Inspection on 03/02/06 for Mill Lane Nursing Home & Retirement Home

This inspection was carried out on 3rd February 2006.

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

Mill Lane Nursing Home &... 14/09/05

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 Unannounced Inspection 3rd February 2006 13:15 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 DS0000024448.V283350.R01.S.doc Version 5.1 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. DS0000024448.V283350.R01.S.doc Version 5.1 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 DS0000024448.V283350.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 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. The company has a strong commitment to training, with a comprehensive inhouse training programme, employing dedicated training staff. There is a good management structure, overseeing a suitable quality assurance programme, and staff are well supervised. The company has consistently achieved the Investors in People award, and in 2005 also received a Work Life Balance award. DS0000024448.V283350.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second statutory inspection of the home carried out within the current year (April to March). It focused on outcomes for service users when considering progress regarding previous requirements and recommendations, significant developments, staffing and management arrangements, and the views of service users. The inspection used observation, examination of records and other documents, and discussion with management, staff, and residents, to assess these outcomes. The inspection concluded that the home has a very high level of compliance with the national minimum standards, and the staff and management are to be congratulated on achieving such a good standard of service. What the service does well: What has improved since the last inspection? The company continues to maintain and improve the accommodation, investing in an effective programme of re-decoration and refurbishment, together with planned enhancements to the environment (such as the fitting of decorative guards to all radiators). Training for staff and management continues to develop their skills and experience, to meet the commitment of the company to continuous improvement. This is driven by the company’s increasingly effective quality assurance process, and overall commitment to high standards. DS0000024448.V283350.R01.S.doc Version 5.1 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. DS0000024448.V283350.R01.S.doc Version 5.1 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 DS0000024448.V283350.R01.S.doc Version 5.1 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: DS0000024448.V283350.R01.S.doc Version 5.1 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): 9 The arrangements for the storage and administration of medication are generally good, but attention is needed to ensure accuracy at all times. EVIDENCE: An examination was made of the medication arrangements. The home uses a Monitored Dosage System, which is a simple and efficient method by which the supplying Pharmacy provides pre-packed solid medication for residents in blister packs containing the required dose. Storage of medicines was satisfactory – a specialist drugs trolley, which is stored in a locked cupboard and secured to the wall when not in use. The storage of controlled drugs (which require a second, internal, metal cupboard) was also satisfactory. Medication records were generally well kept and in order, but a sample examined revealed a missed dosage of night medication for a service user which had been signed off as given. In addition, the record of temperature checks on the medication fridge had not been completed daily. DS0000024448.V283350.R01.S.doc Version 5.1 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, 13, 14, 15 Daily routines are well suited to service users’ preferences. The catering has been reviewed to provide an improved service. EVIDENCE: A number of service users were consulted during the inspection, and there was a good level of agreement that the home is well organised to meet their individual needs regarding daily routines, such as rising and retiring, and appreciated the flexibility around meals, with many able to eat in their rooms if they wished. Most residents are served breakfast in their own rooms. The appointment of a new chef has led to a review of the catering arrangements and she has already consulted with service users and relatives. As a result, the menus have been revised and some suppliers have been changed. Service users consulted during the inspection confirmed that the standard of catering has been maintained, and improvements made to the supper provision. During the inspection it was observed that staff offered residents fruit when serving drinks, and that most took up this offer. Residents agreed that although fruit was always available (left out in bowls in the lounge) they seldom took any, but that being offered it was very encouraging and they were DS0000024448.V283350.R01.S.doc Version 5.1 Page 11 very likely to then accept. This is a simple, but very positive and pro-active approach by staff that ensures that residents receive a more enjoyable and nutritious diet, and is commendable. In other respects, staff were seen to have very positive interactions with residents throughout the day. Their approach was positive, polite and supportive. They engaged residents in conversation, and when carrying out care tasks these were explained to residents before and during the action, and a good amount of reassurance was given. Relationships were warm and friendly with much good-humoured banter. There were a number of visitors to the home during the inspection and it was clear that they felt welcome and at home. A number spent time talking to staff and spoke very positively about the care provided. DS0000024448.V283350.R01.S.doc Version 5.1 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 are well protected and feel confident and secure living in the home. EVIDENCE: All the service users consulted during this inspection confirmed that they felt secure and comfortable living in the home, saying that they were well looked after, and confident that any concerns or complaints they might have would be addressed. They felt that both the staff and management were responsive and supportive, listening to what they had to say, and acting upon it. Previous inspections have confirmed that management and staff and well trained in abuse awareness and local Protection Of Vulnerable Adults procedures (known as POVA procedures). There have been no significant complaints since the last inspection. DS0000024448.V283350.R01.S.doc Version 5.1 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, 20, 21, 22, 23, 24, 25, 26 The environment is being well maintained and continues to meet the needs of service users. There is a programme of continuing improvement. EVIDENCE: On the day of the inspection the home was clean, tidy and fresh (with no odour). The good standard of furniture and furnishings is being well maintained, as is the décor. The home was warm and comfortable for service users, despite the low temperatures outside, with residents confirming that it was ‘cosy’. The programme of re-decorating bedrooms (including fitting of new carpets) continues, and the bathroom on the first floor has been made more homely with net curtains, patterned tiles, and ornaments. The rear corridor floor has been repaired and a new carpet fitted, and the floor of the sluice room has been resurfaced. A new changing area for staff has been created on the second floor. DS0000024448.V283350.R01.S.doc Version 5.1 Page 14 The fitting of cover guards to all radiators has been completed, and as they are well designed and fitted, this has enhanced the appearance of the home as well as offering a greater level of protection. A suitable restraining device has been fitted to the fire door leading into the dining room, and on the day of the inspection a contractor was checking the fire safety equipment in the home. Mrs Leatherman stated that arrangements were in place for the local Fire Service to visit the home the following week to check the fire safety arrangements. This is in addition to the home’s own fire safety risk assessments. Residents spoken with were very happy with their accommodation, describing their bedrooms as comfortable, and spacious enough for their needs. DS0000024448.V283350.R01.S.doc Version 5.1 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, 28, 30 The home is well staffed, with competent, well-trained carers. EVIDENCE: At the time of this unannounced inspection there were 7 care staff on duty, including 2 qualified nurses, as well as a team of ancillary staff (Chef, Kitchen Assistant and 3 domestics). A new Housekeeping Team has been created and the manager reported that this has had a very positive affect on the cleaning regime of the home. Staff turnover is very low. Two members of staff are about to start as Adaptation Trainers for staff from abroad seeking to convert their qualifications to NMC (Nursing and Midwifery Council) standards. A training session for all staff was recently provided by a Chiropodist, to enable them to treat residents who are considered low risk. This treatment will only be agreed following a suitable assessment by a Podiatrist. The home agreed to ensure that this process is properly recorded. Further training in caring for people with dementia is planned, in addition to the home’s usual training programme, which is comprehensive and thorough. An internal Training Officer visits the home every Monday, and a specialist Supervisor had been working in the home on the morning of the inspection. Service users were very appreciative of the staff, describing them as friendly, and helpful, though often very busy. DS0000024448.V283350.R01.S.doc Version 5.1 Page 16 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, 33, 37, 38 The home is well managed, with and effective quality assurance process in place. The home is run in the best interests of the service users. EVIDENCE: The Manager, Mrs Leatherman, has recently completed the National Vocational Qualification level 4 Registered Care Manager’s Award, and is now awaiting external verification before this can be awarded. A report of the home’s Quality Assurance audit for 2005 has now been produced and made available to service users, relatives and other interested parties, including the Commission, and has been incorporated into the home’s Statement of Purpose. Records examined during the inspection were in good order (with a minor shortfall relating to medication – see Standard 9). Hoists displayed stickers DS0000024448.V283350.R01.S.doc Version 5.1 Page 17 confirming that they are regularly serviced and maintained, and fire safety arrangements are up to date. The general atmosphere in the home is relaxed and friendly, with residents at ease with carers and managers. This reflects the positive ethos established in the home. Service users spoken with during the inspection agreed that the home was run in their best interests, and felt consulted and listened to. DS0000024448.V283350.R01.S.doc Version 5.1 Page 18 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 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 2 3 DS0000024448.V283350.R01.S.doc Version 5.1 Page 19 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 OP37OP9 Regulation 13(2) Requirement Care must be taken to ensure that all medication records are accurate. Timescale for action 03/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000024448.V283350.R01.S.doc Version 5.1 Page 20 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 DS0000024448.V283350.R01.S.doc Version 5.1 Page 21 - 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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