Inspection on 28/09/05 for Millbrook House

This inspection was carried out on 28th September 2005.

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 17/03/06

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 28 September 2005 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 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. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Millbrook House Address Child Okeford, Blandford, Dorset, DT11 8EY Telephone number Fax number Email 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 Four Seasons Healthcare (Dorset) Ltd Mrs Sharon Chalke CRH - PC Care Home only 33 Category(ies) of OP - 33 registration, with number of places Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 23 March 2005 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 two passenger lifts for accessing the floors above ground level. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 8.45am and 2pm. The aim of the inspection was to follow up on the 14 requirements and 6 recommendations made at the previous inspection and to evaluate the home against the core standards. Through discussion with the registered manager, viewing records and speaking with about half of the residents, it was found that all but one of the requirements had been met and all of the recommendations met. In general the residents spoke very highly of the home, the staff team and the care that they received. 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. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 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 standard(s) 3 Residents benefit from an assessment of their needs being undertaken prior to being offered a place at the home. EVIDENCE: During the inspection a sample of three resident’s personal files were viewed and there was evidence that a pre-admission assessment had been carried out prior to that person being admitted to the home. Residents spoken with said that their needs were being met at the home. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 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 standard(s) 7 & 8 The new care planning system ensures resident’s personal care and health needs are met. EVIDENCE: Since the last inspection the home has changed the format for recording care planning. The new recording format provides a sheet for manual handling assessments thus meeting a requirement made at the last inspection. The three records sampled demonstrated that care needs were being discussed and agreed with residents. The records also provided evidence that resident’s health needs were being attended to. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 12 14 & 15 Residents are consulted and activities arranged accordingly. The residents benefit from a good standard of food. EVIDENCE: Within the care planning system there is an assessment section concerning activities and a section recording activities for residents. It was noted that communal activities are not run in the home each week. This was discussed with residents with all but one of the residents saying that they did not wish for more activities to be arranged. The manager said that residents were regularly consulted and activities arranged for those who expressed an interest. The minutes of the last resident’s meeting provided evidence that residents had been consulted. There was also evidence that activities were arranged for other residents. There was evidence of the home working with the care manager to provide for one resident who said that they would enjoy more activities and opportunities for stimulation. Residents reported that their spiritual needs were met at the home with visiting clergy or by residents being taken out to services of their choice. Residents also spoke highly of the staff and how their privacy and dignity were Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 10 respected. They informed that their call bells were answered promptly and that the staff were approachable if they had any concerns. The home has two dining rooms, both used for the main meal of the day and one used for the evening meal, a time when many residents choose to have supper in their rooms. The menu for the week ahead is displayed in the reception area in the hallway and this reflected a varied and balanced diet. Residents spoken with all said that they thought the food was of a good standard and that there was always plenty to eat. Although there is no choice of main meal advertised, residents said that if they did not like what was being offered the cook would prepare an option to their liking. This was evidenced on the day of inspection with one person being provided with non fried food, another with a different type of meat and one resident who liked small portions. The home was also catering for one person with a diabetic diet. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 18 Residents have access to the home’s complaints procedure. EVIDENCE: The home has a complaints procedure that is documented within the Statement of Purpose, on the resident’s notice board and within the terms and conditions of residence. Since the time of the last inspection there has been one complaint. The manager reported that the documentation relating to this was with one of the directors as they were currently drafting a response. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Residents benefit from a well maintained environment and well kept gardens. Residents will be better protected when the radiators in older part of the home are covered. EVIDENCE: The original Georgian house has twice been extended over the years and the home now can accommodate 33 residents. The home was found to be in good decorative order throughout and was clean. The gardens that surround the home were also found to be well maintained. Adjacent to the home there are five bungalows owned by the providers and leased to tenants. The bungalows have emergency call bells linked to the home and the tenants are provided with a service akin to that of a wardencontrolled service. Should a resident in one of the bungalows require personal care they enter into a contract with a domiciliary care provider. At the last inspection a requirement was made that the uncovered radiators in the older part of the home be assessed for the risk they posed to residents in Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 13 respect of burns. It was reported that risk assessments have been carried out and it was agreed that the provider would write to CSCI with a proposed timescale when these would be covered. All of the hot water outlets have thermostatic mixer valves fitted in order to protect residents from scalding water. A range of resident’s rooms was seen as part of the inspection, all of which were found to be in good decorative order. It was evident that residents were able to bring their own furniture to personalise their rooms. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 29 The residents are supported with adequate staffing levels. Compliance with the new regulations on checks recruitment information will better protect residents. EVIDENCE: The home continues to provide the same levels of staffing as at the time of the last inspection and these levels have been calculated in line with the levels of the residential forum guidance, (a bench mark guide for staffing levels in residential homes). The residents and the one member of staff spoken with said that these levels met the needs of the residents currently accommodated. In general there are 4 staff on duty between 7.30am to 9am, 6 between 9am to 1pm and then 4 staff until 8pm. During the night time period there are 2 awake members of staff and 3 staff who do sleep-in duties and are available if required. There was evidence from the minutes of the resident’s meetings that residents are consulted as to whether the levels of staffing meet their needs. At the last inspection a requirement was made concerning omissions in the staff recruitment records. A sample three staff records were inspected on this occasion. In general the required recruitment checks were taking place as required and two references were being taken up before a new member of staff starts working at the home. It was found however that the manager was unaware of the changes in the Regulations that took place in July 2004. This Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 15 meant that a reference was not obtained from the person’s last place of employment with vulnerable adults as now required nor full employment histories of applicants obtained. The requirement therefore remains in force. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Residents are consulted and involved in the running of the home. EVIDENCE: A requirement was made at the last inspection that the home improves upon the quality assurance systems. Since the last inspection the manager has conducted a resident’s and relative’s survey and collated the information received. There was also evidence from the minutes of residents meetings that residents are involved the running of the home. Residents were consulted on staffing levels, the food provided and activities that are provided in the home. It was also found that the staff are now receiving appropriate supervision as had been required. The records that were sampled during the inspection were found to be up to date and accurate. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 17 A requirement was made at the last inspection that new members of staff receive training in moving and handling, fire safety and infection control. There was a record of this training in place for the sample of three staff files that were inspected. The fire logbook was inspected and it was found that the fire safety system was being tested and inspected to the required timescales. There was also evidence that staff are being trained in fire safety and that drills are being carried out as required. Prior to the last inspection an incident had occurred and requirements in relation to this were made. It was found at this inspection that the home had complied with these. Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x x Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 19 no 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. 1. Standard 29 Regulation Schedule 2 Requirement You are required undertake the recruitment checks as detailed in Schedule 2. Timescale for action 24/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 Millbrook House D55 S26843 Millbrook House V248264 280905 Stage 4.doc Version 1.40 Page 21 - 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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