorded and it was confirmed by the manager that all the service users had been offered this facility. The monitoring of weight and whether someone ate well was also recorded and chiropody and nail cutting was also mentioned. A pressure sore chart was seen for one person, monitored by the district nurse. In the past there was concern that liaison with the GPs and nurses was not good enough and that medical attention was not requested as consistently as it should have been. There has been a great improvement in this with the new manager. Staff confirmed that they felt able to report to the senior worker any worries with a service user and the senior would call a doctor. They felt this was an area which had improved and that the system of communication was better. To this aim, all staff attend a handover meeting (with the previous shift) when coming on shift to ensure they know what is happening with each service user. The manager also visits every service user when she comes on duty. There is therefore much more oversight of the service users. The GP returned a survey form recording improvements in this area. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 11 There was still a problem recorded by the district nurses (evidence from the survey form received by the Commission from them) in the way they viewed how the staff carried out their instructions and dealt with them. They had experienced difficulties and wondered whether there was a shortage of staff as they were rushed and too busy to help. The manager was able to provide explanations about some of the examples and say what actions had been taken. Some matters had been misinterpreted and some things had been taken up and already dealt with by the manager. A recommendation has been made to address the issues with the nurses direct and look into any deficiencies with staff practice in order to ensure the best care for the service users. The medication records were examined and found to be correctly completed. A drugs round was briefly observed with the staff member following the correct procedure. Recent training on the administration of medication has been provided. Fourteen out of fifteen of the service users returning the survey forms reported that they were treated well by staff and their privacy was respected. Six spoken to in the inspection also echoed this view. Those service users in the bungalows obviously have their own lounges to enjoy but others in the main house also said they could sit in their room when they liked, see their visitors in private and were assisted by staff in private. The personal care of the service users was provided with courtesy and kindness and service users had no complaints about the staff. One area for improvement though was in the shaving of the men. One man complained bitterly about not having his own shaver although the Home were looking into this. However the inspector noticed that several of the male service users were unshaven or shaved unsatisfactorily. One service user said he was helped with shaving but it was not done very well, another said he was shaved only every two days. One service user was seen being shaved in the sitting room by staff which was not the best location. Overall how the men are attended to needs to be reviewed, whether this involves staff training or the allocation of tasks, the manager needs to investigate. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 On the whole service users were quite happy with the way the home was run and they felt their preferences were taken into account. More needs to be done however on satisfying their recreational needs. Where possible, service users stay in control of their own affairs but often need the help of their relatives or the Home. Service users receive a good diet and in general had no complaints about the food. Some issues regarding timing of meals and evening drinks should be reviewed. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 13 EVIDENCE: The routines of the Home were felt to be quite flexible by the service users with times for going to bed and getting up when the service users wanted. Staff said they knew which service users to help first in the mornings as some were early risers. Bathing was usually offered once a week but service users felt they could have more if they wanted. Usually service users eat together in the dining rooms and found the timing of meals acceptable. Four service users who need assistance with their food however were given their main meal at 11.30am because staff said they would not be ready for the main meal for all the other service users unless they started early. This should be reviewed to ensure that even very dependent service users are given a choice and enabled to keep to a normal routine. Those who were able to be interviewed were quite happy with the way things were run and made comments like” I’m quite happy here”, “ this is a lovely home – I have no regrets at all” and “Staff are very courteous”. Regarding opportunities for stimulation, there was a mixed response with two service users seen saying they enjoyed several different kinds of activities like outings, games and bingo, whilst another did not think there were many activities. One person preferred his own company and did not want to join in. The survey forms returned to the Commission showed that about 50 of service users thought there were suitable activities. The home has made some progress on the amount of activities provided such as reminiscence sessions, outings twice a month and a regular piano player coming in but clearly there is still room for improvement, not only on the provision but on making them accessible. In terms of service users being able to exercise control over their lives, many are frail mentally and depend on their relatives to look after their affairs. The Home helps with looking after some personal money only. Service users are able to bring in their own personal possessions to make their rooms familiar. The menus for the Home were available for inspection and confirmed that food was varied and a choice was offered to the service users. Twelve of the fifteen surveys received back from the service users said they liked the food and those seen during the inspection also liked the food. There was a query about whether evening drinks were being offered with three service users saying they did not receive them. This needs to be looked into with the staff. As mentioned earlier, service users who need assistance at mealtimes were seen to be having their main meal at an early time but those who could eat in the dining room were happy with the times of meals. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Procedures are in place for complaints to be dealt but less formal complaints and what is done about them should also be recorded. EVIDENCE: The complaints procedure is in the service users guide and posted up in the home. A record of formal complaints is kept with details of the actions taken. However more informal complaints from service users are not recorded though do happen. One service user mentioned having to ask four times before being listened to. If a recording of all complaints is made with staff being instructed to refer on what service users complain of, then it is easier to see where the problems lie and to see whether the matter was taken seriously. This will give confidence to service users and emphasises to staff that the service user is at the heart of things. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24 and 25 The Home is in a lovely setting but there are discrepancies in the standard of décor and facilities in the building which need to be addressed. Communal space is varied and is brighter than it was. However improvements are still needed. Individual accommodation is on the whole very attractive, homely and comfortable. Most rooms are a good size. Some facilities lack locks and locked facilities would give service users more privacy. Lighting and heating and ventilation are all satisfactory but covers for radiators are required to keep service users safe. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 16 EVIDENCE: The rural location of the building is idyllic with river views and a well laid out patio and garden. It is connected to the village by a country lane which is not very accessible for the service users, having no path. The home is in three parts with a main house and extension and a separate set of terraced bungalows not joined to the main house. The bungalows are new and are built and decorated to a high standard. They have their own kitchens and bathrooms and service users can be private and self contained. However current service users need some assistance from staff and also come to the main building for their meals and entertainment. One comes to the main building for a bath. This does mean that in cold or rainy weather service users and staff are unprotected moving between the two buildings. The extension is single storey and has lovely single mainly en suite rooms. The main part is older and on two floors connected by a shaft lift. In this building, there have been efforts by the manager to brighten up the Home with pictures and plants to make it homely and friendly. It is improved but the paintwork is poor in places and needs redecoration. Hot radiators are also unprotected and need to be covered to prevent service users falling against them and burning. Bathrooms are adapted for older people and there are handrails to help them get about. A call bell is in every room. The communal space is varied though small in area for 44 service users. It consists of three sitting rooms, one with a dining area, a separate dining room in the main house which seats 16, and a small conservatory used by the smokers. The bungalows each have their own sitting rooms which make them very attractive for those service users. However they also come into the main house to sit. The rooms have recently been brightened up and made more homely with pictures and magazines and colourful chairs. The manager said that one of the sitting rooms which was hardly ever used is now opened up (seen at the inspection with two service users sitting in there) and is used for activities. The sitting room in the main house continues to look bare with no carpet on the floor. Only some of the bedrooms were viewed but in general individual accommodation is good and most rooms are of a good size. Those in the extension all have en suite facilities and the bungalows have their own bathrooms with shower. Many rooms have good views. All rooms are currently used a singles. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 17 In terms of fixtures and fittings, electrical fittings and television points are available and furniture is satisfactory, some service users bringing in their own furniture. All service users seen reported that their bed was comfortable. Apart from the bungalows, most of the doors are not fitted with a lock. These should be provided for those who are able to use that facility. Similarly no locked cupboards are provided to enable service users to keep their valuables or money safe. Recommendations have been made. Accommodation was warm and service users could open their windows. Radiators seen had thermostats that were adjustable. Some low surface temperature radiators are provided but others are without covers and were hot to touch and in a location that could be unsafe for the service users. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The ratio of care staff to service users is not being determined according to the assessed needs of the service users and care is being affected as a result. Training has not been as available as it should have been but more staff have now been offered the opportunity to complete a national care certificate. This will promote better practice in the Home. Recruitment procedures are rigorous protecting the service users. One omission has been pointed out. Staff are trained when they first start their job and this equips them to understand the assessed needs of the service users. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 19 EVIDENCE: There was evidence from several fronts that staffing was not meeting the needs of the service users. Five out of seven replies from the relatives felt that there were not sufficient numbers of staff on duty. Three of those felt the staff needed more time for personal contact with the service users. The district nurses who had issues with the staff felt that they were too busy and worked too long hours. The staff seen by the inspector all reported that they were very busy and did not have time to attend to service users as they wanted. Two staff were seen at the inspection feeding dinner to two service users at 11.30a.m. which seemed to be far too early. When questioned the staff said that if they did not start to feed the four service users who needed such help at this time, it would delay the dinner for the rest of the service users. This is not satisfactory. The inspector was also told that the service users in the bungalows could only be attended to after everyone else was seen to in the main house as it put remaining staff under a strain if one staff left the building to go to the bungalows. The inspector also observed nearly every male service user not properly shaved which could indicate they are done in a rush or staff are not able to offer a daily facility. In the information provided for the inspection, all 35 service users have some dementia, and 28 need help with washing and dressing. Seven need two staff to help them. Other information was provided which highlighted the dependency levels of the service users. The geography of the building also makes demands on staff time as it is spread out and attending to people in the bungalows necessitates staff moving out of doors. All of the above point to the staffing not being determined according to the assessed needs of the service users and a review of staffing is urgently required. Only two care staff have achieved their NVQ2 but seven are about to start studying for their qualification. Two staff are taking a break from medical school training so have relevant experience. The Home is currently not meeting the standard on training of 50 trained staff by 2005 but recent efforts will help the home to be closer to the standard in the next year. Staff files were chosen at random to see what recruitment processes were used. All contained a criminal records check and references and identity documents. A medical declaration was made regarding fitness and all staff were given contracts. The only missing document was a photograph of each staff. In two of the files chosen there had been difficulty obtaining references and further action had had to be taken. All turned out well in the end but a contact sheet outlining the process of any change of reference or phone call about a reference would be helpful and a recommendation has been made. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 20 Induction and foundation training workbooks were seen for new staff. In the past the induction training was not completed in the first 6 weeks but this is now being attended to by the manager who does the training herself. Other in house training is offered to staff though attendance at outside courses is rare and staff have to do in their own time. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,36,37 and 38 Service users live in a home with a manager who is fit to be in charge and is discharging her duties very well. Her management approach is leading the home into better practice and although there is still work to be done, her character and commitment are turning the home around. The home looks after the service users’ money safely with correct procedures. Staff are receiving one to one supervision which helps them discuss and improve their practice. Record keeping is good and this ensures that the service users are protected and staff accountable. Health and safety procedures are in place and training is provided to ensure that the home is safe for service users and staff. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 22 EVIDENCE: The current manager has only been in post since April and is a qualified nurse with management experience. She is studying for her NVQ4 management qualification and is nearly finished. She is familiar with the conditions associated with old age and undertakes periodic training to update her skills. Recently she undertook training on reminiscence therapy and on the protection of vulnerable adults. The manager has guidance and support from managers at head office. The manager took over the home at a time of turbulence with staffing difficulties and complaints about practices. She has had to work hard to communicate a clear sense of direction but staff seen at the inspection felt they were on the road of recovery and better systems were now in place to provide a better standard of care. More communication channels have been opened with handover meetings, staff meetings, more accessibility to relatives and more supervision of staff. Resident meetings are also held (minutes seen). A commitment to a high standard of care is communicated and staff are aware of it. There is still some way to go as can be seen from parts of this report but praise should be given for the improvements so far and her willingness to confront the difficulties. The financial records were checked for those service users who have their money looked after by the home. No benefits are collected. The money deposited with the home usually comes from relatives or solicitors to buy personal items for the service user. Two records were chosen at random and found to be correct when the records were cross referenced against the cash held and the receipts. Staff confirmed that they received supervision sessions with the manager or a senior staff member and were able to discuss issues of their practice and their training needs on a regular one to one basis. Records required for regulation were seen to be in place. Records are kept safely and the Home conforms to the Data Protection Act. In terms of health and safety, staff are instructed on safe working practices in terms of fire, moving and handling, first aid and food handling as seen in the staff records. There are also detailed procedures for dealing with safety issues eg for control of infection and COSHH. Electrical and gas systems are serviced regularly and water temperatures are controlled to prevent scalding. The lift service certificate was seen to be up to date. Fire drills are held regularly and the system is checked regularly. Fire alarms are tested but need to be carried out weekly. Accidents are recorded and risk assessments are carried out. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 23 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 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x 2 2 x x 3 2 2 x STAFFING Standard No Score 27 2 28 1 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x 3 3 3 3 Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 24 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 Standard OP10 Regulation 12(4) Requirement The registered person must make arrangements to ensure that the dignity of the service users is respected. In this instance, the male service users should be better shaved. The risks from hot unguarded radiators must be identified and eliminated so far as possible. The registered person must ensure that the numbers of staff on duty adequately meet the individual needs of service users. Timescale for action 31/12/05 2 3 OP25 OP27 13(4)(c) 18(1)(a) 31/01/06 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP8 OP121 Good Practice Recommendations A review with the district nurses should be carried out to deal with any problems regarding the health and welfare of the service users. It is recommended that that those service users who require assistance from staff are catered for at the normal DS0000015661.V254764.R01.S.doc Version 5.0 Page 25 Mill House 3 4 4 5 6 OP12 OP16 OP19 OP24 OP29 mealtimes. The pursuit of more stimulation and activities for the service users should carry on. It is recommended that complaints made by the service users when at an early stage are recorded and any actions taken. It is recommended that redecoration and carpeting is considered. Consideration should be given to the provision of locked facilities and locks on doors in service users’ bedrooms. It is recommended that the recruitment files contain the photos of staff and any explanation where there has been a change of references. Mill House DS0000015661.V254764.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 House DS0000015661.V254764.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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