Inspection on 07/05/05 for Millcroft

This inspection was carried out on 7th May 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Millcroft 15/04/08

Millcroft 17/12/07

Millcroft 13/07/07

Millcroft 06/07/06

Millcroft 08/11/05

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 Andy Denness Unannounced 7 May 2005 13:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Millcroft Address Vines Cross Road Horam East Sussex TN21 0HF 01435 812170 01435 812170 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Millcroft & York Lodge Care Homes Ltd Norma Moore Care Home (CRH) 24 Category(ies) of Old age, not falling within any other category registration, with number (OP) 24 of places Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty four (24). 2. Service users must be aged sixty five (65) years and over on admission. Date of last inspection 10 October 2004 Brief Description of the Service: Millcroft is an extended detached property situated a short distance from Horam village centre. Accommodation is provided on two floors and a shaft lift is fitted to assist access to the first floor. The home has a large rear garden and parking to the front of the building. It is registered to accommodate up to 24 older people. The registered providers are Millcroft and York Lodge Care Homes Ltd. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Inspection took place over an afternoon and early evening in April and lasted 5 hours. To help gather evidence on how the home is performing the Inspector, met with staff and the home’s manager, examined a range of records and written information and undertook a tour of the premises. Discussions took place with ten service users. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 & 5. A failure to provide potential service users with information about the home and a lack in some instances of appropriate assessments means that the home is risking admitting service users whose needs they can not meet. EVIDENCE: The home has a detailed statement of purpose and a service user guide, these were of a good quality, and are intended to provide potential service users with information regarding the service to help them in the decision of whether to move into the home. However service users said that they had not received this information, the manager confirmed that they are not given copies of either document as a matter of course. From an examination of service users care records it was evident that pre-admission assessments had not been carried out in all instances. Some service users said that either they or their relatives had visited the home to look around prior to admission. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 9. The policies, procedures and practices in the home regarding health, personal and social care needs are generally good and help ensure that identified service user needs in these areas are met appropriately and safely. However this is not always the case, in some instances the lack of guidance and assessments could result in some needs not being met or in risk for service users. EVIDENCE: Individual plans of care are in place for most service users; these identify amongst other things what support is required from staff to meet their day-today needs in relation to health, personal and social care needs. A selection of these plans was examined; they were mostly of a good quality. However in one instance no plan was in place and other plans had not recently been reviewed. Pressure care risk assessments were not in place. A monitored dosage medication system is used; records and storage were examined and found to be order. Several service users look after their own medication, there were no assessments of risk in place to assist staff judge if it is safe for this to happen. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Satisfactory arrangements are in place to meet service users preferences in regard to their social and recreational needs. EVIDENCE: The home employs an activities organiser on two days of the week; records examined confirmed that a range of activities is provided for service users. The home has a mini bus that can be used for outings and excursions. However some service users said that only limited numbers can use this and they said that they would like more opportunity to get out and about. Discussions with service users confirmed that they have choice in all areas of their daily living. Records examined confirmed that a varied and wholesome menu is provided; service users spoke positively of the meals provided for them and said that they had choices and alternatives available to them. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 17 Procedures and practices in the home ensure that complaints are managed appropriately. Service users legal rights are protected. EVIDENCE: The home has a written complaints procedure in place for service users or their representatives to follow should they be unhappy with any aspect of the service provided at Millcroft, this was of a satisfactory standard. Records examined confirmed that complaints are investigated and followed up in line with the written procedure. Several service users spoken to confirmed that with staff assistance they had been supported to vote in the recent general election. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 & 26. Physical standards are good and ensure that service users live in a comfortable, safe and hygienic environment. Furnishings and decoration create a pleasant homely environment. EVIDENCE: All areas of the home were inspected. Bedrooms are furnished and decorated in a homely comfortable style. Service users have the option of bringing their own furniture and belongings with the, which many have done this has resulted in pleasant personalised rooms. Sufficient bathrooms and WCs are available; these are equipped and maintained to a good standard. Some bedrooms have ensuite facilities. Service users have the use of a large lounge/dining room and a conservatory; these are furnished and decorated to a satisfactory standard. Standards of hygiene and cleanliness throughout the home were high. At the last inspection it was required that the kitchen floor was replaced, it has holes in it which present a potential trip hazard; this has not yet been done although the situation has temporarily been made safe by Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 12 the manager; she said that quotes have been obtained for a full refurbishment of the kitchen, during which the flooring will be replaced. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staffing arrangements mean that service users needs are met appropriately. EVIDENCE: Records examined confirmed that sufficient numbers of care staff and domestics are employed during the day to ensure that service users needs are met. Service users said that staff were ‘kind’ and ‘very nice’ and that there were always enough on duty to provide them with help and support should they require it. Night staffing currently consists of one waking member of staff; the Ambulance Service have recently contacted the Commission for Social Care Inspection with concerns that on one occasion they had been called to the home to help the lone night worker move a service user back into bed after a fall, they felt that this was an inappropriate use of their service and have said that they will not do this again. Because of this it has been required that the home review their current night staffing arrangements. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 37 & 38 Management and administrative systems help support the good quality of care provided in the home. EVIDENCE: The manager was interviewed during the inspection; she presented as knowledgeable of the needs of older people and committed to her role and is close to completing her management training. Service users spoke positively of her. Records examined confirmed that regular staff meetings take place and that the manager provides regular one to one support sessions for staff. A selection of the records required by inspection were examined, these were of a good quality. However it was noted that care plans for service users which contain personal details were kept in an unlocked room with the door left open wide, action has been required to rectify this and ensure the confidentiality of service user’s records. Since the last inspection improvements have been made to the home quality assurance systems with new service users questionnaires Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 15 introduced. The manager was clearly aware of the importance of ensuring a safe environment for staff and service users, a selection of health and safety records was examined, these were generally in order although it was noted that the fire alarms and emergency lights were not being tested as regularly as they should. At the last inspection it was required that improvements be made to the staff recruitment records, it was not possible to ascertain if this has happened as the records were off site with the proprietor. A second visit was made to the home to examine these records, which were all in order. Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 1 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 3 x x x 3 2 2 Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 17 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Requirement That prospective service users are provided with copies of the homes statement ofpurpose and that the statement of purpose and service users guide are both made available to current service users. That pre admission assessments, care plans and risk assessments are in place for all service users. That risk assessments are undertaken regarding the risk of service users developing pressure sores and the capacity of those wishing to manage their own medication That in line with service users wishes additional excursions and outings are organised for them. That the flooring in the kitchen is replaced. That all records regarding service users needs are stored securely. That emergency lights and fire alarms are tested at the required intervals and the results recorded. That the current night staffing arrangements are reviewed. Timescale for action 7/5/05 2. 3. 7 8 15(1) 12(1)(a) 7/6/05 7/6/05 4. 5. 6. 7. 12 19 37 38 16(2)(m) 23(2)(b) 17(1)(a) 23(4)(a) 7/6/05 7/8/05 7/5/05 7/5/05 8. 27 18(1)(a) 7/6/05 Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Millcroft H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection 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 H59-H10 S21165 Millcroft V225621 070505 Stage 4.doc Version 1.20 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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