Inspection on 14/05/08 for Millard House

This inspection was carried out on 14th May 2008.

CSCI found this care home to be providing an Poor 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

Millard House 07/05/09

Millard House 18/11/08

Millard House 19/12/07

Millard House 16/01/07

Millard House 08/09/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Millard House 364 Church Street Bocking Braintree Essex CM7 5LL Lead Inspector Michelle Love Unannounced Inspection 14th May 2008 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 Millard House DS0000067428.V364086.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. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millard House Address 364 Church Street Bocking Braintree Essex CM7 5LL 01376 325002 01376 324472 surjit@rushcliffecare.co.uk 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) Rushcliffe Care Limited Manager post vacant Care Home 43 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (43) of places Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 43 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 18 persons) The total number of service users accommodated in the home must not exceed 43 persons The 19 service users` bedrooms with an area of less than 10 sq.m., but more than 9 sq.m., will be used only following a written assessment that the facilities in the room are suitable for, and acceptable to, the service user taking into account the service user’s mobility needs. The care plan needs to reflect the assessment findings Service users must not be admitted to the home under the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 19th December 2007 5. Date of last inspection Brief Description of the Service: Millard House is a purpose built two-storey building situated in the residential area of Bocking, near Braintree Essex. The home is owned by Rushcliffe Care Ltd. Accommodation consists of thirty-nine single bedrooms and two shared rooms. Access to the home is good and a passenger lift provides access to the first floor. There are two dining rooms, several lounges and quiet areas. Car parking for visitors is available at the front of the property; this area is shared with the older persons day centre that adjoins the main home. There is a fully enclosed courtyard garden in the centre of the building and further gardens at the front and side of the home, but these areas are not secure for some residents to use. As at 19th December 2007, a notice in the main entrance states the fees as ranging up to a maximum of £643.98 per week Items considered to be extra to the fees include private chiropody, hairdressing, toiletries and newspapers. Millard House DS0000067428.V364086.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 0 star. This means the people who use this service experience poor quality outcomes. This was an unannounced key inspection. The visit took place over one day by two inspectors and lasted a total of 13.10 hours, with all but one of the key standards inspected. Additionally, the manager’s progress against previous requirements from the last key inspection was also inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment. This is a self-assessment document detailing what the home does well, what could be done better and what needs improving. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Prior to the inspection surveys were forwarded from us to the home for distribution to residents next of kin, healthcare professionals and staff who work within the care home. It was positive to note that we received 6 completed surveys from relatives, 2 from healthcare professionals and 3 surveys from staff. Where surveys have been returned to us, comments recorded have been incorporated into the main text of the report. The manager, senior manager and other members of the staff team assisted both inspectors on the day of the inspection. Feedback on the inspection findings were given throughout and summarised at the end of the day with both the manager and senior manager. The opportunity for discussion and/or clarification was given. The main text of the report highlights a number of shortfalls, some of which have been emphasised at previous inspections to Millard House. As a result of concerns relating to care planning/risk assessing and the health and welfare of residents, a Code B notice of the Police and Criminal Evidence Act 1984 was issued on 14/5/08 and a number of documents relating to the above issues were photocopied and provided to the Commission for Social Care Inspection. The Commission for Social Care Inspection may take enforcement action in relation to the outstanding shortfalls. Millard House DS0000067428.V364086.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: Further development is required in relation to the care planning and risk assessing processes so as to ensure that individual plans of care are comprehensive, up to date and reflective of people’s current care needs. Ensure that where people require assistance and encouragement to eat their meal, support is provided by staff and the nutritional needs of individual people are monitored and reviewed. Practices and procedures for the safe handling, administration and recording of medicines must be improved to protect residents from harm. The deployment of staff at the home needs to be reviewed so as to make sure that all residents needs are met at all times. Routines within the home need to be improved so that these are resident led rather than staff orientated. Further training and personal development is required for some staff to ensure they have the skills and competence to meet residents’ needs and to deliver good care. Robust recruitment procedures must be adopted to ensure that residents are supported and protected. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 7 People must be provided with meaningful activities so as to ensure that their social care needs are met both at the home and within the local community. 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. Millard House DS0000067428.V364086.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 Millard House DS0000067428.V364086.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. There is an appropriate system in place to ensure that residents are assessed prior to admission and that the staff team can meet the needs of prospective residents. EVIDENCE: There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective residents’ needs. On inspection of the care file for the newest person admitted to the care home, there was evidence to indicate that a completed pre- admission assessment had been undertaken prior to the person’s admission to the care home. Information recorded was observed to be satisfactory and informative. The manager advised that in most cases it is she that undertakes completion of the pre admission assessment. In addition to the formal assessment procedure, supplementary information is sought from the individual residents’ Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 10 placing authority and/or hospital and this was available for the person case tracked. No information was recorded confirming to the resident and/or their representative that the staff team of the home can meet the person’s needs. Resident’s spoken with were unable to give a view as to whether or not they had been given information about the home (brochure/Service Users Guide), and therefore the manager was advised to record this as part of the pre admission assessment process. The manager advised that prospective residents and their relatives are afforded the opportunity to visit the home prior to admission. It was disappointing that no evidence was available to support the above statement. The Annual Quality Assurance Assessment details under the heading of `what we do well`(Choice of Home), “Encourage potential residents to view the home and spend an hour or two to chat with staff as they go about their daily duties and chat to existing residents to gain first hand feedback of the people who actually chose Millard House as their home”. One staff survey returned to us in relation to information provided to staff about the needs of the residents recorded, “sometimes information quite limited” and “sometimes information relevant to a resident or events does not get passed on at correct time”. The home does not currently provide intermediate care. Millard House DS0000067428.V364086.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents can be sure they have an individual plan of care in place, however significant shortfalls in care planning, risk assessing and medication practices means that residents cannot be assured that their needs will always be met or that their health and wellbeing will be maintained or proactively managed. EVIDENCE: At this site visit, a random sample of 3 care files were examined in full. There is a formal care planning system in place to help staff identify the care needs of individual residents and to specify how these are to be met by care staff. However, this is basic and seen to lack specific detail. Additionally formal assessments are completed in relation to dependency, manual handling, falls and pressure area care. Some staff spoken with during the site visit advised that they have worked at the home for many years and know instinctively the needs of those residents who have lived at Millard House for a significant period of time. Staff confirmed that the care planning format Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 12 lacks detail and provides little information about residents, which some newer members of staff could find difficult and unhelpful. Care records show that further development of the care planning and risk assessment process is required as shortfalls identified, potentially place residents at risk of not having all of their care needs met and provides staff with inaccurate and not up to date information about individual residents. Particular attention must be afforded to individual’s nutritional needs, falls management, refusal of medication and the management of people’s inappropriate or aggressive behaviours. Each file was observed to contain basic information relating to Activities of Daily Living, Quick Reference Care Plans and Social Recreational/Meaningful Activity Care Plans. Evidence indicated that individual resident’s needs are not fully recorded, do not include the interventions required so as to ensure the appropriate delivery of care and are not regularly reviewed to reflect individual resident’s changed needs and how this affects their daily life. For example, a care plan relating to medication had been completed for one person and included details of the person’s prescribed medication, the specific dose, possible side effects, date medication prescribed and evaluation. However, on inspection of Medication Administration Records (MAR) as far back as December 2007, there was evidence to indicate that the person regularly refused their medication. The care plan failed to make reference to the person refusing their medication and there were no guidelines detailing how the staff team of the home were to proactively manage the change in the person’s circumstances. Care records showed that the person’s refusal of key medications had been noticed but not followed up. The care file for this person also recorded that they exhibited inappropriate and/or aggressive behaviours towards others. There was evidence to indicate that these behaviours had been present for some considerable time, however a care plan was only devised in January 08 and May 08. It is of concern that failure to devise and implement a care plan/risk assessment sooner has potentially placed the person and others at risk and harm and evidences that preventative measures, should have been in place much sooner to protect all parties. We recognise that the care plan dated May 08 is detailed and informative and now provides staff with clear guidelines to deal effectively with the individual’s behaviours. Additionally we are aware that measures are in place to find this person an alternative placement that can meet their needs. The above person’s care file was observed to record some information that was conflicting and following discussions with the person’s relative, gaps in information relating to the individual’s care needs were noted. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 13 A formal falls risk assessment was completed for one person case tracked and indicated that they were at high risk of falls (May 07). There was evidence to indicate this was reviewed and noted, but not followed up. No care plan/risk assessments were devised for the newest resident admitted to the care home. Formal assessments were completed for dependency levels and pressure area care and Activities of Daily Living Care Plan and the Quick Reference Care Plan were also completed. The assessment from the Local Authority Care Manager recorded that the person’s mobility was poor, that they needed assistance with personal care, was at risk of self neglect, malnutrition/dehydration, falls and was non-compliant with medication. Daily care records recorded that since admission the person had refused their personal care, ate only a small diet and needed encouragement to get dressed and to come downstairs. None of the above was highlighted or a care plan devised. Of those care plans inspected there was little evidence to suggest that these had been devised with the resident and/or their representative. This is disappointing as the registered provider’s policy for `development and monitoring of a residents plan of care` details that the resident and/or their representative should sign the document to indicate they are satisfied with the plan of care. Additionally of those care plans inspected there was evidence to indicate that these had not been regularly reviewed and/or updated to reflect changes to individuals care needs. This was observed to not be in line with Rushcliffe Care’s own policy, as this states, “Once developed, the residents plan of care will be regularly reviewed (at least monthly) to ensure that the resident is responding in a satisfactory manner, i.e. that the care given is what the resident requires and needs. Adverse reaction to the resident’s plan of care by the resident will result in an immediate review of the plan by the key worker and care staff and amending it as needed” and “All amendments to the residents plan of care will be fully documented”. The manager advised that care plans are written by the care team leaders and all received training in relation to care planning when Rushcliffe Care took over Millard House in 2006. The Annual Quality Assurance Assessment details under the heading of `what we do well`, “Detailed care planning-reviewed monthly or as needs change” and under the heading of `what we could do better`, “I am going to train staff on how to use the care plan as it was intended to be used, but there is much more we could add to form a more in depth plan of care for individual residents”. The document also states under the heading of `how we have improved in the last 12 months, “The care plans are up to date with basic information”. The above statements do not concur with the findings of the inspection. Audits had been completed by the manager in relation to the care planning process. The inspector was advised that where gaps of information are missing, these are discussed with care team leaders/care staff at supervision. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 14 As a result of concerns relating to care planning/risk assessing and the health and welfare of residents, a Code B notice of the Police and Criminal Evidence Act 1984 was issued on 14/5/08 and a number of documents relating to the above issues were photocopied and provided to the Commission for Social Care Inspection. Staff, were observed interacting with residents in a respectful and dignified manner when carrying out tasks. Several residents made positive comments about staff, but recognised that staff were very busy doing other jobs and were unable to spend time with them. During the inspection staff, were observed to interact positively with individual residents however routines at the home are task based and not person led e.g. when staff were serving resident’s their meals, little verbal interaction was noted and staff were observed to walk through dining/lounge areas without speaking to residents. One relative advised in their survey, “with the severe shortage of staff, the carers do their best to meet the needs of their relative” and they wanted their member of family to be bathed more frequently. Another relative survey returned to us also concurred with the previous comments by stating, the home “provides day to day genuine care in a friendly manner” but the home could improve by, “having more regular arrangements for bathing”. A relative spoken with on the day of the inspection also expressed concern that there were occasions when their member of family had not been bathed regularly. Comments from relatives in relation to the service provided at the care home were mixed, and ranged from people feeling that staff were providing appropriate support to their member of family that was efficient and caring, “provides day to day genuine care in a friendly manner” to concerns that one person had recently developed a pressure sore and was left in their wheelchair for long periods of time, one person’s glasses and hearing aid and been lost and another person stated, “I wouldn’t recommend the home to anybody” and “standards have dropped since Rushcliffe Care have taken over”. The majority of medication is managed through a monitored dosage system (blister pack). Administration of medication to residents was observed during the morning and this was seen to be satisfactory. During the lunchtime period, the inspector observed one resident being given their lunchtime medication (in a pot with a glass of water), however the care team leader was noted to walk away without witnessing the person taking their medication and the other care team leader was noted to sign the MAR record without knowing as to whether or not the person had actually taken their medication. This is seen as poor practice. Medication records were not up to date, with gaps in recording and information. This refers specifically to no record of some medicines having been given to the resident when they were due, as the entries on the MAR record had been left blank and not signed/initialled by staff. Where the Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 15 prescriber’s instructions state 1 or 2 tablets to be administered, the actual dose administered was not always recorded. Additionally the MAR record for some people did not always record the quantity of medication received, the date the medication was received and the initials of the person receiving the medication. This is disappointing as the medication audit conducted on 12/5/08 confirmed the receipt of medication. Both the home manager and senior manager of Rushcliffe Care were advised as part of good practice procedures, to ensure that where MAR records are handwritten, these are signed by two people so as to ensure that the information recorded is accurate. The morning medication round was observed and this commenced at 08.45 a.m. and was completed at 11.00 a.m., however the lunchtime medication was administered at 1.20 p.m. and completed by 1.40 p.m. The time span between the morning and lunchtime medication was observed to be short and could result in some residents receiving their medication too soon. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 16 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 poor. This judgement has been made using available evidence including a visit to this service. Significant shortfalls in the activities programme at the home, means that the majority of people do not have their social care needs met. Not all residents have their nutritional needs met and this means that some residents do not receive a varied and balanced diet, which could affect their health and wellbeing. EVIDENCE: At the time of the site visit the home was without an activities co-ordinator. The senior manager advised inspectors that the organisation were interviewing for the post over the next 2 weeks and it was hoped that an appointment would be made. The improvement plan dated 11/4/08 details that the manager is to identify a staff member on a daily basis to carry out meaningful activities, however in the event of staff absence and/or inadequate staffing levels, this resource will be used for `direct` resident care. Both the manager and the senior manager confirmed the above and stated that care staff are carrying out activities for residents when staffing levels permit. Of those staff rosters examined there Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 17 was little evidence to indicate that a staff member had been identified to initiate activities for residents. On inspection of 5 residents care records relating to activities, there was little evidence to indicate that people are having their social care needs met or being given the opportunity for stimulation through a varied programme of leisure and recreational activities, both in house or within the local community. For example one person’s records evidenced only 5 entries since 1/1/08 of them participating in activities, one care file had no entries recorded since 24/1/08, one care file had no entries since 2/12/07, one care file had no entries since 23/10/07 and one care file recorded 8 entries between 11/07 and 05/08. On the day of the site visit no activities were observed throughout the day for residents and there were long periods of time when residents, were observed to be sat in lounge areas with either the television or radio on and without any staff support. One resident spoken with at the time of the inspection advised the inspector that they had not had the opportunity to visit the local community since moving to the home and another person stated “not much to do but watch TV”. Another resident confirmed that they spent the majority of their time watching television or listening to music but enjoyed an external singer visiting the care home recently. Another resident spoken with said, “I get a bit fed up sometimes as not much to do”. One relative survey returned to us recorded, “I feel very strongly regarding the lack of any stimulation. Little or no sign of any activities, certainly not on a regular daily/weekly basis, as and when a carer might have five minutes to spare, certainly no designated person to take on this role. A TV turned on in the corner of every lounge seems to be the only kind of stimulation”. Another relative survey returned to us recorded, “there is a total lack of activities for the residents-they sit in circles all day everyday, and sleep off and on, totally bored”. The Annual Quality Assurance Assessment details under the heading of `our evidence to show that we do it well`, “Activity-records for individuals and activities taken place”. This does not concur with our observations on the day of inspection or our findings from inspection of people’s individual care files. There is an open visiting policy whereby visitors to the home can visit at any reasonable time. People spoken with confirmed that they are made to feel welcome by care staff. The lunchtime meal was observed within two dining areas. A menu depicting the choices available for the day was displayed on a notice-board within the large dining area. Consideration should be given to devising the menu in larger print and/or pictorial format so as to enable the majority of residents to make an informed choice. There is a rolling 4 week menu and this was seen to offer people a varied choice of items. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 18 Food served to residents within both dining areas looked appetising and well presented. Tables were attractively laid with tablecloths, cutlery and serviettes. Condiments were not available on all tables and jugs of juice were not placed on tables so as to enable residents to maintain independence and skills. Staff within the main dining area were observed to be very busy and to take trays of hot food to other areas (people’s bedrooms and the small dining area). Staff within the main dining area were observed to talk to residents in a respectful manner but did not have the time to engage in conversation with residents whilst serving the meal. In the small dining area there were 7 residents and 1 member of care staff. The member of staff was observed to sit with 3 residents and provide support and assistance that was respectful and sensitive to people’s needs. However, the lunchtime dining experience for one person was observed to be poor. This refers specifically to the resident receiving their meal at 1.10 p.m., however no encouragement/support was given to the resident to eat their meal until 1.25 p.m. whereby the member of staff was observed and heard to state, “[name of resident] are you going to eat your dinner, you going to eat your dinner”. The resident was observed to drink their juice but made no attempt to eat their dinner. At 1.35 p.m. another carer entered the dining room, took the residents plate away with no verbal engagement with the resident and returned a short while later with the food reheated. The resident was then assisted by the member of staff to eat their meal, however after a few mouthfuls refused to eat anymore. Dessert was offered to the resident but they refused the choice offered. No further choice of dessert was offered and the resident was not offered an alternative choice of meal, despite having eaten very little. Following this observation and from discussion with the care team leader, discussion with care staff and from inspection of the person’s daily care records, it was evident that the resident often refused to eat their meal or ate a small diet. There was no evidence within the person’s care file as to how this was being monitored or proactively managed as there was no weight chart in place and no food/fluid charts. Additionally the manager was also noted to come into the dining room and to speak to residents. One resident was spoken with and they advised the manager “I didn’t like the food”. The manager asked them if they wanted anything else and the resident was overheard to reply, “never been asked that before”. The manager replied, “I’m sure you have” and an alternative to the meal was offered, however they declined. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 19 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. Although there is an appropriate complaints procedure and system for logging complaints, not everyone feels their concerns are taken seriously and acted upon. EVIDENCE: The management team has a corporate complaints policy and procedure in place. The compliments and complaints folder had a copy of the policy and this was dated March 06, however when highlighted to the manager, the policy manual was presented to the inspector and this contained a complaints procedure dated July 07. On inspection of the complaint log, this contained evidence of letters sent by the registered provider to the original complainant but did not contain evidence of the actual complaint/issues raised. The manager advised the inspector that the senior manager was in receipt of this information, including the initial complaint forms. The manager/registered provider must ensure that there is a clear audit trail available within the home evidencing the specific details of the complaint, details of any investigation and action taken. The Annual Quality Assurance Assessment details under the heading of `our evidence to show that we do it well`, “Compliments and complaints folder kept along with responses and outcomes”. It is evident from the relatives surveys returned to us, that people know how and are clear about how to raise any concerns. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 20 Since the last inspection there have been no safeguarding issues. The Annual Quality Assurance Assessment details that Rushcliffe Care are part of a pilot scheme on partnership with `Action on Elder Abuse`. Policies and procedures relating to safeguarding are readily available within the home. Staff spoken with demonstrated an awareness and understanding of safeguarding procedures and advised that should an issue arise, information would be passed to the person in charge of the shift. Several staff members spoken with advised that they had recently received safeguarding training. Neither, the manager or senior manager, were aware that new local authority safeguarding guidelines have been introduced. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. The environment enables residents to live in a safe, well maintained and comfortable environment. EVIDENCE: A partial tour of the premises was undertaken as part of this key inspection. A random sample of resident’s bedrooms were inspected and all were seen to be personalised and individualised with many personal items on display e.g. ornaments, photographs etc. Residents spoken with confirmed that they liked their personal space and were happy with the home environment. Since the last inspection some bedrooms have been redecorated. The premises, were observed to be clean and there were no odorous smells throughout the day. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 22 No health and safety issues were highlighted on the day of inspection. The Annual Quality Assurance Assessment details under the heading of `how we have improved in the last 12 months`, “health and safety has improved” and “the culture of the home is becoming more health and safety conscious”. There is a code entry system in place for the dementia unit on the first floor. We recognise that there is some signage around the home, however this is minimal and needs to be improved so as to aid orientation for people residing at the home. The maintenance person at the home is employed for 37.5 hours per week and there is a continuing programme of maintenance and redecoration. The inspector was advised that the maintenance person carries out a daily audit of the premises and prioritises jobs according to importance. The maintenance person advised the inspector that there is a `float` of monies available to purchase items as necessary, however this often runs out and impacts on the jobs he can do. The registered provider advised us that the maintenance person has an account card for a large DIY store, which they can use to purchase necessary items. The maintenance person advised that he likes working at the care home and “likes to be his own boss”. He confirmed that he has received training relating to health and safety, manual handling and safeguarding. A random sample of safety and maintenance certificates showed that fire systems within the home, fire alarm/emergency lighting testing and fire drills were serviced/tested regularly. The maintenance person advised the inspector that most of the information has been transferred from previous records, however this is still work in progress and will be completed shortly. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 23 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 poor. This judgement has been made using available evidence including a visit to this service. The level of staffing and staff deployment restricts the ability of the service to deliver person centred care and to ensure that people’s needs, can be met and that they are safe. Inadequate recruitment procedures and insufficient evidence of training for some people mean that residents are not safeguarded and staff working at the care home may not have the necessary skills to meet the assessed needs of residents. EVIDENCE: The manager advised the inspector that staffing levels at the home are 1 care team leader and 5 care staff (morning), 1 care team leader and 4 care staff (afternoon) and at night there are 2 waking night staff. The inspector was advised that one care team leader is responsible for compiling the staff roster. Rosters presented to the inspector were noted to be completed in pencil, with some changes highlighted in ink. Both the manager and senior manager were advised that staff rosters are a statutory record and should be completed in ink. Additionally the staff rosters should include a key detailing codes used e.g. E, L, R/D, N, SN etc. In addition to the above, ancillary staff are utilised at the home (cook, kitchen assistant, housekeepers). A separate roster is available for the management team and this details that the manager is supernumerary most days. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 24 On inspection of 4 weeks’ staff rosters these evidence that staffing levels as detailed above are not being maintained. We have not received any Regulation 37 notifications advising us of the staffing shortfall and measures undertaken to deploy staff to the home. Additionally the staff rosters show that some staff are working long days e.g. one member of staff was noted to complete a late shift, followed by a waking night shift (total 17.15 hours) and that one member of staff worked 9 consecutive days without a day off. This is not good practice and potentially places staff and residents at risk. Staff surveys forwarded to us recorded, under the heading of are there sufficient staff to meet individual needs, “at present time, a number of staff have left or are about to leave and some staff are unreliable, therefore on some shifts we work short and under stress”, “since going private the staff on duty got reduced. When the home is full and the type of residents that live at the home, work can become stressful for staff as there are not enough on duty” and “I believe the home provides enough numbers of staff but they are not flexible in giving extra staff when needed. For example, when clients of high dependency increases, management would insist we have enough staff. When difficulty of handling the clients increases, and because there are only a number of staff, some clients don’t get enough time and attention they need. They are not neglected but I think they don’t get the level of standard of care they deserve”. Another survey recorded that the home is always short staffed and the registered provider appear keen to not use agency and are very reliant on existing staff to cover vacant shifts. One relative’s survey returned to us recorded, under the heading of ‘how do you think the care home or agency can improve`, “to employ more staff, both carers and domestic”. Two relatives spoken with on the day of inspection advised inspectors that there have been occasions whereby there have appeared to be too few staff on shift. It is evident from the inspection that the deployment of staff during the day needs to be improved so that staffing levels meet the needs of the people using the service and enables person centred care to be provided. As stated previously, staff spent little time with residents and there were long periods of time when people were left without staff support. We are concerned about the current staffing levels at night. The registered provider must provide sufficient evidence as to how this works in practice, as we are aware that the dependency levels of many residents at present is recorded as medium to high. The Annual Quality Assurance Assessment details that a significant number of people require “two or more staff to help with their care” at night. At the time of the inspection there were 37 people living at Millard House (4 people assessed as having `low` care needs, 18 people assessed as having `medium` care needs, 13 people assessed as having `high` care needs and 2 people assessed as having `very high` care needs). Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 25 One staff survey recorded, “I believe the company/home tries to do things to improve the home, to help the staff and clients, unfortunately it has always been difficult to ask for additional staff on shift”. Another staff survey recorded, “I feel able to do my job well due to my own capabilities and experience but feel things could be improved at times”. Although some staff completed and returned surveys (anonymous) to us, it was disappointing on the day of the site visit that some staff (carers and care team leaders), were reluctant and felt unable to speak to inspectors for fear of reprisals and/or possible repercussions. The manager advised inspectors that staff vacancies are for 4x full time care assistants (2 are forward projections as staff have not yet left the home’s employment) and 1x activities co-ordinator (20-25 hours per week). Inspectors were advised that there have been steps undertaken to recruit staff to the home. The senior manager advised inspectors that when there are staffing level shortfalls, efforts are made to provide additional staff from their sister home, and if this fails, agency staff can be provided. This is at odds with information provided by the manager, who advised that agency staff, are not used as the home has not formally registered with an external agency. The manager does not have autonomy to authorise the use of agency staff and this must be granted through the senior manager. A random sample of staff files (6) were examined including those for newly recruited staff. Records relating to 2 members of staff were not available and the manager had to request records to be faxed from head office to the care home (this included the file for one person that had transferred from another service within the organisation). Shortfalls were identified in relation to no application form and no written references for one person and no records of training/qualifications for 3 people. Evidence of staff induction was only available for 3 out of 6 files inspected. Where no evidence was available staff were in possession of an induction booklet. Completed induction booklets were seen for other staff members and the procedures seemed to be thorough and detailed. The inspector was advised that 7 staff members have completed NVQ Level 2 and that 1 member of staff is currently working towards NVQ Level 3. The manager stated that she has recently sourced funding to provide more staff with NVQ training. Records of staff training were located in several areas (individual staff files, manager’s desk and in the manager’s draw) and once located indicated that a significant amount of training had taken place since the last inspection relating to medication management, palliative care, safeguarding, infection control and manual handling. The manager advised that most of the training is carried out by the senior manager for the home. The manager has devised her own training plan however it was difficult to decipher and did not include all relevant training associated with the needs of older people, but did include training relating to diabetes, medication and infection control. The Annual Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 26 Quality Assurance Assessment recorded under the heading of `our evidence to show we do it well`, “training records”. This does not concur with the inspector’s findings on the day of the site visit. Clear records were available for when staff had undertaken training up until 2006. Under the heading of `our plans for improvement in the next 12 months`, the Annual Quality Assurance Assessment detailed “more training-training plan needed for 2008”. Two staff surveys returned to us recorded, “more training could be offered-I don’t feel there’s enough ongoing training although I’m sure if I spoke to my manager about it she would arrange it” and “Training is given on various subjects but is not always available at the correct time”. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 27 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, 32, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management arrangements in the home are unsatisfactory and the shortfalls identified throughout this report adversely affect outcomes for residents. EVIDENCE: The manager has been at Millard House since 2006 and has experience working in care both within the private sector and within social services. The manager has achieved D32/33 Assessors Award and the A1 Conversion for D32/33. Additionally the manager advised she has undertaken training relating to medication, challenging behaviour, first aid, infection control etc. The manager advised she is not keen to undertake NVQ Level 4/Registered Manager’s Award and would prefer to undertake a different management course, which does not limit her options for the future. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 28 The manager advised that her ethos for the home is to “lead by example”. She stated that she is `hands on` and wants to change `others` thinking and to change institutional practices at the care home. The manager advised that the main challenges are not having sufficient administrative support, not having a deputy manager to assist in the running/management of the home, feels that staff, are very defensive, that there is a `blame culture` and that shortfalls were also evident when the home was owned by the local authority. The manager stated that she feels the home provides a good level of care to the residents, but feels there is insufficient evidence to support this and that the main areas of improvement required relate to staff training and staff supervision. The manager advised, she feels that the organisation, are very supportive and that she receives good support from the home’s senior manager. Staff surveys recorded, “my manager is there for me if I need to talk to her about my workor my personal life” and “manager is always willing to offer advice and practical support when she is at work. She can usually be contacted by phone on other occasions”. At the time of the inspection, the manager had submitted an application to be formally registered with the Commission for Social Care Inspection and this was being progressed. It is evident from this inspection that insufficient progress has been made to address previous identified shortfalls. Areas which continue to require further development relate to care planning/risk assessments, proactive management in meeting individual resident’s care needs, providing a range of activities which meets people’s social care needs, ensuring medication practices and procedures in the home are safe, staffing levels appropriate to meet residents dependency needs, sustained training and development of staff particularly around those conditions associated with the needs of older people and developing consistent staff supervision. The management team at the home must demonstrate a proactive approach to addressing and sustaining good practice, so as to ensure residents continued safety, wellbeing and positive outcomes. The manager must demonstrate a clear sense of direction and leadership, which staff, residents and other parties understand. All sections of the Annual Quality Assurance Assessment were completed. We recognise that the assessment form was completed and submitted to us in December 07, however the information recorded does not give an accurate account of the current situation within the service as some elements provide little and/or no evidence to support the claims made within it. A random sample of residents monies/records were inspected and these were found to be correct. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 29 A random sample of staff supervision records, were inspected and these evidence that although some staff are receiving supervision, these are not as regular as detailed within the National Minimum Standards e.g. no records of supervision for 2 people, 1 record of supervision for one person since 2005, 1 record of supervision for one person since 2006, 2 records of supervision for one person since 07/07 and 2 records of supervision for one person since 11/07. The manager confirmed to the inspector that the above was not happening as frequently as they should, but this would improve in the future. The manager advised that for the future care team leaders, will undertake staff supervisions and it is hoped that they will receive training in this area. The Annual Quality Assurance Assessment under the heading of `our evidence to show that we do it well` states, “supervision records” and under the heading of `how we have improved in the last 12 months`, “more regular supervision and appraisals for staff”. No supervision records were available for the manager. The manager advised that she does not receive formal supervision, however she meets with her senior manager on a regular basis. There was evidence to indicate that regular staff meetings are undertaken. No records of resident meetings were evident, however the manager advised the inspector that these had taken place. A health and safety policy was observed within the home. Accident records were inspected and records were well maintained and included all necessary information. A random sample of safety and maintenance certificates showed that these had been serviced, and remain in date until their next examination. The gas safety certificate was not available and the manager was requested to fax a copy of this to us. At the time of writing this report no copy of the certificate had been forwarded to us. This must be forwarded to us within 7 days of receiving this report. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 30 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 X X 3 1 X 2 Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 31 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 OP7 Regulation 15(1)(2) Requirement Care planning at the home must identify, and be effective in meeting all residents’ assessed needs and ensure that these are regularly updated/reviewed to reflect the most up to date information. Previous timescale of 1.4.07 and 1.4.08 was not met. Risk assessments must be devised for all areas of assessed risk so that risks to residents can be minimised. Ensure that the health and welfare of individual residents is promoted and proactively managed. This refers specifically to ensuring that where people require support, records are updated, staff have the skills to recognise when to contact healthcare professionals and to provide appropriate interventions. Ensure that people are protected from harm by having medication administered safely and in accordance with the prescriber’s DS0000067428.V364086.R01.S.doc Timescale for action 14/05/08 2. OP7 13(4) 14/05/08 3. OP8 12(1)(a) 14/05/08 4. OP9 13(2) 12(1)(a) 16/06/08 Millard House Version 5.2 Page 32 5. OP9 13(2) 17(1)(a) 6. OP12 16 (2) (m)& (n) instructions. Records of medicines 16/06/08 administered to residents must be completed. This will show that residents receive the medicines prescribed for them. Ensure that residents receive a 16/06/08 varied programme of stimulating and interesting activities both `in house` and within the local community so as to ensure people have their social care needs met and do not become bored. Previous timescale of 1.5.07 and 1.5.08 not met. People who live at the care home 16/06/08 must receive adequate quantities of food so as to ensure their health and wellbeing. This refers specifically to monitoring and keeping people’s nutritional needs under review. A record must be kept of all 16/06/08 complaints received that include the date received, a brief description of the complaint, the outcome and whether the complainant was satisfied. Previous timescale of 1.3.08 not met. Ensure there are sufficient staff on duty at all times, and that the deployment of staff is appropriate to meet the needs of residents and to ensure their safety and wellbeing. Previous timescale of 1.4.08 not met. Ensure that robust recruitment procedures are adopted at all times for the safety and wellbeing of residents. Ensure that staff, receive appropriate training to the work DS0000067428.V364086.R01.S.doc 7. OP15 12(1)(a) 8. OP16 22 9. OP27 18(1)(a) 16/06/08 10. OP29 19 16/06/08 11. OP30 18(1)© 01/10/08 Page 33 Millard House Version 5.2 12. OP31 10(1) 13. OP36 18 (2) they perform. This refers specifically to those conditions associated with the needs of older people. This will ensure that staff, have the competence, confidence and ability to meet resident’s care needs. The manager of the home must manage the home with skill and competency so as to ensure the smooth running of the home, that residents’ needs are met and that the home is run in their best interests. Ensure that staff, receive regular supervision so that they feel supported and residents know that staff are appropriately managed. Previous timescale of 1.4.08 not met. 16/06/08 14/07/08 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 OP1 Good Practice Recommendations People that use the service should be provided with a user-friendlier version of the Service User Guide to the home to enable them to have a clear understanding of the services and facilities available. Not inspected on this occasion. Evidence should clearly depict where residents and their representatives are invited to visit the care home prior to admission. Evidence should be available in writing from the registered provider to confirm that residents needs, can be met. As part of good practice procedures, ensure that handwritten MAR records are double signed by staff so as to ensure information recorded is accurate and correct. DS0000067428.V364086.R01.S.doc Version 5.2 Page 34 2. 3. 4. OP3 OP3 OP9 Millard House 5. 6. 7. 8. OP12 OP15 OP27 OP28 9. OP38 Devise an activity programme that is in large print, simple language and/or pictorial so as to enable people to make an informed choice. Consider devising the menu in larger print and/or pictorial format so as to enable people to make an informed choice. On the staff duty roster devise a key for the codes utilised e.g. E, L, N, SN etc. Every effort should be made to increase the number of staff with a NVQ qualification in order to ensure that all people at the home can enjoy the benefits of being cared for by competent and trained staff. Ensure that the home’s gas systems are serviced/safe and that there is documented evidence to support this. Millard House DS0000067428.V364086.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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