Inspection on 23/07/08 for Millfield

This inspection was carried out on 23rd July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Millfield 13/08/07

Millfield 13/06/06

Millfield 21/10/05

Millfield 03/06/05

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Millfield 9 St Catherine`s Road Littlehampton West Sussex BN17 5HS Lead Inspector Diane Peel Unannounced Inspection 10:00 23rd July 2008 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 Millfield DS0000063418.V367577.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. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millfield Address 9 St Catherine`s Road Littlehampton West Sussex BN17 5HS 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) 01903 714992 Mrs Pauline Anne Shanahan Mrs Pauline Ann Shanahan Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 11 service users in the category old age (OP) not falling within any other category. 13th August 2007 Date of last inspection Brief Description of the Service: Millfield is a care home registered to accommodate up to eleven service users in the category of Older People. It is a semi-detached Edwardian house located in the town of Littlehampton. The house overlooks a park and is a few minutes walk from the towns shops, public transport, local amenities and the sea front. The accommodation is provided on three main and two mezzanine floor levels with a lift providing access between the lower floor and the first main floor. The service is privately owned and managed by Mrs Pauline Shanahan who is also the registered manager. At the time of this visit the scale of charges for the home was £385 - £410 per week. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. Mrs Diane Peel carried out this unannounced visit to Millfield on the 23rd July 2008. During this visit the intended outcomes for 28 standards were assessed; these included the key standards for care homes providing a service to older people. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home and this was used to address areas of improvements. Have Your Say surveys were returned to us by two staff working at the home prior to the visit. On the day of our visit two people who usually lived at the home were in hospital but we met with all the other people living at Millfield and spoke with people further to get their opinion of the service. A case tracking exercise for four out of the eleven people living at the home was undertaken to look at how the assessed needs of this group of residents were being met. Staff were spoken with during the visit and observed during their interaction with people living at the home. What the service does well: The service provides people with a comfortable homely environment, which is well maintained. To ensure that people who come to live at the home receive the care that they require the manager ensures that peoples needs are assessed prior to them moving into the home and that they are then involved in putting together a plan of care which will meet their needs. People are encouraged to continue to remain part of the community for as long as they are able. They are encouraged to pursue their own interests and the Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 6 service has purchased an electric mobility scooter so that individuals can retain their independence. People who live at the home told us that they like the “ proper home cooked food” which they have. People working at the home tell us that they are well supported and have opportunities to improve their skills by attending courses, which help them to do their job and achieve qualifications, which recognise their competences. What has improved since the last inspection? What they could do better: Further improvements could be made to the homes own medication policies to incorporate the new system in use. The manager has already identified this as a further improvement. The registered manager has told us about the plans for the outdoor space at the rear of the property which will take place after the inside work has been completed. The registered person must ensure that appropriate risk assessments are in place for hot water outlets, which do not have thermostatic valves already, fitted and must continue to monitor hot water temperatures. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Millfield DS0000063418.V367577.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 Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into the home have good information about the home available to them so that they can make decision if the home is suitable for them. EVIDENCE: Millfield has a statement of purpose and service user guide in a format, which includes photographs of the home and key rooms within the property. It clearly explains that it is not able to offer a home to people who are “wheelchair bound or unable to walk without aids” because of the layout of the property and the number of steps. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 10 It also has a section with photographs of the staff and informs people who the staff are and what qualifications and training they have had. The document together with the statement of purpose details what prospective people using the service can expect, what they are paying for and gives clear guidance on how to raise complaints. We were told that the template is kept on a computer so that changes can be made as and when they are required for example when staff leave and their photographs need removing. All prospective people coming to live at the home have a needs assessment carried out prior to them being offered a service. The registered manager told us that she carried out the assessments. The AQAA returned to us by the registered manager told us “ we pre assess potential residents to ensure that we can meet their needs and they in turn feel confident that we can do this.” During our visit to Millfield we sampled four peoples care plans and saw that all four people had pre assessments carried out. Millfield does not offer intermediate care. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have person centred care plans, are respected as individuals and have their healthcare needs met by other healthcare professionals so that they know that the know that the care that they receive is based on their individual needs. EVIDENCE: The AQAA returned to us by the registered manager said “ from the last inspection we recognised the need to keep a more comprehensive care plan for our residents. I feel that we have achieved this.” and “ we have reviewed our care plan system and it is more comprehensive to ascertain residents needs.” Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 12 We looked at four care plans during our visit to Millfield. We saw that each had a personal profile, which included a photograph and information about the person’s prior life, job, interests and people important to them. The plans identified each area of need, had objectives to be met and described what interventions were required to achieve the objectives. They took into account people’s own preferences about how they wanted their personal care to be carried out. Risk assessments were in place for areas of risk which had been identified for people individually and for people who remained independent their was recognition of this and any prompting or reminding which they might need. The plans were regularly reviewed and daily records were also in use to monitor the health and welfare of each person. When asked in staff surveys “ are you given up to date information about the needs of the people you support and care for (for example in the care plan)? Both staff returning surveys to us said “yes.” Later in the surveys one member of staff told us “all staff are well informed about anything going on in the home.” Visits by specialist health care professionals are recorded the in the care records and on the day of our visit the registered manager was heard to contact the local health centre to book an appointment for someone’s blood test. We were told about and shown a diary system in place to ensure that appointments are not missed. The home has a system in place for hospital admission, which consists of a transfer sheet. This included all the medical information, which would be needed at the hospital such as medication being taken and allergies and medical history. There is also a photograph of the person and information about their doctor. On the day of our visit two people who usually live at Millfield were in hospital for treatment. We were told by the registered manager that the hospital staff had rung up to say that one person would be coming home but after further discussions she had found that there had not been enough improvement or treatment carried out. The registered manager could not be assured that the person’s needs could yet be met by the service they had not been able to return home yet. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 13 If any individual person had the need for their diet or fluid intake to be monitored this was recorded in a daily diary system, which was crossreferenced to the care plan and daily care records. The home had a medication policy, which the registered manager told us could still be improved after bringing in the new medication system since our last visit to the home. The medication system in use at Millfield is a monitored dosage system supplied by a local pharmacist. The system includes each individual person having an identity sheet, which has a recent photograph of them and information about their doctor, date of birth and their room number, and any allergies, which they might have. Each file of medication in the dosage system also has a matching photograph and then each medication administration sheet also has a photograph and personal information about them at the top. Each individual medication prescribed in boxes, bottles or tubes also had a photograph of the person the medication was prescribed for and their personal details. Medication was observed to be being stored in a locked cupboard on the day of our visit and we saw storage for controlled medication was already in place. We discussed the format of recording controlled drugs register with the registered manager who agreed to refer to the Royal Pharmaceutical Society guidelines to ensure that the recording system in place was sufficient although at the time of our visit the drug being recorded (according to the Royal Pharmaceutical Society guidelines) was not one which needed to be recorded in the controlled drugs register. Sample signatures of staff administering medication were seen and the medication records sheets observed were recorded up to the date of our visit with a key code system being used when medication had not been taken. The AQQA returned to us in April 2008 told us that all staff working as care staff at the home had had medication training. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are encouraged to makes choices about what they want to do, keep contact with their friends and relatives so that they can live as full a life style as they are individually able to. EVIDENCE: The residents charter in the statement of purpose and service users guide is proactive in the promotion of individuals rights to live an ordinary and meaningful life as far as their abilities allow both at home and in the community. Peoples interests were observed to be recorded in their care plans along with information about their past lives and their contact with their relatives and friends. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 15 The AQAA returned to us in April 2008 told us “we encourage residents to pursue their own choices in life i.e. church services, shopping, local community activities. We provide in house entertainment. Weather permitting we take residents on outings: beach, park, and crazy gold. We take residents to the town so that they can purchase shopping. We have in house activities: bingo, card games, and painting. We have theatre trips.” When we arrived at the home one person living at the home was just returning from a walk out. They told us that they liked to do this most days when the weather was good. When we were leaving the home later in the day another person whom we had met during our visit to Millfield was also taking a walk out towards the seafront. The registered manager also told us that one person had their own care, which they kept nearby. The hairdresser was also visiting on the day of our visit. During our visit we saw an activities programme on display on the notice board in the dining room. We were told about a lady who comes to the home to play music to people in their individual rooms and that sometimes the people living at Millfield join people living at the other care home owed by the same provider for parties and outings. The home has installed sky television and has a DVD player and music system in the lounge for people to use. We were also told about the electric mobility scooter, which the home has purchased and insured for use, by anyone living at the home. We saw the visitor’s book on display in the hallway, which recorded regular visitors to Millfield. The manager gave us examples of how the service has supported people to maintain relationships with friends and families this included people who had complex diverse needs. The service user guide actively encourages people to stay in contact with friends and relatives and invite them to “your home as and when you wish.” There is a four-week rotating menu at Millfield, which we were shown during our visit. It showed that meals are varied and that there is always a choice on offer at the main meal of the day. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 16 We also saw the system in use for recording what people have chosen if they don’t want the main courses on the menu. On the day of our visit people eating in the dining room told us that they were enjoying their meal. It was a roast turkey dinner, which had vegetables of carrots, potatoes and beans. The service does not employ a separate cook and staff preparing meals have now had food hygiene training. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure so that people know that if they have any dissatisfaction they can voice their concerns. Safeguarding people form abuse and harm is taken seriously so that people can feel protected. EVIDENCE: The home has a complaints procedure, which was on display in the hallway and information about how to make complaints was observed to be included in the statement of purpose and service user guide. The AQAA returned to us told us that the home had not received any complaints and the registered manager confirmed this during our visit. Staff returning surveys to us told us that they knew what to do if a service user, relative or advocate has concerns about the home. The home has its own safeguarding adults policy in addition to the West Sussex Multi Agency safeguarding policy. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 18 The registered manager told us that she had just recently been on safeguarding training herself and information in the AQAA told us “ most of the staff have now had POVA training.” The AQAA returned to us from Millfield reported that there had been no safeguarding referrals and no safeguarding matters or complaints have come to our attention. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have a well-maintained comfy environment to enjoy so that they can feel at home in their surroundings. EVIDENCE: Since Mrs Shanahan became the registered provider of the home four years ago the property has undergone a major refurbishment programme and since we last visited Millfield she has continued with environmental improvements to the home. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 20 The shower room, which was undergoing refurbishment on the day of our last visit, is complete and on the day of this visit the bathroom on the upper floor was being refurbished. Mrs Shanahan has told us that once work is complete within the property the rear garden area will be improved so that people have outside area, which they can enjoy. The service user guide describes the facilities of the home, has photographs of the communal areas and a sample bedroom. It also is clear to stress that the home does not accommodate people who are “wheelchair bound or unable to walk without aids” because of the layout of the building although the home does have a lift. The home has good quality homely furniture and fittings in its communal areas, which consist of a lounge at the front of the property and a dining room down a few stairs at the end of the hallway. There is also a small reading room People have individual bedrooms, which they have personalised with items of furniture, brought to the home and pictures and mementoes, which they have collected. We were told in the AQAA returned to us in April that there is already in place a programme to replace taps in peoples sinks in their bedrooms or en suite facilities so that all hot water outlets have thermostatic valves. People who we visited in their rooms told us that they liked their rooms and we saw that for one person they had their room set up as a bed sitting room. The majority of the home was clean and fresh but the registered manager did discuss with us issues for one room which there was difficulty because of unpleasant odours .She told us that she is trying to find a solution for this one individual but it is not simple to over come and may need to consult other health care professionals. Since we last visited the home when we expressed concerns about laundry being transferred to the laundry facilities in the basement via the edge of the dining room the registered manager has implemented a system of using dissolving bags to convey soiled laundry. The last inspection report described failure in infection control, as there was lack of hand drying facilities suitable to reduce infection control. This is now resolved. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 21 Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have a well-trained consistent staff group so that they know that their care will be delivered in the way that they require. EVIDENCE: There were two staff working at the home when we arrived and nine people living at the home (two people were in hospital). The manager told us that there are two people on duty in the afternoon and evening and then one person awake and one person asleep at night. The registered manager told us in the AQAA returned to us in April 2008: “at the last inspection I admitted that I accepted CRB checks if they were produced in previous three months. I now realise that this was wrong and now requested CRB checks for all staff.” We looked at the recruitment documentation for two people during this visit to Millfield, which included a person who had just recently been employed. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 23 A job application was on file, two references; evidence of verification of identity had been confirmed for both people whose recruitment documents were viewed. There was evidence of POVA first clearance in place for the person most recently employed who we were told was being supervised in their work until the full CRB disclosure arrived. For the other person evidence of full CRB disclosure was seen. We also saw documented evidence of induction, staff supervision and appraisal in staff files. We received two Have Your say surveys from staff prior to our visit which informed us that both the staff returning the surveys thought that their was always enough staff to meet the individual needs of people using the service. These two staff also informed us that they thought that their induction had covered everything that they needed to know when they started the job, that they had training relevant to their role, which helps them understand the individual needs of the service users and that they met with their manager regularly to for support and to discuss how they are working. Since our last visit to the home staff have had improved opportunities to update their skills and knowledge. Data in the AQAA returned to us informed us that out of the seven staff employed to work at Millfield four are currently working towards an NVQ. There is currently no staff already qualified with an N.V.Q at level two or above. Recent training attended has been medication handling, nutrition and health; fire training safeguarding adults, food hygiene and moving and handling and dementia awareness. Information returned to us in the AQAA told us that future training included infection control, health and safety and first aid. Two requirements made at our last visit to the home to ensure that staff get the training, which they need to provide a safe service to people who live at the home, has now been met. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home and their relatives can be confident that the registered provider wants to run the home in the best interests of the people that live there, but to achieve this must ensure that environmental risk assessments must cover all risk areas including identifying the risks from hot water outlets which do not yet have thermostatic valves fitted. EVIDENCE: Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 25 Mrs Pauline Shanahan is the registered provider and manager of Millfield. She has owned the service for four years and in that time has completely refurbished the home. She has a City and Guilds qualification in management and is currently undertaking the NVQ level 4 registered managers award. Mrs Shanahan has told us that further improvements will included the outside areas to the rear of the property. The two staff who returned surveys to us commented: “Pauline is the best manager I have ever had. She is very supportive and approachable.” and “ the manager is a good woman and staff are nice and friendly towards residents.” A formal quality assurance system has been set up which includes surveys to be distributed to people’s families. These were seen during our visit ready to be sent out. Staff supervision and appraisal documentation were observed in the staff records viewed during our visit. We were told that that the service does not look after money for anyone living at the home. Any expenditure not included in the fees is invoiced to the individual, their next of kin or their advocate. We also know from information provided in the AQAA returned to us in April 2008 that the service recently introduced health and safety quality audit system provided by an outside consultancy. Two statutory requirements have been made following this visit to the home to ensure that the registered person addresses issues with offensive odour in one specific area of the home and ensures that people are protected from hot water outlets which are yet to be fitted with thermostatic controls. Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 3 3 3 4 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP26 Regulation 16.2 (k) Requirement Appropriate advice must be sought and action taken to as far as possible keep the home free of offensive odour. Environmental risk assessments must cover all risk areas including identifying the risks from hot water outlets which do not yet have thermostatic valves fitted. Timescale for action 01/09/08 2 OP38 13.4 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Millfield DS0000063418.V367577.R01.S.doc Version 5.2 Page 29 - 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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