Inspection on 26/09/06 for Millbridge

This inspection was carried out on 26th September 2006.

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 17/11/05

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 Mrs Geraldine Allen Unannounced Inspection 26th September 2006 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 Millbridge DS0000061023.V316045.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. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 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) 01485 570349 millbridge@inhcare.com Integrated Nursing Homes Limited John Stanfield Hayes Care Home 53 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (52), of places Physical disability (1) Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 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.V316045.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day. This report contains information provided by the home before and during the inspection. Prior to the inspection, the home provided a completed pre-inspection questionnaire together with documents relating to practice at the home. On the day of inspection, some records were seen and evidence was obtained by talking with residents, visitors, staff and the manager. A meal was eaten with residents in the main dining room and a tour of the house and gardens conducted with the manager. Overall, this home provides excellent care that is centred on the individual needs of the residents. Letters of appreciation were seen and spoke of “tender loving care”, excellent care and support”, care and compassion” and “courteousness, patience and professionalism”. What the service does well: What has improved since the last inspection? What they could do better: Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 6 There was some discussion about how the home can achieve continuous improvement. Because of the high standard to which this home operates, recommendations that have been made are about recognised best practice. These include making sure that records about the care given to residents do not focus exclusively on the tasks completed by staff and about ensuring contact details for resident’s next of kin are completed and kept up to date. As stated above, rooms currently in need of redecoration will be dealt with following completion of the building works. 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. Millbridge DS0000061023.V316045.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 Millbridge DS0000061023.V316045.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs assessed to ensure they can be met by the home. EVIDENCE: Residents have a full needs assessment completed before moving into the home to ensure that the home can meet their physical, social and emotional needs. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans were holistic and generally well presented. The home has good relationships with local agencies to ensure residents receive healthcare support in a timely way. Medication procedures are robust and followed. Good records were seen. Residents were treated with respect and their privacy and dignity was protected. EVIDENCE: Three care plans were looked at in detail and showed they are based on full and regularly reviewed assessments of need. Staff spoke about how they provide care to residents and their practice was observed throughout the day. Staff were seen treating residents with respect and dignity throughout the day. Residents and relatives spoken to confirmed they felt well cared for and that their privacy and dignity were respected by staff. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and visitors speak highly of the care provided. Residents enjoy a very good quality of life that is in accordance with their wishes and preferences. Residents are supported to exercise autonomy and control over daily living. EVIDENCE: Residents said they were able to take part in a variety of activities and felt able to make choices about this. They also described how they are encouraged to make choices about their daily living and these are respected by staff. Residents felt fully informed about what was going on in the home and a copy of the monthly newsletter was seen. Residents spoke enthusiastically about the quality, variety and choice of food. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 11 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are aware of the complaints procedure and feel confident that their concerns will be taken seriously and acted upon. Staff are well trained and knowledgeable about adult abuse matters. EVIDENCE: The home’s complaints procedure was displayed in the entrance hall. Residents spoken to were aware who they should speak to and were confident any concerns would be taken seriously and acted upon. Staff receive training about abuse awareness and staff spoken to were knowledgeable about this matter. Staff practice was observed and was respectful. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 12 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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and the home’s maintenance worker completes routine maintenance work efficiently. Planned building works have delayed some decoration but this will be dealt with once the building is completed. All areas were clean and tidy. EVIDENCE: A tour of the premises was made and this showed that the home is well maintained, clean and safe. Resident’s bedrooms were personalised with many items, including furniture. The gardens were accessible to residents and provide a pleasant external environment for residents to enjoy. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 13 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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s recruitment and training policies. Training is of a particularly high standard, with in-house trainers available to offer timely support and instruction in some instances. Staff are employed in sufficient numbers to meet the needs of residents and there is a good skill mix on each shift. EVIDENCE: Two staff files were looked at in detail. Three staff were spoken to in private and all staff on duty were seen during the staff handover meeting. The home operates very good recruitment processes that protect residents. Staff are very well trained in all matters that affect the care and any conditions of residents. The staff duty sheet showed there were sufficient staff on duty to meet the needs of residents. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 14 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, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some elements within this group are excellent, specifically how the home seeks the views of stakeholders and the way in which the health & safety of residents, staff and visitors are protected. A very competent, experienced and qualified manager runs the home. Resident’s personal allowances are kept with the home using good practice. Staff supervision takes place on a regular basis. EVIDENCE: Time was spent speaking with Mr Hayes, who is a competent, experienced and well-qualified manager. The home operates very good quality auditing procedures that include seeking the views of all people who receive care or Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 15 have dealings with the home. The records kept for residents whose personal allowances are looked after by the home were seen. There was evidence of good practice seen. The home has policies in place to ensure the health and safety of residents, staff and visitors to the home. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 16 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 17 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. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard OP7 OP7 Good Practice Recommendations It is recommended that the daily accountability record includes information about daily activity and how the resident spent their day. It is recommended that the emergency contact information sheet on each care plan is completed and signed by the resident’s next of kin in all cases. Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 18 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Millbridge DS0000061023.V316045.R01.S.doc Version 5.2 Page 19 - 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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