Inspection on 08/02/06 for Millcroft

This inspection was carried out on 8th February 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 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 08/08/06

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 Louise Bushell Unannounced Inspection 8 February 2006 10:00 th Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 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.V280457.R01.S.doc Version 5.1 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.V280457.R01.S.doc Version 5.1 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.V280457.R01.S.doc Version 5.1 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. 12th April 2005 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. 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 ground 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.V280457.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the homes second inspection of the inspection year. The focus of this inspection was to namely look at the remaining 4 key inspection standards and to follow up on previous requirements and recommendations made. Time was spent with manager, staff and service users, seeking views, taking direct and indirect observations and inspecting documentation relevant to the remaining standards to be inspected. This inspection was extremely positive and shows much progress with regards to the decoration and compliance in line with the Fire Authority following their premises inspection. The reader is encouraged to use the previous report for an entire view of the homes ability to meet outcomes in the best interests of the service users. What the service does well: The home has clear policies and procedures that are well organised, maintained and accessible to all. The atmosphere throughout the inspection was calm and friendly, promoting a good relationship between staff and service users. Staff spoken with during the inspection were complimentary of the management style within the home. The ethos of working openly, honestly and with a transparent approach appears to be effective. The home has a high ratio of staff to service users (2:1) ensuring that individual and complex needs can be met. The home has a stable staff team to promote continuity for the service users. All service user bedrooms are individually decorated reflecting their individual personalities and preferences. Staff should be commended for their efforts. The staff approach within the home ensures that service users are empowered to make choices and encourages service user self-determination. Service users assessments have recently been recompiled ensuring that all changing needs are recognised and assessed. The home is currently adapting and implementing a new corporate care planning system. The care plan is clearly a working document, which is being regularly reviewed. The care plans, once in place will be excellent examples of meeting individual and changing needs. The home has a sound system for the provision of training and many training courses are currently available and are being attended by the staff team. Staff are well supported and the company has recently introduced a new training and development personal plan. This document provides a holistic view of the support in place for each staff member and the supervision and Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 6 appraisal process appears to be an excellent example of an accurate record being maintained meeting the needs of the company and the individual. What has improved since the last inspection? What they could do better: All of the key standards inspected were met. Following the admission of a new service user the use of new equipment determined that further risk assessments were required for the safety of the staff and the service user. These were implemented on the day of the inspection and were person centred and minimised risks as required. Quality assurance was discussed at length and the manager was able to identify a number of methods that are used to ensure quality at the home. Following the completion of the inspection the manager forwarded the company quality assurance policy along with the internal quality assurance monitoring systems and procedures that occur aiming to review their own service and make improvements at al times. The documents when received were satisfactory and met the standards and requirements. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 7 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.V280457.R01.S.doc Version 5.1 Page 8 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.V280457.R01.S.doc Version 5.1 Page 9 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): Standards not inspected on this occasion. Please refer to the previous report for details. EVIDENCE: Standards not inspected on this occasion. Please refer to the previous report for details. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 10 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): 9 Service users are supported to take risks as part of independent living encouraging and empowering them to gain essential life experiences. EVIDENCE: All service users are supported with a wide range of risk assessments. The risk assessments are completed by two staff and aim not to restrict the service user but to encourage and empower the service user to gain and to take part in skills for daily living. The risks are minimised and appear to be well managed. The ethos promotes service user involvement and staff were seen to encourage service users to become involved in tasks. A new service user had recently moved into the home and remains on a trail period, progress plans were in place and risk assessments were being formulated that were person centred and non restrictive. On the day of the inspection risk assessments were completed for the safe management of the profiling bed for the safety of the service user and of the staff team. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 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): 17 Service users are offered a healthy, well balanced nutritious diet, encouraging an active healthy life style. EVIDENCE: The registered person promotes service users health and well being by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. Service users are offered a choice of suitable menus, which meet their dietary and cultural, needs, and which respect their individual preferences. Meals are offered three times daily including at least one cooked meal; and a range of drinks and snacks to meet individual needs are available at all times. Service users are actively supported to help plan, prepare and serve meals. Mealtimes are relaxed, unrushed, and flexible to suit service users’ activities and schedules. Service users’ nutritional needs are assessed and regularly reviewed including risk factors associated with low weight, obesity, and eating and drinking disorders. Service users who need help to eat or are fed artificially are assisted appropriately while maintaining choice of when, where and what they eat; and Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 12 assisted to choose appropriate eating aids. Records are maintained of foods consumed and core food temperatures. Where a specific need has been identified for example and need to ensure a service user is consuming adequate volumes of fluid a specific short term care plan has been introduced and records maintained. Where these records are no longer required they should be filled. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 13 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): Standards not inspected on this occasion. Please refer to the previous report for details. EVIDENCE: Standards not inspected on this occasion. Please refer to the previous report for details. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 14 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): Standards not inspected on this occasion. Please refer to the previous report for details. EVIDENCE: Standards not inspected on this occasion. Please refer to the previous report for details. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 15 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): Standards not inspected on this occasion. Please refer to the previous report for details. EVIDENCE: Standards not inspected on this occasion. Please refer to the previous report for details. The reader must note that although a detailed inspection did not occur on this occasion ongoing monitoring of the homes environmental improvements have noted and are mentioned in the summary of this report. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 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): Standards not inspected on this occasion. Please refer to the previous report for details. EVIDENCE: Standards not inspected on this occasion. Please refer to the previous report for details. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 17 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): 39 Effective quality assurance systems are in place that aims to seek the views of the service users and ensure that the service is specific and effective at meeting individual needs and empowering choices and right. EVIDENCE: Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. There is continuous self-monitoring, using an objective, consistently obtained and reviewed and verifiable method and involving service users; and an internal audit takes place at least annually. Feedback is actively sought from service users (with support from independent advocates as appropriate) about services provided through The views of family, friends and advocates and of stakeholders in the community are sought on how the home is achieving goals for service users. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 18 There is a detailed company quality assurance policy in place and the home has introduced a smaller practice based policy which outlines all the systems and procedures in place that directly or indirectly monitor the quality of the home. A new service user, stake holder, health care professional questionnaire has been devised and will be distributed in April as part of the homes annual quality assurance. Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 19 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 3 X X X X Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Millcroft DS0000019469.V280457.R01.S.doc Version 5.1 Page 21 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.V280457.R01.S.doc Version 5.1 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!