Inspection on 17/03/06 for Millbrook House

This inspection was carried out on 17th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Millbrook House 29/10/08

Millbrook House 03/11/06

Millbrook House 28/09/05

Millbrook House 23/03/05

Millbrook House 18/01/05

Millbrook House 15/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Millbrook House Child Okeford Blandford Dorset DT11 8EY Lead Inspector Martin Bayne Unannounced Inspection 08:45 17 March 2006 th 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 DS0000026843.V283119.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000026843.V283119.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Millbrook House Address Child Okeford Blandford Dorset DT11 8EY 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) 01258 860330 Millbrook House (Dorset) Limited Mrs Sharon Chalke Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places DS0000026843.V283119.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Four rooms only may be used for double occupancy at any one time. Rooms which may be used as doubles are Rooms: 1, 5, 15, 20 and 21 to 28 inclusive. No more than three service users may be provided with day care at any one time. Two service users, known to the CSCI, under the age of 65 may be accommodated. 28th September 2005 Date of last inspection Brief Description of the Service: Millbrook House is registered to provide accommodation and personal care for up to 33 people who have frailty of old age. There is a temporary variation to the registration for the home to accommodate two named people under the age of 65. The home has been extended on two occasions building onto the original Georgian House. The home has large well maintained gardens. The home has 25 single rooms and 6 double rooms. There are two lounge areas and two dining rooms. The home has three passenger lifts for accessing the floors above ground level. DS0000026843.V283119.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place between 8:45am and 1:15pm. The inspector was assisted throughout the inspection by the Registered Manager, Mrs Chalke. The aim of the inspection was to follow-up on the requirement made at the last inspection and requirements made at subsequent visit to the home to investigate a complaint. The home was also evaluated against core minimum standards. During the inspection a tour of the building was made, a sample of records was seen and ten residents spoken with about their experience of living at the home. What the service does well: 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. DS0000026843.V283119.R01.S.doc Version 5.1 Page 6 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 DS0000026843.V283119.R01.S.doc Version 5.1 Page 7 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): 3 The home now complies with the standards for older people in terms preadmission assessment of need. EVIDENCE: A visit was made to the home in December to investigate a complaint. A requirement was made that once an assessment of need has been completed, a letter should be sent out confirming that the home can meet the needs of a person referred to the home. The file relating to one resident who was admitted to the home since this time was viewed and it was found an assessment of need had been carried out by the registered manager prior them being offered a place at the home and a letter had been sent to confirm that their needs could be met at the home. DS0000026843.V283119.R01.S.doc Version 5.1 Page 8 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): 8, 9 & 10 Daily recording concerning residents’ stay at the home has improved. The medication policies and practices are in line with good practice however greater safety would be promoted by the staff who administer medication receiving formal training. Residents’ privacy and dignity is respected by the staff and working practices. EVIDENCE: A requirement resulting from the complaint investigation was met. This had been made with regards to daily recording, with particular reference to recording any difficulties that the person may have in settling into the home to provide a complete record. It was found in the case of the resident tracked through the inspection that recording was of sufficient detail to assess how the person was settling into the home. The home has a policy for the receipt, recording, storage, handling and administration of medication. Medicines are stored in a medication trolley that is kept in the “watch room” locked to the wall. Only senior member of staff administer medication and there is one set of keys for the medication cabinet, so that there is one person on duty with responsibility for medication. Currently the registered manager gives cascade training to the staff who DS0000026843.V283119.R01.S.doc Version 5.1 Page 9 administer medication. It was recommended that these staff receive some formal training covering the topics listed in the “Older Person Standards”. The medication administration records for all of the residents were seen and these were found to be completed correctly with no gaps within the records. The home uses a unit dosage system and it was found that medicines were being stored correctly. The home has an arrangement with the local pharmacist who visits and advises the home. During the inspection ten residents were spoken and all said that the staff team were respectful of their privacy and dignity. They said that the staff were aware of their care needs and that calls bells were answered promptly. DS0000026843.V283119.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 Residents are consulted as to the activities that are provided with the home and can receive visitors when they choose. The home meets the dietary needs of residents, who are consulted on the meals provided and offered choice. EVIDENCE: A recommendation was made after the complaint investigation that social activities in the home should be generated from individual discussions with residents as well as in a group setting. At this inspection the residents spoken with were asked about activities that take place in the home and this topic was then discussed with the registered manager. The majority of the residents do not want formal weekly activities, preferring to make their own social arrangements through their circle of friends. There is also a group of residents who enjoy communal activities arranged through the home. There was evidence through residents meeting minutes that ideas and the need for the home to organise activities had been discussed regularly during meetings. Since the recommendation had been made, Mrs Chalke, the registered manager has started to meet individually with residents to discuss and review a person’s stay at the home, with activities being one of the topics discussed. The discussions with residents reflected that the majority of residents were satisfied with overall provision within the home with some form of activity or event taking place each day. It was also found that trips had been arranged away from the home later in the year. DS0000026843.V283119.R01.S.doc Version 5.1 Page 11 The residents spoken with informed that they could have relatives and friend visit at any time and there were no restrictions. The residents spoken with were all asked about the quality and food within the home. In general the comments made were positive. A recommendation was made resulting from the complaints investigation that improvements are made to the evening meal. The records of food were seen and these reflected that a wholesome and varied diet was being provided at the home, with a cooked main meal at lunchtime and a full three course meal being served in the evening. There was evidence provided through minutes of the resident’s meetings that residents are involved in menu planning and food that is provided in the home. Each morning the staff consult with residents about their choices for meals of the day. The home was found also to cater for specialist diets should these be required. DS0000026843.V283119.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents have access to the home’s complaints procedure. EVIDENCE: Since the last inspection there has been one complaint brought to the attention of CSCI, parts of which were substantiated with recommendations and requirements made. These are referred to throughout the report. DS0000026843.V283119.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home will provide a safer environment to residents with the covering of radiators. Residents are protected through infection control policies and procedures being in place. EVIDENCE: On the day of inspection the home was warm, clean, in good decorative order and free from adverse odours. Residents spoken with informed that these standards were always maintained in the home. It was evident from visiting residents in their rooms that they were able to bring their possessions to personalise their rooms. At the last inspection it was agreed that a plan would be put into effect of covering the radiators in the older part of the building in order to protect residents form the risk of burns. It was found at this inspection that work had started on covering radiators that posed the highest risk and all radiators are to be covered. DS0000026843.V283119.R01.S.doc Version 5.1 Page 14 Since the last inspection the stairway, landing and hallway in the original part of the building has been re-painted and quotes have been received to re-carpet these areas. The home has policies and procedures concerning infection control and staff are provided with gloves, aprons and protective clothing and alcohol gel for cleaning of hands are available. The home had recently suffered an outbreak of a viral gastro-intestinal illness and the and had worked closely with the infection control nurse in eradicating the illness from the home. The home has a macerator for disposal of pads and also has a contract for disposal of clinical waste. The senior staff are trained in continence care. DS0000026843.V283119.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 Residents could potentially be put at risk through POVAFirst checks not being carried out prior to a member of staff being employed at the home. Staff receive appropriate training in order to carry out their role in the home. EVIDENCE: At the last inspection a requirement was made concerning the records and checks required to be made in respect of new staff. A sample of four staff files was therefore seen and checked against the regulations concerning recruitment of new staff. It was found that in the case of one of these staff members, no POVAFirst check had been carried before this person had started working at the home. In other respects the required checks had been undertaken. The requirement remains in force. A recommendation was also made to amend the staff application form to request from applicants the information required by changes to the legislation in July 2004, such as seeking a reference from the persons last place of employment of not less than three months of working with vulnerable adults. The staff records viewed confirmed that staff receive appropriate induction training and further core training to meet the needs of residents. DS0000026843.V283119.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 & 38 The health and safety of residents is promoted in the home through compliance with the legislation. EVIDENCE: Mrs Chalke informed that all of the residents manage their own finances or receive assistance from their families. The home does not safe keep any monies on behalf of residents. The fire log book was inspected and it was found that the tests and inspections of the fire safety system were being carried out to the required timescale. The boilers had been inspected and certified as being safe. Equipment and portable electrical equipment wiring had been tested as required. The home was last visited by the Environmental Health Officer in 2005 and there are no outstanding issues relating to this inspection. Thermostatic mixer valves are fitted to the hot water outlets in order to protect residents from scalding fro hot water. As mentioned earlier in the report the home has started with the planned covering of radiators. DS0000026843.V283119.R01.S.doc Version 5.1 Page 17 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 X 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 DS0000026843.V283119.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? 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 Schedule 2 Requirement You are required undertake the recruitment checks as detailed in Schedule 2. This is a repeated requirement from 28/9/05 Timescale for action 01/04/06 1. OP29 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 OP9 OP29 Good Practice Recommendations It is recommended that the staff who administer medication to residents receive formal training in line with the standards for older people. It is recommended that the home amend the staff application form to reflect the changes to the Regulations of July 2004. DS0000026843.V283119.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000026843.V283119.R01.S.doc Version 5.1 Page 20 - 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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