Inspection on 15/04/08 for Millcroft

This inspection was carried out on 15th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Millcroft 17/12/07

Millcroft 13/07/07

Millcroft 06/07/06

Millcroft 08/11/05

Millcroft 07/05/05

Millcroft 10/10/04

Millcroft 08/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Millcroft Vines Cross Road Horam East Sussex TN21 0HF Lead Inspector Rebecca Shewan Unannounced Inspection 15th April 2008 09:25 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 Millcroft DS0000021165.V361084.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. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millcroft Address Vines Cross Road Horam East Sussex TN21 0HF 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) 01435 812170 bozena@millcroft.plus.com Millcroft and York Lodge Care Homes Ltd Vacant post Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-four (24). Service users must be aged sixty-five (65) years and over on admission. 17th December 2007 Date of last inspection Brief Description of the Service: Millcroft is a care home providing care for up to twenty-four (24) residents, of either gender, over the age of sixty-five (65). Nursing care is not provided at this establishment. District nurses will provide nursing input when required. Conditions of registration may undergo review by the South East Registration Team as part of the Modernising Registration Agenda. The home is a detached property and is located in a quiet residential area a short distance from Horam village. There is access to public transport in the town. There is a mini bus van available for use at the home. There is a large garden at the rear of the building and parking facilities at the front of the home. Rooms are located over two floors. There is a passenger shaft lift available to assist residents to access all areas of the home. Sixteen rooms are for single occupancy of which 15 have en suite facilities. Two of these are less than 10 sq. m in size. There are four double rooms that are provided with an en suite. There are six communal toilets located throughout the home and four bathrooms, of which three have assisted facilities. There is a good-sized combined lounge room and dining area. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Weekly fees range between £420 and £575. There are additional fees for Hairdressing (£6 basic cut), Chiropody (£10 per session), Newspapers and magazines and dry cleaning (prices vary). This information was provided to the CSCI on the 15th April 2008. Potential new service users can obtain information relating to the home by word of mouth, CSCI inspection reports, placing authorities, local newspaper advertisements, Social Workers and GP lists. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place during the morning and afternoon of the 15th April 2008. Incident reports and previous inspection reports, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took seven hours. Records such as care plans, staff files and medication records were also viewed. Seventeen service users (known as residents) were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Registered Provider/Appointed Manager, three staff, three residents and one Healthcare professional were spoken with. The CSCI also conducted Service User and staff surveys. Of which four surveys from service users and four staff surveys were returned. Comments received included: ‘I am happy here’ ‘Staff are always friendly to me’ ‘It would be better if we have somebody outside staff or duty to do activities in the morning and afternoon to give more support and care to residents’ ‘Very good home, am very happy – everything is excellent’ What the service does well: The health needs of service users are met with evidence of well established multi disciplinary procedures taking place. Staff provide personal care and support to residents in such a way that promotes and protects service users privacy and dignity, whilst promoting independence. Resident’s benefit from activities that are stimulating and that are arranged according to their choice. Service users experience mealtimes that are unhurried. There is a comprehensive complaints procedure in place, which ensures that service users benefit from effective and timely complaint responses. The Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 6 homes processes for safeguarding should protect residents in the event of an allegation of abuse. All areas of the home are accessible to service users. The location and layout of the home are suitable for its stated purpose. Service users experience the benefits of a staff team that have the necessary experience to the meet their needs. Staff training is on going and is appropriate to the level of needs of current service users. What has improved since the last inspection? Both the Statement of Purpose and Service user Guide has been reviewed and amended and produced in a format, which is suitable for ease of use by service users. All service users are now in receipt of a new copy of each of these documents. Pre admission assessments have been improved to provide staff with sufficient information in order for them to produce a viable care plan and to provide appropriate care according to service users needs during the care planning process. Care plan reviews are conducted with the individual/representative (where able), to ensure that choice and preferences are reflected in relation to their care and daily routines. Care plans have also been updated to include nutritional care plans, for individuals with specific nutritional needs/requirements. Service users are also provided with a choice of a more varied and nutritional diet. Staff have received formal training in the safeguarding of the people in their care and mandatory training in Health & Safety and Fire matters. Structures are now in place to ensure that at all times suitably qualified, competent and experienced persons are working at the care home, in such numbers as are appropriate for the health and welfare of service users. The standard of English of the staff employed has been reviewed, in order to address issues relating to service users needs being met by staff whose first language is not English. The home is now managed in a manner that ensures that staff are appropriately supervised. Systems have been put in place to monitor the quality of the services provided by this home. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 8 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 Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new service users benefit from receiving relevant and up to date information, which is made available to them prior to admission, allowing them to make an informed choice about the choice of home they wish to live in. The processes in place for ensuring that suitable Pre Admission Assessments are conducted is good, with services being offered to only those service users whose needs can be met. EVIDENCE: Following the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that both the Statement of Purpose and Service user Guide has been produced in a format, which is suitable for ease of use by service users, and all service users should be given a copy of the service user guide. This has been a Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 10 longstanding Statutory Requirement for the past few inspections and has now been addressed in full. Copies of the Service User Guide and Statement of Purpose were observed in each service users bedroom. The Statement of Purpose was also viewed and this was observed to have been amended and updated to include all items required under the Regulations and National Minimum Standards. The Service User Guide was noted to have been amended, though the summary enclosed with the Service User Guide does not read well and is not written in a user friendly manner. The errors were shown to the Registered Provider/Appointed Manager and it was discussed how the summary is not reflective of the good progress made to ensure that the full Service User Guide meets the requirements of the Regulations. Therefore a Statutory Requirement has been made. Following the key unannounced inspection of December 2007, the Registered Provider/Appointed Manager has made improvements to ensure that the pre admission assessment shows the initial actions required by staff to ensure that care needs are met and enables a viable care plan to be formed. Pre Admission Assessments were viewed for two service users recently admitted. These were observed to have been completed in a more comprehensive manner and were written in a style that enable staff to produce a care plan based on the content of the Assessment. The Registered Provider/Appointed Manager and a Senior Carer conduct preadmission assessments. Copies of care management assessments from the placing authority are also obtained, where these exist. The Registered Provider/Appointed Manager addresses any issues, which are highlighted within this assessment. Documented records are maintained of all correspondence with the placing authority. Records inspected showed that preadmission assessments are carried out on all new and potential service users. Intermediate care is not offered by this home. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 11 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans and procedures in place are sufficient to ensure that a good provision of health care and personal support is provided to service users by the home. Care is administered in way that protects residents privacy and dignity. Medication procedures require improvement to ensure that all necessary precautions are taken to maintain the drug store keys, in a safer manner. EVIDENCE: Following the key unannounced inspection of December 2007 and the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that care plans and information in use regarding the care of service users is current and reviewed with the individual/representative to ensure that choice and preferences are reflected in relation to their care and daily routines. This has been a longstanding Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 12 Statutory Requirement for the past few inspections and has now been addressed in full. Care plans were viewed for four service users and these were found to have been updated and reviewed on a monthly basis. Where able, service users and or their representative had been involved in the review process. Care plans are now written in a style that allows the assessor to gain a good overview of all aspects of individuals needs. The current style of care planning is such that it provides care staff with a clear overview of the service users current needs, limitations and required assistance. Care plans have also been updated to include nutritional care plans, following a Statutory Requirement made at the random unannounced inspection of February 2008. Of the care plans viewed it was evidenced that nutritional care plans were in place for those service user who require them i.e. diabetics and those with weight loss/gain issues. A Recommendation for good practice has been made relating to legal documentation, such as care plans, to be written in black or blue ink and the use of pencil and white correction fluid to cease. Of the four care plans viewed it was observed that each care plan contained at least one or two documents that had been written in pencil and/or had had corrections made utilising white correction fluid. The implications of this were discussed with the Registered Provider/Appointed Manager at the time of the inspection. From the records sampled and surveys received, it was evidenced that the health needs of service users are well met. Evidence of good multi disciplinary working taking place, on a required basis was observed. The Chiropodist attends the home six to eight weekly and on an as required basis. Service users are registered with one GP from one of four local surgeries. GP’s visit the home usually, though service users can attend the surgery if able. The local dentist is utilised for all dental treatments and arrangements in place for the dentist to conduct home visits. The Continence nurse and District Nurses attend the home as required, care staff contact the District Nurse team directly or service users are referred via the GP. The Visiting Optician makes annual and as required visits to the home. Audiology appointments are arranged via the GP, service users then attend the hospital for appointments. Speech and Language Therapist, Physiotherapist and Occupational Therapist are arranged via the District Nurse (if required). Medication administration records were viewed and these were found to be maintained appropriately. Staff training in medication is conducted as part of the Induction process, refresher training is also provided. Staff records viewed confirmed this. There were good procedures in place for the monitoring and recording of all drugs administered, disposed of and those entering and leaving the home. At the time of the inspection the keys for the medication stores were kept in a drawer in a cupboard in the staff office. The Senior Carer on Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 13 duty reported that this was not a regular occurrence. The importance and serious implications of the keys being stored in this manner were discussed with the Registered Provider/Appointed Manager and an Immediate Statutory Requirement was made. Personal support is provided to service users in such a way that promotes and protects service users privacy and dignity. Survey responses commented that ‘staff are always friendly’. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A wide range of social, cultural and recreational activities and facilities, including specialist diets is provided for service users, with service user’s choice and wishes being respected. EVIDENCE: There is a published list of activities which details which activities have been arranged for specific days. Activities include: Darts, bingo, quizzes, cards, knitting, skittles, visiting entertainers and music therapy. Records are kept of all activities attended, these were viewed at the time of the inspection. Staff spoken with and surveys received detailed that service users attend activities and outings at a level of their choosing. Service user surveys commented ‘I like to join in (with activities) especially when it is skittles’. Activities are currently organised by care staff and are designed to commence at approximately eleven o’clock each morning, in order to allow for good attendance and for personal care to be administered. Care staff spoken with and survey responses highlighted that care staff felt that service users activities suffered as a result of care staff conducting activities. Care staff Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 15 stated that they feel that being ‘tasked’ to do care duty, laundry duty and activities is too much and that there are often times when it is busy that one of the ‘tasked’ jobs falls below par, usually activities. Comments received include ‘it would be better if we have somebody outside staff or duty to do activities to give more support and care to residents and not take one of the staff off duty’ and ‘Activities require more structure’. Therefore a recommendation for good practice has been made. Discussions with the Registered Provider/Appointed Manager highlighted that although the current service users had similar religious beliefs, the home would welcome any potential new service user who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The Registered Providers of the home believe in promoting an equal and diverse culture amongst staff and service users. Residents are encouraged to attend local community events. Two service users are currently day care attendees. Three service users regularly go out to lunch at local social clubs and with their family. A Beautician attends the home fortnightly and the hairdresser attends every Tuesday. Twice weekly outings are also arranged. The service users have access to ‘personal shopping’ through the resources of the local branch of Age Concern. Service users, where able are also encouraged to attend the gym on a weekly basis. Service users religious wishes are observed and arrangements are in place for residents to receive Holy Communion, if they wish. Non-denominational Holy Communion is held every fortnight and service users who are able are assisted to attend church. Friends and family are welcome at any time and in accordance with service users wishes. It was observed that there is a good rapport between staff of the home and service users. Care staff treat each service user with respect and the promotion of independence was apparent, from the observations of staff interacting with service users when administering care and during activities. Following the key unannounced inspection of December 2007 and the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that service users are provided with a choice of a varied nutritional diet. This has been a longstanding Statutory Requirement for the past few inspections and has now been addressed in full. Recent changes to the homes menus have been made. Staff and service users spoken with stated that the menu has been greatly improved and that supper meals have been increased to include a third option. Both staff and service users stated that sandwiches are the preferred choice for most service users. Kitchen staff spoken with stated that menu changes have been good and that service users have commented that they prefer the new menus. Menus are devised on a dour week rolling programme. Meals consist of Breakfast, lunch and supper. Early morning tea, mid morning tea and biscuits Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 16 and mid afternoon tea (occasionally with cake) is also served. Two meal choices are available for lunch and supper, with an alternative available if requested. The supper menu now consists of soup, sandwiches and salad/jacket potato. Therapeutic and medical diets are catered for. Flexible meal times are arranged as requested/required. Service users can eat in their own rooms or in the communal dining area. Guests can stay for meals upon request. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from a robust and efficient complaints procedure, whilst the homes procedures and processes should protect service users and staff in the event of an allegation of abuse. Staff training in Protection of Vulnerable Adults has been improved and should provide further increased protection. EVIDENCE: There is a comprehensive complaints procedure in place. The home has received four complaints within the past eight months, three of which have been recorded as addressed, whilst one complaint is currently being investigated. Each of the resolved complaints had been appropriately actioned, in order to address the concerns raised. Following the key unannounced inspection of December 2007 and the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that staff receive formal training in the safeguarding of the people in their care. This has been a longstanding Statutory Requirement for the past few inspections and has now been addressed in full. Records viewed confirmed that twelve of the twenty four staff team (50 ) have received Protection of Vulnerable Adults (Protection of Vulnerable Adults) Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 18 training Between December 07 and March 08. The remaining 50 of staff were trained last year and are due to receive refresher training in late April 08, records viewed confirmed that dates for such training have been arranged. Staff records viewed confirmed that Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 19 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 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Accommodation at the home is provided in such a manner that it is safe, hygienic and odour free. Appropriate infection control procedures are in place, in order to reduce or eliminate the risk of infection to staff and service users. EVIDENCE: The home is well maintained and all areas of the home, including the garden, are accessible to service users. The home has an ongoing plan of refurbishment in place. The size, location and layout of the home are suitable for its stated purpose. The home was clean and odour free throughout. There is a daily cleaning schedule in place. The home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 20 confirmed this. Staff were observed adhering to infection control procedures. It was evidenced that a clinical waste contract is in place. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures are effective and protect service users from potential harm or risk associated with poor recruitment practices. English Language skills of staff are in need of addressing to ensure that service users benefit from a staff team that have the necessary English speaking skills to the meet their needs. EVIDENCE: Following the key unannounced inspection of December 2007 and the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users and to meet the aims and objectives of the home. This has been a longstanding Statutory Requirement for the past few inspections and has now been addressed in full. There is a staff rota in place, which details staff numbers and job designation. Staff numbers are satisfactory for the current level of needs of service users. There are currently three staff vacancies at the present time: Head of Care (Deputy Manager) and Two Senior Carer posts, the Registered Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 22 Provider/Appointed Manager stated that two senior cares are currently being recruited from the Philippines. The Head of Care vacancy is being advertised. The Registered Provider/Appointed Manager and staff spoken with confirmed that staff have been conducting extra duties to cover the current shortfall and the use of agency staff has been minimal. There has been a recent high turn over of the staff team, as highlighted in recent previous inspection reports. Staff and Healthcare Professionals spoken with confirmed that the staff team has settled now and that improvements have been made, though the approachability of the Registered Provider/Appointed Manager remains an issue (see Management). Following the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that the standard of English of the staff employed is sufficient to enable them to meet service users needs and to be understood by the service users. It was evidenced that the staff with English language barriers currently attend weekly English classes, English staff spoken with state that there is still a problem with language barriers. No further overseas staff have been recruited since the random inspection of February 08. In view of there being further staff recruited from overseas in the near future, there remains a need for the Registered Providers to ensure that the English language skills of those recruited, is of a satisfactory standard. Therefore a Statutory Requirement has been made. The home has a permanent staff team of the Appointed Manager (not yet registered as manager though is Registered Provider), four Senior Carers, twelve Care Assistants and eight ancillary staff. Four care staff (17 ) are National Vocational Qualification (NVQ), level 2 or above, trained in care and nine care staff (37.5 ) have been enrolled to commence the NVQ level 2, in care training. Therefore a recommendation has been made. Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001. Some of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. The home has an Equal Opportunities policy in place and is an equal opportunities employer. Staff induction training is conducted in line with Care Skills Sector guidance. Mandatory training consists of Fire Safety, Health & Safety, First Aid, Food Hygiene, Infection Control, Protection of Vulnerable Adults, Moving and Handling and medication. Additional training consists of NVQ’s in care, Dementia, prevention of falls, risk assessing and the Mental Capacity Act (MCA), staff were observed receiving informal training relating to the new MCA guidance on the day of inspection. Survey responses commented that ‘the availability of training necessary for the welfare of service users and staff is good’. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users experience the benefits of a home that is well administrated. Consideration must be given to staff and service users opinion in all aspects of provisions provided. Current management approachability issues require resolving, in order to promote an open and inclusive environment. The health, safety and welfare of service users and staff are protected at all times. EVIDENCE: One of the Registered Providers of the home is also the Appointed Manager and has worked in the care home industry for many years. The Appointed Manager is currently in the process of obtaining a CRB check from the CSCI, in order to proceed with the application process for registration as Manager. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 24 Following the key unannounced inspection of December 2007 and the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that the home is suitably managed to ensure that staff are appropriately supervised and supported. This has been a longstanding Statutory Requirement for the past few inspections and has now been addressed in full. Staff records viewed evidenced that regular staff supervision is now being conducted. The Registered Provider/Appointed Manager stated that all supervision is conducted with the support of ‘skills for care’. Staff surveys and staff spoken with confirmed that supervision is conducted and that improvements have been made, though it is felt that management is often unapproachable and not open to new ideas or listening to staff concerns. New staff spoken with were unaware of recent CSCI activity and the homes recent poor quality rating. This does not promote an open and inclusive management ethos. Discussed with The Registered Provider/Appointed Manager that staff surveys, staff meeting minutes and staff spoken with confirmed that management approachability remains an issue within the home. The Registered Provider/Appointed Manager said that she ‘often doesn’t say anything because it’s best not too’. It was explained to the Registered Provider/Appointed Manager how this does not promote an approachable, open and inclusive environment for both staff and service users. The Registered Provider/Appointed Manager stated that she ‘understood what was being said and would take the comments as constructive criticism’. Therefore a Statutory Requirement has been made. Following the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that the registered person shall put in place a system to monitor the quality of the services provided by this home. Quality Assurance processes are such that Regulation 26 visits are conducted and reports are produced. Regulation 26 reports for Jan/Feb/Mar 08 were viewed. Comments noted in these reports highlighted that staff and service users felt that there was a laundry issue, relating to staff being occupied with care duties. Staff meetings are held six to eight weekly, the minutes of which were viewed. Comments noted in these minutes highlighted staff concerns about being unable to conduct laundry and activities duties whilst also being designated to undertake care duties. There was no evidence in these minutes to detail that any actions had been taken to address the issues raised, or that any further discussions about the issues had taken place. Service user meetings are held three to four times a year, the minutes of which were viewed. Laundry delays were noted as an issue raised by service users. Therefore Statutory Requirements have been made. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 25 Service user questionnaires were conducted in March 08 and other Professionals questionnaires were conducted in January 08. Healthcare Professionals and service users spoken with confirmed that they had not received any feedback as to what was the outcome of the recent audit. The Registered Provider/Appointed Manager reported that service users were given feedback of previous Quality Assurance audits at residents meetings. Residents meeting minutes viewed confirmed this. There is a need for the results of Quality Assurance audits to be published and made available to all interested parties and other stakeholders. Therefore a Recommendation has been made. The home does not take any responsibility for many of the resident’s finances and most residents have family, friends or representatives who protect their financial affairs. Following the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that the registered person ensures that all staff undertake the mandatory training in Health & Safety and Fire matters. Sixteen care staff (66.6 ) had received Health & Safety and Fire training between January and March 08. Further training dates had been arranged for those who did not attend training in the previous months, records viewed confirmed this. Following the random unannounced inspection of February 2008, the Registered Provider/Appointed Manager has made improvements to ensure that staff ensure that the appropriate equipment is used in moving and handling of residents. Hoist training for all staff was conducted in March 08. Records viewed of training sessions attended and staff spoken with, confirmed this. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks, health & safety checks and water checks had been carried out. There were no health & safety issues noted at the time of this inspection. Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 26 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 2 Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 5 (1) (2) (3) & (6) Requirement The Service user Guide summary should be produced in a format, that is written in a user friendly manner and that is reflective of the full Service User Guide. That appropriate measures are taken to ensure that the drug stores keys are maintained in a safe and risk free manner. This is an immediate Statutory Requirement. That the Registered Providers implement a means of testing the standard of English Language skills of overseas staff and ensure that staff with poor English are not introduced into the home environment until they are satisfied that by employing them will not have a adverse impact on service users or the staff team. That the Registered Provider/Appointed Manager promotes an approachable, open and inclusive environment for both staff and service users. DS0000021165.V361084.R01.S.doc Timescale for action 15/06/08 2. OP9 13 (2) 15/04/08 3. OP27 18 (1) (a) 15/06/08 4. OP32 22 15/05/08 Millcroft Version 5.2 Page 28 5. OP33 24 (1) (2) & (3) That the Registered Providers put in place a system to monitor how issues raised during Quality Assurance audits are addressed and actioned. That copies of Regulation 26 visit reports are sent on a monthly basis to the CSCI Regional Contact Team. 15/06/08 6. OP33 26 15/06/08 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 OP7 Good Practice Recommendations That all legal documentation is appropriately maintained and the use of white correction fluid and writing in pencil must cease. That consideration is given to staff and service users comments relating to the management and administration of activities. That 50 of care staff are trained to NVQ Level 2 or above in care. That an analysis is completed of the quality assurance surveys received and the results are published and shared with prospective service users/representative and any other interested party or stakeholders. That consideration is given to the comments made by staff and service users in the recent Quality Assurance audit, staff and residents meetings, relating to the management and administration of laundry services. 2. OP12 3. 4. OP28 OP33 5. OP33 Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Millcroft DS0000021165.V361084.R01.S.doc Version 5.2 Page 30 - 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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