Inspection on 14/09/05 for Mill Lane Nursing Home & Retirement Home

This inspection was carried out on 14th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

Mill Lane Nursing Home &... 14/02/07

Mill Lane Nursing Home &... 03/02/06

Mill Lane Nursing Home &... 10/03/05

Mill Lane Nursing Home &... 18/11/04

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 Lane Nursing Home & Retirement Home 79 Garrison Lane Felixstowe Suffolk IP11 7RW Lead Inspector Mike Usher Announced Inspection 14th September 2005 10:00 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 Lane Nursing Home & Retirement Home DS0000024448.V252431.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 Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mill Lane Nursing Home & Retirement Home Address 79 Garrison Lane Felixstowe Suffolk IP11 7RW 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) 01394 279509 01394 279509 Pri-Med Group Ltd. Mrs Jocelyn Leatherman Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2005 Brief Description of the Service: Mill Lane Nursing and Retirement Home is owned by the Pri-Med group and registered as a care home with nursing, for up to 25 older people. The home is in Felixstowe at the junction of Garrison Lane and Mill Lane, and stands back from the junction, in its own pleasant gardens. It is not central to the town of Felixstowe, however there is easy access to both the shopping area and the sea front, about half a mile away. The building is a converted three-storey house with car parking to the front with ramped access to the front door. A large passenger lift serves the first floor, and there are ample assisted bathrooms and WC’s. There are 21 single bedrooms and two double bedrooms. The lounge and dining room are located on the ground floor. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection focused on progress regarding previous requirements and recommendations, significant developments, management issues, and the views of service users and staff. The inspection used observation, examination of records and other documents, discussions with management, staff, and residents, and made use of information provided by the home prior to the inspection visit. In addition, 4 relatives, 2 carers, and 4 service users returned survey forms expressing their views on life in the home. The home achieves a high level of compliance with the National Minimum Standards, with only four minor shortfalls noted during this inspection. A good standard of care is provided, but with increasing dependency levels of service users, both physically and mentally, attention is needed to ensure that the needs of all service users can be fully met. What the service does well: What has improved since the last inspection? The environment continues to be maintained and improved. The fitting of radiator guards continues, and there has been a considerable amount of redecoration and repair having been carried out recently. The bathrooms and WC’s in the home have been improved to make them more homely and comfortable. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.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 Lane Nursing Home & Retirement Home DS0000024448.V252431.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): These standards will be looked at in more detail at future inspections. EVIDENCE: Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.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, 10 The personal and healthcare needs of service users are well met. EVIDENCE: Care plans are satisfactory and provide a good level of information with regard to risk assessments, care needs, preferences and requirements. Daily records are kept of the care provided and significant events. The arrangements for the safekeeping and administration of medication will be looked at in detail at the next inspection, which will be unannounced. Both service users and relatives spoken with during the inspection were satisfied that staff behaved appropriately when providing personal care, and felt that their privacy and dignity were respected at all times. Records confirm that the health needs of service users are well documented and that access to health professionals outside of the home is adequately promoted. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 10 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 - 15 The home encourages and facilitates family and communal contact, and offers a range of suitable activities. Attention needs to be paid to service users feedback as to the adequacy of catering. EVIDENCE: Service users and relatives spoken with during the inspection felt that there was a good range of activities and entertainments provided, and a calendar of events for the month was displayed throughout the home. Whilst this may appear somewhat institutional, it was popular with the residents and their visitors, and several of them went out in the afternoon on the planned trip to the sea front, in the minibus provided - which incorporated a tail-lift for wheelchairs and easy access. During the inspection is was possible to share lunch with service users, and this was a relaxed and sociable affair, with residents who require help being assisted by 4 carers, in appropriate fashion. On the day it was notable that some service users were seated at the dining tables for some considerable time before food arrived, and the manager had to assist in order to complete the meal in good time. She later confirmed that this had been exceptional due to the particular circumstances on the day. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 11 Residents spoken with felt that the food provided was good quality and with a good variety and choice, and catering for special diets such as diabetics. The dining room is comfortable and nicely furnished, if somewhat cramped due to the number of wheelchair users needing to get in and out. A number of service users take their meals in the lounge or in their own rooms, through choice, which saves the dining room from being even more congested. Food portions were satisfactory, though no second helpings were offered, and a number of service users and relatives expressed the view that the food offered for supper (served at 5pm), whilst very nice, was not adequate in terms of amount – this meal having to last residents through to breakfast the next morning. Of the 3 service users returning survey forms, two said that they did not like the food offered, and the third said they liked it only ‘sometimes’. One commented “Corned beef sandwiches followed by jelly do not make a good supper”. A number of visitors were in the home on the day of the inspection, and those spoken with said that they were always made welcome, and that there were no undue restrictions on their visiting. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 12 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, 18 Service users and well protected and safeguarded. EVIDENCE: The home has a suitable complaint procedure in place, and a record is kept of any complaints made, together with the outcome. Examination of these records found that none of them was serious, and all had been addressed appropriately by the management. Service users and their families consulted during the inspection expressed confidence that any concerns that they may have would be properly dealt with, and none could recall having had any need to complain. Staff undertake adult abuse awareness training and the management are familiar with the local Protection Of Vulnerable Adults (POVA) procedures. Residents spoken with said that they felt safe and secure living in the home, and felt that they were well cared for. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 13 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 - 26 The environment is well maintained and meets the needs of service users, though communal areas have become more cramped due to the increasing needs of residents. EVIDENCE: On the day of the inspection the home was clean, tidy, in good order and free from odour. A programme of re-decoration is continuing, and it was noticeable that the home is being maintained in good order, with very little sign of the considerable wear and tear to which it is obviously subject. New carpeting has been laid in the rear corridor, although further work is required to address problems with the floor beneath. Bathrooms have been made more homely, and a number of bedroom doors have been fitted with suitable restraining devices to enable them to be kept open when desired. However, it was noted that the dining room door was being held open by means of a wedge, which is not appropriate. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 14 The first floor staff WC now has a wash hand basin fitted, and the fitting of low surface covers to radiators is continuing, on a risk-assessed priority. Mrs Leatherman agreed that a reasonable timescale for this work to completed would the end of November. It was observed during the inspection that the main lounge is quite cramped. With two relatives visiting, it was difficult for staff to seat them easily without much moving of chairs and tables around, in addition to staff having to manoeuvre hoists in and out to assist residents. To a lesser extent the same issue relates to the dining room. This matter was discussed with the manager and it was agreed that this area of operation will be monitored to assess what action is needed. Residents spoken with said that their bedrooms were comfortable and met their needs adequately. New storage facilities are being installed in bedrooms for residents to keep their belongings more securely. The gardens are well kept and there are several areas for residents to use that have been adapted to allow safe and easy access. The area containing waste bins is nicely screened but it is suggested that the area be made secure, or the clinical waste bin be kept locked shut as an additional safety feature. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 15 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 - 30 Staff recruitment, supervision and training are satisfactory, but further monitoring is required to ensure that staffing levels are adequate. EVIDENCE: On the day of the inspection there were 5 Carers on duty, with the Nurse–incharge, Manager, Chef and Kitchen Assistant, Housekeeper, Domestic and General Assistant. This represents a good level of staffing, although it was noted that staff were kept very busy throughout the day, especially with the amount of equipment that is used, such as hoists, and where 2 carers are required to assist individuals. This impression was confirmed in discussion with service users and relatives, who felt that staff, whilst very attentive, were often too busy to chat, and a common criticism was the length of time taken to respond to the call bell. Of the 4 relatives who returned survey forms, 3 expressed the opinion that the home was no adequately staffed. Mrs Leatherman agreed to monitor the situation to assess what improvements might be possible. Recruitment procedures are satisfactory, with the necessary checks and references being undertaken, and staff files contained the appropriate records for employment, induction, training, and supervision. The home continues to experience delays with the processing of CRB and POVA checks on new staff, which has been frustrating when trying to recruit staff to cover vacancies. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 16 In common with most care homes in recent times, Mill Lane has been recruiting carers from abroad to maintain a full complement of staff. The management have sought to maintain a balanced team, and have assisted foreign staff with English courses, and also ensured that their induction covers cultural issues as well as communication. Service users spoken with during the inspection said that they had not experienced any communication problems, and were very pleased with all the staff. Where staff from abroad are employed, a specialist agency is used, and the required documentation was on file. The home employs a suitable number of qualified nurses, and operates a comprehensive internal training programme for staff that is designed to cover all essential training (such as First Aid, Moving and Handling, Food Hygiene and Health & Safety), and enable carers to develop towards National Vocational Qualification (NVQ) at Level 2, which is widely recognised as the basic qualification for care staff. Currently, the home has 8 carers with NVQ2, which is very close to the 50 target identified in the standards. Relatives and service users consulted agreed that the staff team are friendly and competent. They found them to be polite, helpful, and very attentive to issues of privacy and dignity Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 17 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 – 33, 35 - 38 The management of the home is on a sound footing, with appropriate policies and procedures. Suitable records are kept and properly maintained. EVIDENCE: Mrs Leatherman is an experienced and competent manager, and will be completing the NVQ4 Care Managers Award in November. The company is currently carrying out a Quality Assurance audit of the home, with all service users being surveyed, with relatives helping out where required. In addition, the company’s Training Officers have visited to interview residents, and an anonymous survey of staff is being conducted, and the views of external agencies have been canvassed. The Regional Manager will be collating and analysing the results, which will be incorporated into the home’s Annual Plan, and advise any revision to the Statement of Purpose. It was discussed with the management team how this process may be developed to Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 18 allow the results to be shared more directly with service users and the commission. Records relating to staff supervision were examined and confirmed that appropriate supervision is being offered to staff on an individual basis at regular intervals. Staff consulted during the inspection confirmed that they received adequate supervision. Where the home looks after service users’ money, appropriate records are kept and these are checked by the manager at regular intervals. It would be good practice for an occasional check to be made part of the monthly visits carried out by senior managers. Other essential records examined were in good order, including fire safety and health and safety, and policies and procedures are in place to ensure the safeguarding of service users. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 3 3 3 Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 20 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 OP15 Regulation 12 Requirement Timescale for action 14/09/05 2 3 OP19 OP33 13(4) 23(4) 24 4 OP25OP19 13(4) (a)(c) The adequacy of food provided during the evening needs to be reviewed taking into account the views of service users as detailed in this report. Fire doors must only be held 14/09/05 open by appropriate means. The Quality Assurance system 31/03/06 needs to be developed further in order that results may be reported to service users and the CSCI. The safeguarding of high 01/12/05 temperature surfaces needs to be completed. This requirement is carried over from previous inspections. 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 OP27 Good Practice Recommendations Staffing levels should be reviewed to ensure that the DS0000024448.V252431.R01.S.doc Version 5.0 Page 21 Mill Lane Nursing Home & Retirement Home 2 3 4 OP20 OP35 OP19 needs of service users can be adequately met. The communal areas within the home should be reviewed to ensure that the provision is adequate to the needs of service users and their visitors. Occasional checks of service users’ monies held by the home should be carried out during visits to the home under Regulation 26. Clinical waste should be stored securely and be inaccessible to service users. Mill Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Lane Nursing Home & Retirement Home DS0000024448.V252431.R01.S.doc Version 5.0 Page 23 - 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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