Inspection on 06/07/06 for Millcroft

This inspection was carried out on 6th July 2006.

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

Millcroft 15/04/08

Millcroft 17/12/07

Millcroft 13/07/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Millcroft Vines Cross Road Horam East Sussex TN21 0HF Lead Inspector Jennie Williams Unannounced Inspection 6th July 2006 10:30 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 Millcroft DS0000021165.V298459.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.V298459.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 Millcroft and York Lodge Care Homes Ltd Norma Moore Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Millcroft DS0000021165.V298459.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. 8th November 2005 Date of last inspection Brief Description of the Service: Millcroft is a care home providing care for up to twenty-four (24) residents over the age of sixty-five (65). Nursing care is not provided at this establishment. There is a large garden at the rear of the building and parking facilities at the front of the home. 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 available for use at 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 under 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 £325 and £480. There are additional fees; hairdressing (£10), Chiropody (£8), newspapers and for personal dry cleaning. This information was provided to the CSCI in June 2006. Prospective residents/representatives are provided with a Statement of Purpose and Service User Guide that offer information on the services and facilities provided at the home. There are copies of previous inspection reports located at the entrance of the home. Residents/relatives know about the service through social service referrals, word of mouth and from living in the area. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Millcroft will be referred to as ‘residents’. This inspection took place for thirteen and three quarters hours spanning over two days on the 6 and 7 July 2006. Eleven residents, of both genders and over the age of 65 years, were spoken with during the inspection. One resident did not wish to speak with the Inspector and their choice was respected. Fifteen resident surveys were sent to the home prior to inspection, of which ten were returned. One care plan was looked at in detail. Specific areas of care needs were looked at in four other care plans. With permission from another individual, the Inspector went through their care plan with them. The Registered Manager and seven staff; five carers, the housekeeper and a cleaner were spoken with. Nine staff surveys were sent prior to the inspection of which seven were returned. Three staff files were inspected. A visiting district nurse was spoken to during the inspection. Out of four GP comment cards sent out prior to inspection, three were returned. No contact was made with visiting relatives/visitors. A pre inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Activity records, fire records, accident records and medication procedures were inspected. The quality assurance system was checked and complaint records were viewed. Previous requirements at the home were assessed to ensure compliance. The staff rota and menus were viewed. The Inspector ate lunch with the residents. Apart from fire records, no other health and safety records were viewed as this information has been provided in the pre inspection questionnaire. There is a new Responsible Individual employed by the registered providers, who is overseeing the management within the home. There were 16 residents residing at the home on the day of the inspection. What the service does well: Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents felt that their privacy and dignity are respected. The home has a good rapport with visiting health professionals, Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 6 ensuring that residents’ health needs are being met. Visitors are welcomed at the home and residents may receive visitors in private. Residents feel comfortable and know how to make a complaint and feel that they will be listened to. Residents are happy with their individual rooms and are able to personalise them. The home has implemented a quality assurance system to ensure the home is run in the best interest of residents. Residents’ finances are safeguarded. What has improved since the last inspection? What they could do better: Clearer communication is required in the home to ensure staff and residents are aware of the changes occurring in the management structure. The recent management changes were not handled in the best way. Resident surveys received and from speaking to residents at the inspection evidenced that a lot of residents felt that their home was closing and created a lot of anxiety and stress for some individuals. Staff were also not informed of the changes that were occurring. The Statement of Purpose and Service User Guide will need amending to reflect these changes. Action is required to ensure that the pre-admission assessment is expanded to cover all areas of care needs so that comprehensive care plans can be drawn up using this information, ensuring that all needs of an individual can be met at the home. Care plans need to reflect actual current practice and the reviewing process should include the resident/representative to ensure choice and preferences are reflected. Some risk assessments are in place but additional ones need to be implemented, with particular attention to falls to ensure any activity that poses a risk is identified and eliminated so far as is practicably reasonable. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 7 Risk assessments implemented for those residents who self-medicate must be kept under regular review, to maintain the safety of this individual and other residents. A policy for dealing with medication when a resident goes on social leave needs to be developed to ensure any medications provided to the home can be accounted for. Urgent action is required to ensure residents are provided with suitable and fulfilling activities. Residents will be better safeguarded if there is a clear procedure in place for dealing with allegations of abuse. Action is required to ensure the provision of food is nutritional, consistent and takes into account residents’ choice. Work is required to ensure that all internal and external areas of the home are kept clean and in a good state of repair. Immediate requirements left on the day of the inspection were as follows; that there are suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of residents, that evidence be provided that all appropriate recruitment checks have been undertaken, that door wedges be removed and any fire door having to remain open have suitable fire safety devices installed, and that all staff receive suitable training in fire prevention and undertake regular fire drills. 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. Millcroft DS0000021165.V298459.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.V298459.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home, however inadequate pre-admission assessments place some residents at risk of their needs not being met. EVIDENCE: Prospective residents/representatives are provided with information about the services and facilities provided at the home. The Statement of Purpose and Service User Guide needs to be amended to reflect the recent changes in management structure. There were no shortfalls noted at the last inspection so the content of these documents were not read. Eight resident surveys received showed that they received enough information about the home to decide if it was the right place for them. All residents have an assessment undertaken prior to being admitted into the home. A pre-admission assessment for a newly admitted resident was not available for inspection. The Registered Manager confirmed that she had taken Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 10 this assessment home to be typed up. Information pertaining to an individual should remain securely within the home. Other pre-admission assessments viewed demonstrated that these need to be expanded to cover all areas of care and not just if assistance is required or not. The Registered Manager confirmed that there was no one residing at the home from any minority ethnic communities, social/cultural or religious groups with any specific need or preferences. Prospective residents are encouraged to visit the home prior to moving in. One resident survey stated “I spent two weeks here on a temporary basis before deciding it was right for me”. One newly admitted resident stated that she did not visit the home prior to moving in and received no information. Other residents confirmed that they or a relative had visited the home prior to admission. It was confirmed by the Registered Manager that the contract states that the first four weeks of being admitted to the home is a trial period. The home does not have dedicated accommodation to provide intermediate care, however respite is available if there is a vacancy. Millcroft DS0000021165.V298459.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” There is a risk of some residents needs not being met due to care plans not being updated to reflect actual current practice. Risk assessments must be improved to promote the safety and well being of residents. EVIDENCE: There was evidence that care plans were being reviewed on a monthly basis, however care plans are not updated to reflect these changes. A form is used for the monthly reviews and some sections have recorded ‘no changes’, based on the previous months review. There is a risk of the information of changes in needs not being retained, as care plans are not being updated to reflect these. There was no evidence that these were being reviewed with the individuals or a representative’s input. Some residents spoken to were not familiar with their care plans whilst others were aware of their own plan of care. The resident that the Inspector viewed the care plan with confirmed that the information was ‘pretty accurate’. This individual uses a zimmer frame indoors and this was not reflected in the care plan. The care plan showed that this Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 12 individual self-medicates, however it was confirmed that this individual no longer deals with their own medication. This individual stated they do not eat cheese, fried foods or baked beans; this was not recorded in any of the dietary information. Staff must be reminded that using white correction fluid is not permissible on legal documents. Residents’ health needs are being met at the home. A district nurse was visiting a resident on the day of the inspection and staff were arranging for another resident to be taken to an appointment. All GP comment cards demonstrated that there was always a senior member of staff to confer with and staff demonstrate a clear understanding of the care needs of residents. Specialist advice is generally accessed through a referral by the GP. A chiropodist visits the home every six weeks. A visiting health professional spoken with stated that they had no concerns on the care provision at the home. Some residents observed to be wearing glasses confirmed that they are provided with eye checks when required. Of the residents that were asked, all confirmed that they are provided with regular dental checks. A resident that require to use a hearing aid confirmed that regular hearing checks are undertaken and the batteries are tested regularly. Some forms in use throughout the assessment process and risk assessing were not dated or signed. There was no evidence of the date that the assessments were undertaken or by whom. Risk assessments are not being regularly reviewed. They did not identify the overall risk or provide clear guidance for staff on action to take to reduce risks. On inspection of accident records it was noted that one resident was frequently having falls. There was no clear risk assessment in place paying particular attention to falls. Risk assessments should also be in place for those residents having a lock to their individual room door. Risk assessments should be completed for residents when travelling in the bus to identify how many staff may be required to assist residents. If the driver is a carer, this person should not be counted in the numbers. Medication Administration Records (MAR) charts inspected demonstrated that medication was being signed for at the time of administration. It was confirmed that there are policies and procedures in place for all aspects of dealing with medication. The content of these were not read. There was no procedure in place for dealing with medications when a resident may go on social leave for a period of time. There are records maintained for all incoming and outgoing medication. Some prescriptions on MAR charts had hand written amendments on them, that had not been signed to show who had made the changes. Any Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 13 handwritten prescriptions on MAR charts should be checked and double signed by two staff who have undertaken medication training, to ensure staff and residents are safeguarded from errors being made. All staff administering medication have received training. The Registered Manager needs to ensure that the homes policies and procedures and the training provides guidance for staff regarding handwritten MAR charts. Signature samples need to be kept within the home of staff administering medication. Medication is stored appropriately and there are accurate records of controlled drugs being kept. Two residents self medicate. There are risk assessments in place for these residents, however one inspected demonstrated that this had not been reviewed since May 2005. When residents are allowed to self-medicate, there must be a clear detailed procedure outlined in the care plan and this procedure must be risk assessed. The risk must be reviewed at pre-determined intervals. Documented evidence must be available for this action. Millcroft DS0000021165.V298459.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents lifestyle within the home is their own choice, however residents are not provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: There has been no activities person employed at the home since December 2005 and the home is not currently actively recruiting to replace this person. The Registered Manager, staff and residents spoken with confirmed that no activities are being regularly provided to residents, however four resident surveys received stated there were always activities they could participate in and two stated there were usually activities provided. Staff on duty are providing activities when they have the time. There were no activities observed on the day. It was confirmed by the Registered Manager that with the current staff issues, staff do not have time to provide activities. Residents spoken with were unsatisfied with the provision of activities. Some stated that ‘going on outings was something to look forward to.’ Activity records viewed demonstrated that activities are not being provided on a regular basis. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 15 Visitors are welcomed at the home and there is a visitor’s book at the entrance of the home that all people must sign when entering and leaving the building. Residents spoke positively about the times that they are able to go into the community in the bus, however this is not occurring at present. All residents asked confirmed that there were no restrictions for visitors and they were able to receive visitors in private. Of all the residents asked, all felt that their lifestyle within the home were their own choice. Individuals choose when they go to bed and get up etc. Residents were observed to move freely around the home. Staff were observed to be attentive to residents. There were mixed feelings about the food being provided at the home. The cook has left employment and some staff working at the home have been doing the cooking. A new cook is to commence employment once all appropriate recruitments checks have been undertaken, however this person was cooking on the second day of the inspection due to staff shortages. The Inspector enjoyed sausage casserole and rhubarb crumble for lunch with the residents. Those residents who did not want this were provided with an alternative. Comments about the food ranged from ‘not too bad’ through to ‘very good’. Some residents confirmed that some days they are provided with a choice, depending on who is cooking and what is available. Some residents confirmed that food is improving. It was required at the last inspection that professional advice is sought from a dietician for reviewing of the menu planning to ensure that suitable arrangements are made to ensure consistency in the quality of meals provided. The Registered Manager confirmed that this was done, however work was not continued and the information has not been passed to the cook. The Registered Manager confirmed that she will be making arrangements to seek professional advice again. It is recommended that a list of residents’ likes/dislikes/allergies in relation to food is provided to the cook and kept in the kitchen. Environmental health inspected the home’s kitchen in January 2006. There were requirements/recommendations made at this visit, which the Registered Manager confirmed are being addressed. The flooring of the kitchen is in the process of being changed. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 16 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 & 18 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Written policies and procedures for the Protection of Vulnerable Adults (POVA) will better safeguard staff and residents. EVIDENCE: The home has a complaints procedure in place. There is a central record kept of all complaints. The home has received two complaints since the last inspection. Records were not available at the home in relation to these complaints as the registered provider dealt with them and has not provided a copy of the correspondence to the Registered Manager. No complaint has been raised with the CSCI since the last inspection. Old complaint records were viewed and there was evidence that the Registered Manager maintained a copy of all correspondence relating to these complaints. Residents spoken with and surveys received showed that the majority of residents would know who to speak to if they were unhappy or had to make a complaint. Staff confirmed that they have received training in adult protection. The Protection of Vulnerable Adult procedure was not available on the day. There have been no allegations of abuse made at the home since the last inspection. The Registered Manager needs to ensure that senior staff left in charge of the Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 17 home in her absence, are familiar with the procedures to take in the event of an allegation being made. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25 & 26 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents live in a homely environment, however work is needed to ensure that the home is kept clean, reasonable furnished and safe. EVIDENCE: The home is currently being monitored by environmental health due to problems with the electrical system within the home and recent issues within the kitchen. The Inspector ate lunch with the residents on the first day and only half the lounge/dining room was provided with lighting. Some residents were heard to say that they couldn’t see what they were eating as it was too dark. It was confirmed that an electrician was due to return to the home the following week to complete installing the lighting in the lounge. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 19 Radiators were seen to be unguarded and not of guaranteed low surface temperature. Some radiators that were guarded need repairing and some were not attached securely in place. Some flooring in individual rooms is in need of replacement. Some of the homes’ furniture is also in need of repair or to be replaced. Individual rooms were noted to be personalised to reflect the individual’s choice and character. Residents spoken with were happy with their individual rooms. There is a good-sized garden at the rear of the building. Some section of the patio is blocked off as the paving tiles are being repaired. Consideration must be given to fix the whole patio area, as the Inspector noted that other paving tiles were lose and uneven, posing a trip hazard. It was noted that there were hand towels in communal areas. This practice does not promote good infection control and suitable measures should be implemented. One downstairs bathroom/toilet was out of action and priority needs to be given to ensure this is fixed. The pre-inspection questionnaire demonstrates that there are policies and procedures in place for communicable diseases and infection control. The content of these policies were not read. A cleaner spoken with confirmed that they are provided with enough equipment and sufficient time to clean the home. There were no offensive odours noted on the day of the inspection and most areas were reasonably clean, however some areas are in need of attention. Attention needs to be paid to cleaning soap holders and under bath hoist seats in communal bathrooms. With a resident’s permission, the Inspector stripped the bed sheets back and found the mattress to contain a considerable amount of dust and fluff. This was pointed out to a staff member at the time. Some residents complained to the Inspector of the lack of cleanliness within the home and have to dust their own rooms. The majority of residents surveys received demonstrated that the home was usually fresh and clean. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” There is a risk of residents needs not being met due to insufficient staffing levels. Residents will be better safeguarded if clear recruitment records are maintained on all staff members. EVIDENCE: Staff and residents spoken with confirmed that there are insufficient numbers of staff on duty. Seven staff have left employment at the home since the last CSCI inspection and there continues to be staff vacancies at the home. This included three care staff, the handyman, the chef, a housekeeper and a cook/housekeeper. Staff remaining working at the home should be commended on the dedication they have demonstrated to ensure residents remain cared for. Residents spoken with were very complimentary about the staff working at the home. A visiting professional also confirmed that they felt there was a shortage of staff on occasion. The Registered Manager confirmed that there usually three staff members working during the day, but due to staff leaving employment and staff holidays, there is at present two carers working the day shifts. The home currently has one carer working a waking night duty. Some of the staff have to do cooking, which reduces the number of staff on the floor to provide care for residents. Staff commented that there were often two carers working in the afternoon and that one of them would need to do the cooking. The rota provided to the Inspector also demonstrates there are some days where there Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 21 are staff shortages and agency staff are have not been used at the home. Staff confirmed that they have received a job descriptions and are clear of their roles. There is currently nine staff employed at the home of which seven have achieved National Vocation Qualification (NVQ) level 2 or above. Four have achieved NVQ level 2 and three have obtained the NVQ level 3 qualifications. There were some shortfalls noted in the recruitment process. The staff files inspected did not provide a full employment history and the health survey that staff complete needs to be expanded to include current illnesses and not just past health issues. At least two references are obtained prior to a person commencing work. A reference viewed was not signed and some did not demonstrate in what capacity the referee knew the applicant. Interview notes are kept by the home. Criminal Record Bureau checks (CRB) are undertaken, however provides the reader with no indication of the date it was completed, no evidence of a POVA check having been undertaken and no evidence for what establishment it pertains to. There was no evidence that overseas staff were eligible to be undertaking employment within the United Kingdom. The Registered Manager confirmed that she is only involved in the interviewing of staff and the registered providers dealt with the other recruitment processes. Staff spoken with confirmed that they are provided with training relevant to their roles. Records inspected demonstrated that some recent training provided in the last 12 months included manual handling, health and safety and medication administration. Staff confirmed that there is more training currently being arranged. Management need to ensure that all staff are kept up to date with all mandatory training. A staff members training record viewed demonstrated that they had not received manual handling training since June 2004. It was discussed with the Registered Manager that the home ensures that all visiting professionals that may have unsupervised visits with an individual have undertaken a CRB check. This includes hairdressers and church members etc. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35, 36 & 38 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents and staff will benefit if there is clear communication between the home and external management. Residents’ safety is being put at risk through inadequate fire safety precautions being in place and insufficient training for staff. EVIDENCE: It became apparent throughout the inspection from speaking with staff and residents that the changes with external management were not handled in the best way. The Registered Manager, staff and residents were not informed of the changes occurring and stated that ‘strange people were visiting to look around the home’. Resident surveys received and from speaking to residents evidenced that a lot of residents felt that their home was closing and created a lot of stress for some individuals. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 23 Staff spoken with were complimentary about the Registered Manager at the home and find her very approachable and supportive. The Inspector was informed and it was noted in staff comment cards that there was not good communication between the home and external management. The Registered Manager has completed the Registered Manager Award and is currently completing NVQ level 4 in care. The Registered Manager participate in training provided to staff and ensures that she undertakes periodic training to update her knowledge and skills. The Registered Manager confirmed there is a developed quality assurance system in place where written feedback is often sought from people involved within the home. There was evidence that residents completed questionnaires in October 2005. There was no analysis completed of the results, however it was confirmed any issues identified are acted upon wherever possible. Some questionnaires completed were not dated so it was unclear of when feedback was received at the home. Staff meetings are held every three months where they are provided an opportunity to raise any issues. Resident meetings are held every three months to discuss issues and how improvements could be made. Some residents informed the Inspector that they don’t wish staff members to be attending these meetings at all times. This information was passed on to the Registered Manager who will discuss with residents how they want resident meetings to be run in the future. The home does not hold any personal allowance for residents. Residents manage their own finances or have a relative/friends to assist in dealing with their finances. It was confirmed by the Registered Manager that due to recent changes and staff shortages, supervision is not currently being provided to staff. Staff confirmed that supervision was occurring approximately every six months. The pre-inspection questionnaire demonstrates that there are policies and procedures in place, with the majority having been reviewed in August/September 2005. All policies and procedures were not inspected. Hot water taps sampled evidenced that water is being delivered around the recommended 43°C. Water temperatures are regular checked within the home and action is taken if required. It was noted that some staff had not received fire training since November 2004. Some staff could not remember when they last had fire training. Some staff spoken with confirmed that they have not participated in a fire drill for three years. There were dates recorded identifying that fire drills are regularly undertaken, however these forms provided no information on which staff Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 24 attended, how long it took and if any action was required. It became apparent that there is confusion between weekly fire alarm testing and fire drills. Fire doors were also observed to be wedged open. There was a fire risk assessment dated March 2002. An additional risk assessment was in place, however it did not appear completed and there was no date or signature to identify when this was last completed. Some staff have undertaken their first aid training but did confirm to the Inspector that there is not always a qualified first aider on duty. The pre-inspection questionnaire demonstrates that other health and safety checks are undertaken. Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 25 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X 3 X X X 2 2 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 26 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 6 Requirement That the Statement of Purpose and Service User Guide are updated to reflect the recent changes in management. That a thorough pre assessment is undertaken on all prospective service users. That care plans reflect actual current practice and that evidence be provided of service users/representatives input into the reviewing of care plans. That forms used throughout the assessment process are dated and signed. That risk assessments are implemented and are regularly reviewed. To ensure any self-medication in the home is managed under a risk assessment basis and kept under review. That a policy and procedure is developed for when medication is taken home with the individual to ensure all medication provided and administered can be accounted for. Timescale for action 31/08/06 2. 3. OP3 OP7 14(1) 15 31/08/06 31/08/06 4. 5. 6. OP7 OP7 OP9 17 13(4) 13(2) 31/08/06 31/08/06 31/08/06 7. OP9 13(2) 31/08/06 Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 27 8. 9. OP12 OP15 16(2) (m & n) 16(2)(i) 10. 11. OP18 OP18 13(6) 13(6) 12. 13. 14. 15. OP19 23(2)(d) 23(2)(b) 13(4) 13(4)(c) OP19 OP25 OP26 16. OP27 18(1)(a) 17. OP29 Schedule 2 18(1) (c)(i) 18(2) 23 23(a) 18. 19. 20. 21. OP30 OP36 OP38 OP38 That service users are provided with suitable and fulfilling activities. That service users are provided with wholesome and nutritious food and are provided with a choice. That a copy of the Protection of Vulnerable Adults procedure is available and the home. That staff left in charge of the home are familiar with POVA procedures to take in the event of an allegation of abuse being made. That all parts of the home are kept clean and reasonably decorated. That the care home is kept in a good state of repair externally and internally. That radiators are suitably and securely guarded. That hand-drying towels are removed from communal bathrooms and alternative measures implemented. 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. (Immediate Requirement) That evidence be provided that all appropriate recruitment checks have been undertaken. (Immediate Requirement) That all staff are kept up to date with all mandatory training. That all staff are provided with regular supervision. That door wedges be removed. (Immediate Requirement) That fire doors having to remain open have suitable fire safety DS0000021165.V298459.R01.S.doc 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 30/09/06 31/08/06 31/08/06 08/07/06 31/07/06 30/09/06 30/09/06 06/07/06 07/08/06 Millcroft Version 5.2 Page 28 22. OP38 23(4) (d & e) devices installed. (Immediate Requirement) That all staff receive suitable training in fire prevention and undertake regular fire drills. (Immediate Requirement) 21/07/06 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. 3. 4. Refer to Standard OP9 OP9 OP9 OP33 Good Practice Recommendations That signature samples of staff administering medication be maintained. That handwritten prescriptions on MAR charts be checked and double signed by two staff who have undertaken medication training. That any hand written amendments on MAR charts are signed. That an analysis is done of the quality assurance surveys received and the results are published and shared with prospective residents/relatives and any other interested party. That residents are supported and enabled to undertake their own meetings. 5. OP33 Millcroft DS0000021165.V298459.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Millcroft DS0000021165.V298459.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. 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