Inspection on 19/12/07 for Millard House

This inspection was carried out on 19th December 2007.

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 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 14/05/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Millard House 364 Church Street Bocking Braintree Essex CM7 5LL Lead Inspector Brian Bailey Unannounced Inspection 19th December 2007 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.V356818.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.V356818.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.V356818.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 16th January 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. CSCI inspection reports are also available from the home, Rushcliffe Care and on our website www.csci.org.uk. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that was carried out on the 19th December 2007 and lasted 7.5 hours. It was a “Key” inspection, which focused on the intended outcomes that related to Care Homes for Older People. The report has been written using accumulated evidence gathered prior to and during the site visit. The inspection visit to the home included: discussion with the manager and staff; inspection of communal areas, a sample check of bedrooms, bathrooms and toilets, the kitchen and the laundry; inspection of a sample of records and policies; conversations with 8 staff, 6 people that live at the home and 3 relatives; and feedback questionnaires from staff. This report also draws on any other information relating to the home received by the commission since the last inspection visit such as notifications of any incidents. The manager completed an Annual Quality Assurance Assessment (AQAA) although this was not made available to us within the timescales required. Outcomes relating to 26 standards were inspected: there were thirteen requirements resulting from this inspection, and three good practice recommendations have been made. The staff were very welcoming, helpful and constructive throughout the inspection. What the service does well: What has improved since the last inspection? There were no identified improvements to the home since the last inspection, although a core group of experienced and confident staff continue to support people living at the home. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 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 Millard House DS0000067428.V356818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is poor. Pre-admission assessment practices do not ensure that prospective people can be sure that the home fully understands their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home is available in the Statement of Purpose and the Service User Guide; copies of these are available in the office at the home. It was not possible to determine from the care records however, whether people are provided with this information when they are considering whether to live at the home. The care records of three people were checked and although each contained a contract between the home and the resident, these had not been completed. Information was available to show that an assessment of need had been carried out, but these lacked detailed guidance for staff and a very limited range of care needs and had not been signed or dated. There was no evidence Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 9 to show how the service had determined that they were able to meet the care needs of the people admitted or how this information been conveyed to each person. Assessments from the placing authority were available on two files. The home’s AQAA indicates that the manager undertakes in depth preadmission assessments, but there was a lack of evidence to support this statement. This home does not provide an intermediate care service. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 10 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 adequate. Care plans still need to be developed to ensure that people’s needs will be met in accordance with their wishes. Medication practices were sufficiently robust to fully protect people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files and care plans of three people were checked. Each file had basic details listed such as the GP, next of kin, photograph (one file only), contact details, an inventory of possessions at the time of admission and a “Getting to know you form, which was signed by one person, dependency levels, Waterlow tissue viability assessment, manual handling assessment, a weight record, and an “Activities of Daily Living Care Plan”. Issues raised in the local authority assessments of need were not translated into care plans and guidance for staff. Review notes were seen for one person dated 28/3/07 when all present agreed the placement should continue as no problems had been encountered, which does indicate that the person was happy with living at the home. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 11 The health care needs of people were being met as diary notes were seen of visits by health care professionals. A survey form returned to us stated, “Care staff call for home visits appropriately and also inform the district nurse of any changes to the service users’ health and well being”. The quality of the information varied on each file from minimal to reasonable. In discussion with all staff on the morning shift and the afternoon shift, all considered they care for the people to the best of their ability. This view was based on many years of experience, in one case over twenty years, training undertaken and good team support. Four staff said they had no doubt that people at the home were safe and were not at risk from being supported other that than the way that wanted. Staff did acknowledge that due to a lack of information and guidance, care provided in the first weeks following admission did not necessarily reflect people’s wishes. Care plans identify some of the needs without providing sufficient guidance to staff as to how each care need is to be met. The home uses a monitored dosage system (MDS) for administering medication, which means that the majority of medication is dispensed from blister packs prepared by the pharmacist. MAR sheets were checked and found to be accurate and up to date. Each MAR sheet had an identification photograph of the resident. The home has a detailed medication policy available for staff. At the end of each shift a formal handover for the responsibility for the medication is carried out. The shift leader demonstrated how the system works and confirmed that only senior staff that have received the appropriate training are permitted to be responsibly for administering medication. Controlled drugs are kept in a separate lockable cupboard and a register is maintained of medication administered and the balance remaining with two signatures for each entry. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. People living in the home are not supported or have the opportunity to participate in activities appropriate neither to their capabilities nor in accordance with their interests. People using this service benefit from being provided with a healthy and balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not employ an activities co-ordinator. As reported at the previous inspection, staff complete a form “Getting to know you” for each person that is admitted to the home. These were seen on the three files checked and they did contain information about their interests and hobbies. The home’s annual quality assurance assessment (AQAA) states that daily papers or magazines are to commence on the day of admission, the adjacent day care centre is available on Saturdays and that staff read newspapers to Residents/do crosswords in a group/ do impromptu activities (as time dictates) and Residents choose which activities they want daily and through Residents meetings. Evidence was not available on the day of the inspection to support this and no staff were observed undertaking any activities. One visitor spoken Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 13 with considered that more opportunities for stimulation was required. Visitors said they did feel able to visit and to come and go as they please. People living at the home were observed in the lounges but the majority were either watching television or asleep. Three people spoken with were very happy to chat but none were involved in any form of activity. One person said they had no complaints and “I like it here, the staff are kind”. Observation of people in the first floor lounge and landing showed they were not involved in any form of activity although staff were seen to spend time and to speak to people and they always responded to requests for assistance. People living in the first floor lounge do not have free access to the ground floor or gardens with out the support of staff. As the number of staff allocated to the first floor is two, there appears to be very little scope for people to be supported to have time away from their unit. One staff member stated in a survey returned to us “The service would be better if there was more staff on duty and we would then be able to offer more to residents individually, by taking them to town, garden centres for tea and walks out and sitting talking to them”. The cook, care staff and people living at the home confirmed that there is a choice of meals offered every day. The dining room facilities consist of the large dining area on the ground floor adjacent to the main kitchen and a dining area of the lounge of the first floor and an adjacent landing. Records were maintained to show what meals people had selected. It was noted that some people had their meals liquidised; the individual elements of the meal were liquidised separately meaning that different flavours were still present for people to enjoy. Good food stocks were available including fresh fruit and vegetables. In the ground floor dining area, the midday meal observed was well presented and looked appetising; dining tables were well laid out and drinks were provided. Staff were observed assisting people to eat their meal in a respectful manner and were not attempting rush people. The dining areas on the first floor appeared rather crowded and owing to the high level of dependency of most people, the two staff were observed to provide close attention throughout the meal. Three people spoken with that were in the dining room being served with their lunch confirmed they were very happy with the quality and quantity of food provided. Staff were observed asking people for their selections of meals. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. People that use this service will be protected by the homes’ procedures but are not shown information to confirm this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which is printed in both the Statement of Purpose and the Service User Guide. The procedure states that an investigation will be carried out into all complaints; there is a time scale for responding to complainants and contact details of the head office of Rushcliffe Care. The home’s AQAA states that the home has received two complaints in the last twelve months; both were investigated and both complaints were considered as upheld. At the last inspection of this home in January 2007, complaints received were recorded and kept in a file together with responses to the complainant, but this evidence of the way the home has dealt with complaints since then was not available for this inspection. There are clear policies and procedures in place to ensure the protection of people living there from abuse. There had not been any protection incidents in the past year. The training data available at the last inspection showed that all but one member of the care staff had received POVA training and that further sessions were planned for February, March and April 2007. Information was not available to confirm this although all staff spoken with during the inspection visit confirmed they had received training. The home has indicated Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 15 in their AQAA that they plan to provide more POVA training during the next twelve months. The home has a Whistle blowing policy. . Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 16 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, 20, 24, 25 & 26. Quality in this outcome area is adequate. People that use this service will find that much of the accommodation is bright and cheerful, but for some people, they may be disappointed that there is an area that smells and that a bathroom is out of action. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is a large detached purpose built two-storey property that was designed so that the majority of lounges are on the ground floor and most of the bedrooms are on the first floor. There is a passenger lift that provides access to the first floor, which broke down earlier in the year and was out of action for more than five days. This had been a cause for concern by a relative who contacted us, as they had received a poor response from the manager when they raised it with them. A partial tour of the building was carried out that included the kitchen, laundry, lounges, dining room, bathrooms, toilets and some bedrooms. The majority of Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 17 areas were clean and tidy, but odour control was not effective in the first floor lounge and the adjacent dining facilities area in the corridor/landing. From observation at 10:15am and at 4:30pm, the bathrooms and toilets were clean. The laundry was clean and well organised. A bathroom on the first floor was observed to be out of use and according to staff, this has been the situation for several months and they had no idea when repairs would be carried out. The kitchen is well equipped and the standard of hygiene and cleanliness was again observed as good. Access at the front door is good. Previous issues relating to a lack of disposable protective clothing for staff have been rectified. No further complaints have been received and a plentiful supply was observed at the home. Lounges on the ground floor appeared to be little used and one room was rather disorganised and contained several large boxes. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. People that use this service will be supported by a team of caring staff but they may be at risk if staff are not employed in sufficient numbers or adequately trained. People may also be at risk if staff recruitment procedures are not followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On arrival at the home it was noted that five care staff plus a shift leader and the manager were on duty for the morning, but one care staff member was designated to work in the servery, which according to staff is the normal practice and means that in reality, the care staff team as one less person. The staff roster was not available to check the number of staff that had been on duty the previous week. In addition to the care staff, there were two cooks, a laundry person and a cleaner. Eight care staff spoken with were of the opinion that the current system for the management of the home was not working well. They felt there were insufficient staff to support the manager, which was also the opinion of two visitors spoken to. Staff said that as one member of the care staff is designated to work in the servery each day and shift leaders spend time administering medication and answering phone calls and general queries, this often leaves a care staff team that struggles to cope. Care staff spoke of not being able to recruit staff from an agency or have the Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 19 use of bank staff, which often leaves them short. Staff also said that when a shift leader is not available for duty because of sickness or there is a vacancy, the manager has to take on that role, which means the home is not being managed effectively. Staff felt strongly that they were not respected by the owners and it was due to their experience, long term service and their commitment to work as a team and to be supportive of each other that has ensured people living at the home receive a good level of service. Three surveys were returned to us from staff, one person stated, “Millard House has a very good team of genuine carers and although we are usually stretched to our limit, we are still very caring, warm and friendly”. Three visitors spoken with were complimentary about the staff but didn’t believe there were enough staff. Two visitors said there was often no one available to answer the phone when they rang the home and they wanted the key worker system reintroduced. The home’s annual quality assurance assessment (AQAA) states that all staff employed in the last 12 months had satisfactory pre-employment checks. However, recruitment documentation was not available for sample checking as staff files were kept in the manager’s office, which is locked in their absence. It was not possible therefore to check whether references and Criminal Record Bureau Disclosures for each new member of staff had been obtained, and that staff had been checked against the Protection of Vulnerable Adults register prior to commencing employment. However, at the last site visit to Millard House, the files of five staff employed by Rushcliffe Care were checked. These were up to date and included the correct documentation such as Criminal Record Bureau disclosure information, application forms, contracts, training certificates and references. The AQAA also states that of the 25 permanent care staff, 8 have achieved National Vocational Qualification (NVQ) level 2 or higher and 2 only are currently working towards a NVQ level 2. Records were not available at the home to confirm the accuracy of these figures. Based on these figures though, the home has not managed to meet the recommended target of 50 of care staff obtaining this level of qualification. The home’s AQAA states “All new staff have to complete an induction programme based on Skills For Care induction” and that they “Encourage staff to progress in the company by furthering their skills and offering opportunities to undertake senior training/mentoring”. Evidence of training information to support this statement was not available for inspection. The previous site visit to Millard House also considered that only minimal information on induction training was available Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. People do not benefit from living in a home, which is well run and considers their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current manager has been in post since December 2006, and an application for registration with us remains outstanding. The manager does not have the benefit of a deputy manager to share the managerial responsibilities of the home or an administrator to assist with maintaining records. The manager, staff and relatives spoken with consider this to be a major problem. Two relatives spoken with said that they often have to wait a long Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 21 time for the telephone and the front door bell to be answered. Shift leaders said they were also concerned as they often had had to interrupt administering medication to answer the telephone and this is potentially dangerous. As required by regulations, the annual quality assurance assessment (AQAA) was not returned within the required timescales. The home has a good range of policies and procedures that are reviewed regularly and include an up to date health and safety policy. The AQAA indicates that essential equipment and safety systems are maintained but the required dates of when the fixtures and equipment in the home were last inspected and serviced were not included. The AQAA does state, “Regular audits are undertaken to ensure that quality is maintained and improved on, including all aspects of Health & Safety”. However, during the site visit, mobile hoists seen had labels attached to show they had been serviced within the past six months. Two staff spoken with did comment that one of the hoists on the first floor had a faulty switch that was difficult to operate. Information was available to show that fire drills are held and the fire detection system was serviced 24/7/07. The Health & Safety records available in the office contained limited information only and it was not possible to verify whether all appropriate servicing had been carried out such as to the gas supply and boilers. The home’s AQAA indicates that surveys of residents and relatives are carried out, but no information was available for inspection to show when the last survey was conducted or what the outcome was or that any actions had been taken as a result of this. Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 22 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 3 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 X X X 3 3 2 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 X 2 Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 (1) a, b, c, d. Requirement Detailed pre-admission assessments must be obtained for all prospective individuals to enable the home to determine whether it can meet the person’s needs. Care plans must continue to be expanded and developed to ensure that staff are provided with clear guidance to enable them to support people in a manner that meets their wishes. This is a repeat requirement from the last inspection. The timescale of 1/4/07 was not met. A range of stimulating and interesting activities must be developed and residents encouraged to participate and pursue any interests and hobbies. This is a repeat requirement from the last inspection. The timescale of 1/5/07 was not met. Timescale for action 01/02/08 2 OP7 15 (1) 01/04/08 3 OP12 16 (2) (m) (n) 01/05/08 Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 24 4 OP16 22 (8) A record must be kept of all complaints received that include the date received, a brief description of the complaint, the outcome and whether the complainant was satisfied. This remains a repeat requirement, as the information was not available to check. 01/03/08 5 OP18 18 (1) a The registered manager must 01/05/08 ensure that all staff receive up to date training in the protection of vulnerable adults from abuse. This remains a repeat requirement, as the information was not available to check. Repairs to the bathroom on the first floor must be carried out to ensure the room is made available again to people and they are not inconvenienced by the disruption. Odour control must be improved in the area of the first floor lounge and adjacent dining area to provide people with a cleaner and more pleasant environment. The manager and/or senior staff must have contingency plans available to ensure that in the event of staff sickness and/or when there are staff vacancies, sufficient staff are always available to support people at the home. The staff duty roster must be available. Staff induction training records must be available to demonstrate that staff have been provided with the necessary skills to carryout their DS0000067428.V356818.R01.S.doc 6 OP21 23 (2) c 01/03/08 7 OP26 23 (2) d 01/02/08 8 OP27 18 (1) (a) 01/04/08 9 OP30 17 (2) 6 g 01/04/08 Millard House Version 5.2 Page 25 10 OP33 24 (1) (a) (b)24 (3) duties. The home must carryout regular quality assurance surveys of residents, relatives, staff and others, as their feedback will contribute to and influence improvements to services and standards. This remains a repeat requirement, as the information was not available to check. Regular supervision must be provided to all staff to guide the way staff work, to reflect on their work practices and as a means to support staff to ensure that residents receive care to a consistently high standard. This is a repeat requirement as the information was not available to check. 01/05/08 11 OP36 18 (2) 01/04/08 12 OP37 17 (1) (2) & (3) All records required by the 01/03/08 regulations must be available for inspection at all times so that the Commission can be satisfied the home has taken all measures necessary to protect people at the home. All staff must be trained in accordance with the Health & Safety regulations, which include, first aid, fire training, food hygiene and moving and handling. This remains a repeat requirement, as the information was not available to check. 01/04/08 13 OP38 23 (4) (c) (iii) (e) Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 26 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 OP28 Good Practice Recommendations Every effort should continue to be made to increase the number of staff with a National Vocational Qualification in order to ensure that all people at the home can enjoy the benefits of being cared for by competent and trained staff. 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. A log should be maintained of all matters relating to the servicing of equipment and services. This information would be more readily available than currently and provide assurance that all the necessary Health & Safety checks have been carried out to safeguard people. 2. OP1 3. OP38 Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Millard House DS0000067428.V356818.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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