Inspection on 17/11/05 for Millbridge

This inspection was carried out on 17th November 2005.

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

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

Other inspections for this house

Millbridge 26/09/06

Millbridge 02/06/05

Millbridge 01/02/05

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 Millbridge 4 Lynn Road Heacham Norfolk PE31 7HY Lead Inspector Jenny Rose Unannounced Inspection 17th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Millbridge Address 4 Lynn Road Heacham Norfolk PE31 7HY 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) 01753 643106 Integrated Nursing Homes Limited John Stanfield Hayes Care Home 52 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (52) of places Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 Brief Description of the Service: Millbridge is a 52-bedded Care home with nursing, and provides care for elderly people and elderly people over 65 who have Dementia. It is a large detached home which has had a number of extensions added, one of which was recently completed to a high standard. It is set in its own grounds on the edge of the village of Heacham, three miles from Hunstanton. The home receives its medical services from the local Medical Centre. The home was purchased by Integrated Nursing Homes in 2004. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the annual inspection programme. It took place over 6 hours on a weekday. On the day of the inspection there were 47 residents in the home. Preparatory work had taken place in the CSCI office beforehand. The Manager was off sick on the day and Mrs Melanie Carr, Senior Nurse, began the inspection. Mrs Sandra Smith, Deputy Manager was attending an in-house Course on Alzheimer’s Disease. Mr Gautam Saraogi, CEO of Integrated Nursing Homes, was present for part of the time and Mrs Ruth Hayes, Operations Manager, later accompanied the Inspector for the rest of the inspection. A tour of the home was carried out and a number of records, policies and care plans were examined as part of this inspection. During the inspection 3 visitors, a group of 5 and a group of 3 members of staff and 4 residents were spoken to. Comment cards were left for the Management, Visitors and Residents at the close of the inspection What the service does well: * Opportunities for prospective residents and their representatives to know that the home will meet their needs. * Provides good personal care * There is an enthusiastic staff team with good communication with management * High priority is given to staff training * All members of staff are included in training courses on Alzheimer’s Disease, not only the nursing and care staff. * The home employs an Activities Organiser who provides group activities as well as a one-to-one service for individual residents. * The health, safety and welfare of residents appear to be well monitored. * The attractive gardens are open to the community for special occasions during the year and visitors welcomed at any reasonable time. * There are several areas of good practice within the running of the home and these are noted in the text of the report. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 and 5 The home works hard to meet the needs of those people with cognitive impairments and prospective residents and their families/representatives are invited to visit the home on a trial basis before making their decision to stay. EVIDENCE: There is evidence of good practice within the home, which demonstrates that the home attempts to meet the needs of people with dementia or cognitive impairments. For some, there are photographs on bedroom doors to indicate ownership of bedrooms and other indicators, like red tape, to indicate other facilities, such as the toilet. There is also close liaison with healthcare professionals with advice on specialist services in the community. Prospective residents and their families/representatives are invited to visit the home before making their decision to stay on a permanent basis. There are also opportunities for prospective residents to receive respite care before making their decision about permanent care. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 9 As well as these visits, there are other occasions upon which people can attend the home for other events, so that the facilities within the home are widely known in the community. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 There are informative detailed care plans, with which residents and their relatives/representatives are involved, if appropriate, and this involvement recorded. EVIDENCE: Four service users were spoken to, as well as some of their visitors and the care plans seen. It was evident from these and from talking to the residents’ visitors and staff, that the recommendation from the previous inspection was met, in that the service user and their relatives/representatives were involved in the assessment, planning, implementation and review of these plans, which ensures that residents’ changing needs are met as far as possible. Three visitors who were spoken to all confirmed that they were involved with their relatives’ care plans and felt able to participate in these with the staff on behalf of their relatives, if appropriate. The plans include detailed healthcare needs, as well as daily and nightly records and reviews, menu preferences, wishes for funeral arrangements and risk assessments. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 11 The home also demonstrates good practice in including signed agreement for residents for others to access their notes and there is also a signed agreement for the use of photographs within the care plans. The Activities Organiser, who works 28 hours a week, provides group activities, as well as one to one services, such as jigsaws or nail care, also keeps records of residents’ life histories, with the residents’ agreement, as well as hobbies and interests, where appropriate, in order to co-ordinate activities for individuals in line with their aspirations and this is seen as good practice. She is also involved in the care plan reviews with other staff, where this is appropriate. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 The home supports residents in maintaining contact with family, friends and the wider community, as well as supporting residents in exercising choice and control over their personal lives; all of which enhances the residents’ quality of life. EVIDENCE: Three visitors were spoken to privately, and all said that they visited most days and stayed for long periods. One reported that the staff were all “very nice and helpful”, that his relative’s clothes were kept well and that there was a good variation of food. He found the management approachable and felt able to raise any issues concerning his relative’s care with them, if necessary. The Operations Manager reported that visitors were encouraged to visit for meals if they wished and this was confirmed by one of the visitors spoken to. The local community were welcomed into the home, again confirmed by a visitor, and the home hosted local events, such as the Scarecrow Festival and the annual Dog Show. Two residents spoken to demonstrated that they were able to exercise choice and control over their lives. These residents were both choosing to stay in Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 13 their rooms at the time, and one was listening to her choice of music, having just been out. One resident said she was pleased to be able to entertain her visitors, not only in her room, but also in the ‘conservatory’ area on the same floor, where there was an attractive view on to the river. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents and visitors are aware that there is a complaints procedure and feel able to raise any concerns if they had any. EVIDENCE: There is a clear complaints procedure and this is displayed around the home. The visitors spoken to were all aware of the complaints procedure and reported that they felt able to approach the Management if there were any issues they wished to raise. One visitor had had cause to raise an issue, but had found this had been dealt with satisfactorily, and this was confirmed by another visitor. Two residents spoken to were aware of the complaints procedure and felt able to complain, if necessary. The complaints file was seen and complaints had been dealt with appropriately and the CSCI were notified in writing. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 The attractive buildings and surrounding gardens are well maintained and provide a safe and comfortable home for the residents. EVIDENCE: The original buildings of the home contain some attractive, old, architectural features, which have been retained, including decorative fireplaces in some bedrooms and a wall painting. The gardens surrounding the home include a river running through them, which not only provide an attractive, wellmaintained outlook from many rooms, but also are also accessible by wheelchair so that all residents can enjoy the gardens, if they wish. There is also much wildlife in the garden, including ducks and other birds, which provide interest for residents. The home employs a part-time gardener. The home employs a full-time maintenance person and his weekly log and maintenance schedule was seen to be well kept, which is seen to be good practice. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 16 The maintenance person deals with water temperatures, the chart for which was seen to be in order and also keeps a redecoration chart. He has recently been supplied with a lap top computer upon which he can keep his own records. There are plans to extend and refurbish the home in the coming year to provide up-to-date facilities for the residents. A number of bedrooms were seen, these were comfortably furnished, some with residents’ own furniture and were personalised with residents’ possessions. The communal rooms were also seen to be comfortable and homely. There were a number of radiators, particularly in communal areas and in some bathrooms and toilets, which were not covered, due to problems with the suppliers. The Operations Manager reported that it was hoped that these would be completed in the near future, however, there is a Requirement that these be risk assessed in the meanwhile. There were two, easily remedied, trip hazards identified on the day of the inspection. In one bedroom there was a trailing flex for an extension lead to a reclining chair and in another bedroom, a telephone flex had become unpinned from the threshold to a doorway. In this particular room there were French doors to the outside, which were a Fire Exit. These were locked, but there was no key visible. There is therefore a Requirement that all these potential hazards are risk assessed. The Environmental Health Officer had last visited on February 2005. There were two recommendations, which had been complied with. All areas of the home seen were clean and hygienic. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 Emphasis on training for all staff, the observable teamwork and good communication further ensures that the residents’ changing needs are met and that their safety is protected as far as possible. EVIDENCE: There is a high proportion of qualified staff employed in the home in all strata. The Manager and Deputy Manager have management qualifications and the Administrator has an NVQ in Business Administration. There are a high number of staff with NVQs in care, and 7 with NVQs in Hotel Services. All staff complete the TOPSS training. The Nursing staff are kept up to date with their skills and the home gives adaptation training to nurses from abroad, two at a time. The staff team also welcomed the input of students on placement from time to time from the University of East Anglia. A group of five staff were spoken to, all of whom were enthusiastic about their work in the home. The home has a dedicated laundry person, dedicated domestic and kitchen staff and the home operates a policy of including all staff on training courses. A good example of this on the day was that 9 members of staff were attending a course on Alzheimer’s Disease, including the cook, domestic staff as well as care assistants, which is good practice. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 18 The majority of staff members have now attended a course on Alzheimer’s Disease. The members of staff spoken to were appreciative of the training opportunities offered to them. They were all aware of the issues surrounding adult protection. The home runs its own in-house adaptation training for nurses from abroad and there is a training matrix demonstrating that all nursing staff are encouraged to improve and maintain their nursing skills. A tutor arrived during the inspection to deliver a course on wound care. A high number of nursing staff have been trained in pain control, palliative care and bereavement care. A Senior Carer spoke of a “happy ship” being run in the home and it was evident from observation on the day, in the manager’s absence, from this group and from another group of staff spoken to that there was an effective staff team work and good communication between them. All members of staff said that they found management staff approachable and they felt well supported at all times and through the supervision process. One visitor commented that she was ‘delighted with the care’ given to her relative and that she visited frequently, unannounced, at different times of the day and had always found the staff very kind and approachable. A resident remarked, “the place couldn’t be any better”. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35, 38 Good records are kept of the high priority given in the home to respecting the residents’ best interests, be they financial, or their health, safety and welfare. EVIDENCE: The recommendation from the previous inspection that there should be a published residents’ survey, has been carried through. There is now available in both sections of the home an analysis of the biennial survey of residents’ and others’ views of the home. It is in chart form and easily read. Residents’ meetings take place once a month and are announced in the monthly newsletter for residents produced by the Activities Organiser. Also, there was a recommendation from the previous inspection that there should be numbered receipts for residents’ small, personal monies and this was seen to be complied with. The home does not handle fees or any other financial transactions on behalf of residents. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 20 Many records were viewed with reference to health and safety issues in the home, including an electrical inspection, which had taken place on 4 November 2005. The home employs a full-time maintenance person who deals with everyday issues, and has a weekly maintenance schedule and report and he records his work on a lap top computer. The Operations Manager has completed an Advanced Health and Safety qualification and is in overall charge of the development of policies and procedures on the these issues in the home. Maintenance records for such equipment as the lift, the boiler and hoists were seen to be up to date. There was an Infection Control Audit and a full Health and Safety Audit and a two monthly internal care audit, covering such issues as record keeping, staff training, environment, catering and recreation. Task risk assessments and moving and handling issues were updated six monthly. There were fire, windows and call system risk assessments and risk assessments in their working practices for staff who were pregnant. The Accident Book was seen and a routine Falls Audit was taking place during the inspection. All of the above is seen to be good practice, but as mentioned elsewhere in the report, there were two issues, which have elicited a Requirement regarding risk assessments for trip hazards and uncovered radiators. Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13(4) Requirement The registered person must ensure that a risk assessment is undertaken for all areas of the home to ensure that any unnecessary risks are reduced. Timescale for action 18/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Millbridge DS0000061023.V267348.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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