Inspection on 08/08/06 for Millcroft

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Millcroft 08/02/06

Millcroft 12/04/05

Millcroft 21/09/04

Millcroft 20/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Millcroft Royston Road Barkway Royston Hertfordshire SG8 8BU Lead Inspector Mrs Alison Butler Unannounced Inspection 8th August 2006 10:00 Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 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 DS0000019469.V308244.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 Adults 18-65. 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 DS0000019469.V308244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millcroft Address Royston Road Barkway Royston Hertfordshire SG8 8BU 01763 848306 01763 849440 millcroft@craegmoor.co.uk 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) Conquest Care Homes (Peterborough) Limited Mrs Katharine Ellen Tones Care Home 8 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1), Physical disability (1) of places Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one young adult (under 65 years of age) with learning disability together with associated physical disability and who will be accommodated in a ground floor bedroom. The home may accommodate one elderly person (of 65 years of age and above) with learning disability and who will be accommodated in a ground floor bedroom. 8th February 2006 2. Date of last inspection Brief Description of the Service: Millcroft is a care home providing personal care and accommodation for 8 adults with a learning disability, one who may have associated physical disabilities and one who may be over the age of 65. Fees for the services are £980-£1,450 per week. Additional charges are made for newspapers, toiletries etc. (this was correct as at 08/08/06). The Home is owned by Conquest Care Homes (Peterborough) Limited, which is a subsidiary of Craegmoor Healthcare Limited. The home is located in the village of Barkway, which is situated in a rural area of Hertfordshire and it has its own means of transportation. The home was opened in 1998. Accommodation is offered on 2 floors. The ground floor comprises of a lounge, a quiet room, a dining room, a kitchen and 2 bedrooms (which are used to accommodate service users with mobility impairment as the home does not have a passenger lift) and one assisted bathroom with toilet. The first floor consists one lounge, 6 further bedrooms and 2 bathrooms with toilet. The entrance to the grounds is gated. There is ample parking facility to the front of the home and an extensive and well-maintained fenced garden at the rear with patio and lawn areas. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one inspector between the hours of 09:00 and 15:30. The aim of this inspection was to assess all the key standards. The majority of the inspection was spent talking to residents, relatives and staff. Care and administrative records were checked. Where information remains the same this has been brought forward from previous reports. This inspection also involved obtaining information to support a variation that had been received at the Commission For Social Care Inspection office. What the service does well: What has improved since the last inspection? Further decorating has occurred, this is to try and ensure the home is as homely, bright and airy as it can be. This is an on going task due to the age of the building, which makes it very difficult. A pharmacy inspection took place on 6th July 2006 in which requirements and recommendations were made, action had been taken to address the issues with the exception of all medication not being signed in on entering the home. (A letter is available regarding this visit on request). Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 6 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. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to the home. Residents have their needs assessed and reviewed to ensure that their needs can be met within the home. EVIDENCE: Full assessments are made prior to the residents moving into the home. The assessment is comprehensive and is a working document to ensure the changing needs of the residents can be addressed and met. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to the home. Residents’ choices and needs are being promoted and residents are empowered and encouraged to make decisions about their lives. They are supported to take risks as part of independent living. EVIDENCE: There are a wide range of risks assessments and these are regularly reviewed and up dated as appropriate. A risk assessment for the use of monitors must be put in place to protect the privacy and dignity of the residents concerned. Staff must be reminded of the importance of following infection control guidance regarding universal precautions. The plan for the resident who suffers from epilepsy should be updated and a list of staff that are trained in the administration of rectal diazepam be included. A discussion with the manager took place and a different protocol may be used as training is difficult to access and the residents’ seizures appear to be managed with regular medication. The staff continue to promote that the residents own their own care plans. The care plans are clearly working documents and the manager should consider these to be reviewed on a three monthly basis rather than monthly, as it appears it can Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 10 be just a paper exercise as staff know they need to be done. This would bring them into line with the reviewing of the risk assessments. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to the home. Personal opportunities are encouraged and residents take part in the local community and engage in activities of their choice. Residents are offered a healthy and nutritious diet. EVIDENCE: Residents’ health and well being is promoted and they have a various and well balanced diet. Meals are provided by staff who are knowledgeable about the residents likes and dislikes. Snacks and drinks are available throughout the day and on request to the residents. Residents are assisted during meal times appropriately and are encouraged to be as independent as possible. Mealtimes are flexible to suit residents’ activities and choice. (See also comments in the environment section). Residents access various day services and colleges to meet their needs and choices. Staff support residents as appropriate to access the local community and take part in appropriate leisure activities. Good interaction was observed during the inspection between residents and staff. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to the home. Personal and health care is well maintained within the home. Some of the medication practices need to be improved for the safety of the residents. EVIDENCE: The care that residents receive at Millcroft is tailored to meet their individual needs and choices and preferences being promoted. Residents are supported as appropriate to meet their health care needs and records are well kept. Examination of the medication showed that not all medication had been signed in on entering the home. This must be carried out to be able to carry out reconciliation at any time. When adding new medication on to the recording sheet the instruction must be copied as per the dispensing label so that errors do not occur, the author should then sign the record. All returns medication and storage was well maintained, with a bring forward system in place. Temperature of the storage is recorded and remains with the recommended levels. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to the home. Residents feel safe and listened to. A complaints procedure is in place. EVIDENCE: There is a comprehensive complaints policy in place. No complaints have been received by the home since the last inspection. A record would be maintained detailing any actions and outcomes as necessary. The complaints procedure is on display within the home. Staff receive training in adult protection and are aware of the Hertfordshire Adult Protection Procedure and of whistle blowing and what to so in the event of witnessing or being told of an allegation of abuse. Residents appear to feel safe with the home and have a good relationship with their key workers. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality outcome in this area is poor. This judgement has been made using the available evidence including a visit to the home. The home is still in need of replacement or renewal of furnishings and flooring to ensure it is homely and comfortable environment to live in. EVIDENCE: Whilst a great of decorating has happened since the last inspection there are still areas requiring attention. Following a tour of the building, discussions with the manager and staff, two residents bedroom flooring, all corridor flooring and the main lounge flooring is in need of replacing, these are badly stained and look unsightly. The flooring needs to be robust and be appropriate for the needs of the residents as some have mobility problems and use wheelchairs. The dining area, which has the appearance of a canteen, is looking very tired and the furniture is in a poor state of repair. This must be replaced with suitable tables and chairs purchased to meet the needs of the residents and provide a homely and safe environment to them. The homes driveway is laid with gravel, an emergency concrete pathway was created from the front door, which unfortunately finishes in the middle of the driveway and not at the assembly point as per the fire procedure of the home. This may result in staff Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 15 injuring themselves when evacuating residents in wheelchairs due to the uneven path. The pathway must finish at the assembly point and it would be beneficial if it extended to the front of the main gate to allow easy of access for staff and residents who wish to walk to the village. The staff write any maintenance issues in a folder and when the work has been carried out the maintenance person signs and dates the record, this supports trying to maintain a safe environment. The laundry is separate from the main building, promoting good infection control procedures. Red alginate backs are used for soiled laundry and plenty of protective clothing is available to staff. The manager needs to purchase soft disposable hand towels for staff as recommended by the infection control team. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to the home. The home is well staffed and staff have received the appropriate training to meet the needs of the residents. Staff records were well kept with all the relevant information held with the exception of a photograph EVIDENCE: Staff talked to during the inspection were clear of their roles and responsibilities. Adequate staffing levels were in place to meet the residents’ needs, which is provided on a 2:1 ratio. A full training programme is in place. 2 staff are working towards a NVQ 2 award with 3 working towards a level 3. Three staff are working towards NVQ level 4. Two staff have achieved the assessors award. The manager has nearly completed her Registered Managers Award. 6 staff are to be registered for either level 2 or level 3 NVQ in September 06. Training carried out this year includes COSSH, food hygiene, infection control, fire, adult protection, equal opportunities, and health and safety. Examination of the staff records showed that all the relevant information had been obtained prior to commencing with the exception of a photograph on the newest member of staff. This must be obtained as soon as possible. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 17 Staff are supervised although there are a number of staff still require formal supervision to be carried out to ensure that the home meets the minimum standard of six times a year. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to the home. The management in the home is effective and ensures the changing needs of the residents are met. Health & safety systems are in place although some work is required to ensure the safety of all is maintained. EVIDENCE: Good interactions between staff and residents were observed during the inspection. The management of the home creates an open, positive and inclusive atmosphere. Staff spoken to felt well supported and encouraged to attend training that will support them in meeting residents’ needs. A copy of the most recent regulation 26 report was examined during the inspection and 3 issues identified for action. The company have a detailed quality assurance policy in place and this will be monitored to ensure the home will continue to review the quality of care Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 19 provided by seeking the views of the residents, relatives, staff and other professionals and that it continues to meet its aims and objectives. Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 21 NA 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 YA7 Regulation 12(4)(a) Requirement The manager must compile a protocol for the use of monitors to ensure the resident privacy and dignity is observed at all times All medication must be signed in on entering the home. When adding information to the record sheet the instructions must be copied exactly from the dispensing label and then be signed by the author. The bedrooms identified during the inspection must have their carpets replaced with a suitable flooring to meet their needs. The main lounge and all corridors must have the carpets replaced with appropriate flooring to meet the needs of the residents. The dining room furniture must be replaced to meet the needs of the residents The emergency pathway must be extended to the evacuation DS0000019469.V308244.R01.S.doc Timescale for action 31/08/06 2 YA20 13 (2) 31/08/06 3 YA24 16 (2)(c) & 23(2)(d) 23 (2)(b) & (d) & 16 (2)(c) 23 (2)(d) & (c) 13 (4)(c) 30/11/06 4 YA24 30/11/06 5 6 YA24 YA24 31/10/06 30/11/06 Millcroft Version 5.2 Page 22 point 7 YA34 19 schedule & 2 The manager must ensure that a photograph is available within the staff records 31/08/06 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 Refer to Standard YA24 YA30 YA36 Good Practice Recommendations The emergency pathway should be continued to the end of the main drive way to allow easy access to the local village The manager should purchase soft disposable hand towels. The manager should ensure that all staff receive supervision at least six times a year. A matrix should be put in place to monitor supervisions for all staff Millcroft DS0000019469.V308244.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 DS0000019469.V308244.R01.S.doc Version 5.2 Page 24 - 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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