CARE HOMES FOR OLDER PEOPLE
Millfield Lodge Potton Road Gamlingay Bedfordshire SG19 3LW Lead Inspector
Nicky Hone Key Unannounced Inspection 15th February 2007 10:20 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 Lodge DS0000015176.V330848.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 Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Millfield Lodge Address Potton Road Gamlingay Bedfordshire SG19 3LW 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) 01767 650734 01767 651434 Ms Anita Ram Ms Anita Ram Care Home 31 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (31) of places Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd October 2006 Brief Description of the Service: Millfield Lodge is situated on the edge of the village of Gamlingay. It is located at the end of a short private drive and is within about a mile of the shops, doctors surgery and village centre. Gamlingay is on the CambridgeshireBedfordshire border and is approximately a 30 minute drive from Cambridge city and a 15 minute drive from Sandy. Millfield Lodge is a single storey building and has recently had a large extension built to the back of the existing home. The home now has thirty one single bedrooms. The twenty new rooms each have a large ensuite shower room; seven rooms have an ensuite toilet, and four rooms have a washbasin. There are two lounges, one of which has a large conservatory attached which has doors to an enclosed patio area. The dining room has been extended and there are two bathrooms and a shower room, as well as a kitchen, laundry room, offices and staff room. The home has plenty of parking space at the front, and large gardens to the rear and side of the building. The fees for Millfield Lodge are £361 per week, or £455 to £600 per week for dementia care and higher dependency needs. Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the report of a key inspection of Millfield Lodge which we undertook on 15th February 2007. The team of three inspectors included a pharmacist inspector. We have carried out some regulatory activity involving this home since the last key inspection in October 2006. A summary of that activity is given here: reports written following the random inspections have not been published but are available from the CSCI office. 2nd October 2006: a key inspection was carried out. An immediate requirement notice relating to the administration and handling of medication was left at the home, and a further 14 requirements were made. The report of this inspection has been published. 6th October 2006: A Statutory Enforcement Notice was served because the home had failed to obtain the information required before staff are allowed to start work at the home. 25th October 2006: we carried out a random unannounced inspection to check compliance with the Notice served on 6th October. We checked seven staff files and found that all the required information was on each of the files. We considered that compliance with the notice had been achieved. We noted however that some of the information had been obtained some considerable time after some staff members had started work: we reminded the home that this information must be obtained before staff start work so that residents are protected from people who might cause them harm. 6th December 2006: an unannounced inspection was carried out by the pharmacist inspector. In his report he made a judgement on all aspects of medication: “Practices for handling and recording of medicines within the home are poor and there are some shortfalls in record keeping which must be addressed to improve standards of care and protect residents”. Seven requirements were made. --------------------------------------------This inspection took place on 15th February 2007. The pharmacist inspector made a thorough check of all aspects relating to medication. The other two inspectors spent time speaking with residents, staff and the manager, observing practice, looking round the building and checking records. There were 28 people in residence, 13 of whom had been diagnosed with dementia.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 6 Overall we were impressed with the way the home has moved forward since the last inspection. The atmosphere in the home was much improved: residents seemed to be content with the way they lead their lives, and staff were generally relaxed and carrying out their tasks efficiently. The relationships between residents and staff were seen to be very good. The challenge now for Millfield Lodge is to make sure the improvements made so far are maintained, and the home continues to move forwards. What the service does well:
The recent building work and refurbishment of the existing home have significantly improved the quality of the environment and made Millfield Lodge a very attractive home, whose layout is suitable for its stated purpose. The new part of the home consists of a number of single bedrooms, all with ensuite shower rooms, and a new lounge, which opens on to the rear gardens. There is an attractive enclosed central courtyard which is safe for the residents and will be a wonderful suntrap in the summer. One resident we spoke with said the home is “much better than I expected” and that the “staff are excellent”. The manager carried out a survey of views of residents, relatives and visiting professionals. The report written by the manager following this survey summarised that 99 of the responses were positive about the quality of care offered by the home, and all respondents said they would recommend the home to others. Full, detailed assessments are carried out, both by social workers and by the home, to make sure the home can meet each person’s needs. New residents and their relatives are invited to visit the home before they make a decision about moving in. Meals offered are healthy and nutritious, and we saw that the residents enjoy the food. The home has very good written policies and procedures for the safe handling of medicines. Residents are encouraged to look after their own medicines within a risk management framework and appropriate assessments are in place. There are good written protocols for medication prescribed on a “when required” basis. This ensures consistency of use and safeguards residents from misuse of medicines. Complaints are recorded and responded to well, residents’ money is looked after correctly, and records of checks relating to health and safety matters are satisfactory. The home has a good quality assurance system in place, seeking views of residents, relatives and professionals who visit the home. The manager collates the views into a report.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Further improvement is needed in care planning to make sure that each person’s personal, social, emotional and healthcare needs can be fully met by the staff. Records of the administration of medicines to residents must be signed immediately after administration, on an individual basis, and not all together at some later time. Spare keys must be made available for the medication trolley since this cannot be locked, or removed from its storage point as the keys have been lost. All parts of the home must be free from offensive odours and fire doors must close properly. Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 8 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 Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 9 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 Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 10 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): 2, 3, 4, 5, 6 Quality in this outcome area is good. Full assessments of each new resident’s needs are taken into consideration before the person is admitted so that the person knows the home will be suitable for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We checked the files of four residents. The senior staff of the home carry out an assessment for all prospective residents so they can be sure the home can meet the person’s needs. We also saw evidence on the files that the home obtains a full, detailed assessment of needs, completed by their social worker/care manager for people who are supported by the local authority.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 11 Once the assessments have been completed, the manager writes to the person to confirm that she feels the home will be suitable for them. We saw copies of these letters on some of the files. Once the person has been admitted to the home, a series of further risk assessments are carried out, for example relating to falls, continence, nutrition, pressure sores and social interaction. One person who is not funded by the local authority told us that he had received and agreed a contract with the home, and had been given a copy. On the day of the inspection the relatives of a person who was interested in moving to the home had come to look round. Intermediate care is a service offered by some homes which gives short-term, intensive rehabilitation for people leaving hospital before returning to their own homes. This service is not offered at Millfield Lodge, therefore standard 6 is not applicable. Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 12 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 adequate. The information in care plans is improving but more work still needs to be done to make sure staff know how to fully meet everyone’s needs. Medication practices are generally of a good standard so that medicines are dealt with safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Generally care plans have greatly improved since the last inspection. We checked four files and each contained detailed information about each person. We were impressed to note that the care plans included information about each person’s abilities and strengths, as well as their needs. Some of the care plans gave staff good, clear guidance on how the person wants to be cared for.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 13 There was evidence that the care plans had been drawn up using the preadmission assessment information, plus the series of risk assessments carried out when the person was admitted. There was also some evidence that the person, or their representative, had agreed the care plan. We saw daily notes that the staff had written. These were detailed and gave a really good picture of how the person had spent his/her day. Two of the care plans we looked at showed that meaningful monthly reviews of the plan had been done, from November 2006. However, on one person’s ‘mobilising’ plan a note about a change had been written at the top of the page, but the change was not recorded in the review notes and the guidance had not been changed. On another plan the reviews were not so meaningful. On this person’s preadmission assessment it had been noted that s/he needed a ‘pureed diet’. There was no mention on the eating/drinking care plan to show whether this is still required. We saw some references on the files that showed that resident’s health care needs are considered, for example visits to the GP, optician, dentist and chiropodist. However, one person’s care plan said they wanted to see the chiropodist every eight weeks, but only two visits were recorded, in April and October 2006. Written policies and procedures for the safe handling of medicines have been revised and updated. These are now comprehensive and staff follow these. Storage provided for medicines is satisfactory and the temperatures are monitored and recorded regularly. The current trolley cannot be locked or removed from its storage point since the keys have been lost and spares where not available at the time of this inspection. This needs to be addressed and a requirement has been made about this. Records of the receipt, administration and disposal of medicines are of a good standard. However, it was apparent during this inspection that the records of the administration of medicines for the morning of the inspection were not completed on an individual resident basis immediately after administration but were signed at a later time. This is unacceptable practice and a requirement has been made. Where residents are prescribed eye drops, it is important that there is an appropriate instruction, both in the care plan and on the medication record sheet, of which eye is to be treated. Where medication is prescribed on a variable dose basis, e.g. “one or two tablets”, then the actual dose given to the resident needs to be recorded. Stock levels of medication are now at an acceptable level and no medication was found for which there was no record made. Care plans carried appropriate risk assessments for those residents who self medicate and there are good
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 14 written protocols for medication prescribed on a “when required” basis. We spoke to one resident who showed us the lockable facilities he has in his room for storing his medicines. There was a copy of the home’s ‘self-medication’ policy on his file, as well as a detailed risk assessment about selfadministration of medicines. We observed that residents and staff get on well together and staff treat residents with respect. Pictures had been put on the door to some residents’ bedrooms. Although this was an attempt to personalise the rooms, these looked scrappy, were too high for residents to see them and some were very childish. Other than this there was nothing that gave us any concern that residents’ privacy and dignity are not upheld by the staff. Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 15 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 good. Choices available to residents have improved so they have more control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One resident we spoke with said there is a range of activities available which he can choose to join in with if he wants to, such as exercises to music, quizzes, listening to music and a variety of games. He is free to do whatever he wants and enjoys listening to his own music or watching television in his room. On the day of the inspection the activities coordinator was working in the home. As it was a pleasant spring day she spent the time taking people outside for a walk in the gardens. A schedule of activities has been drawn up and is on the notice board in the dining room. Staff told us that these planned
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 16 activities usually take place, as well as other things going on which are more spontaneous. One person who responded to the survey of views carried out by the home asked for more opportunities for people to go on outings away from the home. Residents and their visitors know that visitors are made welcome at Millfield Lodge at any time. Residents choose whether to meet with their visitors in the privacy of their bedrooms, or in the lounges or dining areas. We met some visitors who were having lunch at the home with their relative. One person told us that his family were involved in his move into the home and are able to visit whenever they want to. He is encouraged to maintain contact with his family and visits his sister once a week for lunch. A four-week menu was on display in the dining room showing that a wholesome and varied diet is offered, including a choice of main course at lunchtime. One person told us that staff ask him each day for his choice for lunch. We observed lunch being served in the dining areas of the home. The meal looked appetising and residents clearly enjoyed their food. The serving of the meal was rather slow and some people were getting a bit agitated about why others were eating and they had not been given their meal. Millfield Lodge DS0000015176.V330848.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. Residents can be confident that their concerns will be listened to and acted on, and that staff have received training to make sure they are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure. The procedure is clearly on display in the entrance hall. The home has a hard-backed book to log complaints, details of which are kept in a separate folder. Three complaints had been recorded since the inspection in October 2006: two of these were from relatives who were concerned about the behaviour of one resident who has since left the home, and the third was about money which had possibly gone missing. All the complaints had been fully investigated and there was a letter on file from one of the complainants thanking the manager for resolving the complaint appropriately. One of the senior staff at the home had undergone ‘key practioner’ training in Protection of Vulnerable Adults (POVA) with Cambridgeshire County Council, and has been assessed as competent to train other staff. She had undertaken a training session for staff in January and had several further sessions planned.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26 Quality in this outcome area is good. The standard of the environment in this home is good providing residents with an attractive, comfortable, safe and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recent building work and refurbishment of the existing home have made Millfield Lodge a very attractive home, whose layout is suitable for its stated purpose. The new part of the home consists of a number of single bedrooms, and a new lounge, which opens on to the rear gardens. All bedrooms are single, and all except four have at least an ensuite toilet. Twenty new bedrooms have large ensuite shower rooms. One person showed
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 19 us that he had been able to bring a number of his own possessions into his room. There is a choice of two lounges for the residents to sit in, as well as some small sitting areas around the building, including near the front entrance. The main dining room was extended to accommodate the increased number of residents, and some people choose to eat at a dining table in the conservatory. The home is pleasantly decorated and well maintained, and any defects identified at previous inspections had been rectified. The home was clean and smelled fresh, other than a strong smell of urine in the entrance hall when we arrived. We discussed signage with the manager, especially for people with dementia, as there was little to indicate which rooms were behind which doors. People would have difficulty knowing for example, which door leads to a toilet. The extension has been built round a central courtyard, creating a really good outdoor space where residents can feel safe. The front of the home has been altered since the last inspection. Ramps have been built so that people in wheelchairs can use the front entrance, and can also leave the home in an emergency from the fire exits at either side. Landscaping of the gardens will continue when the weather improves. Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. There are enough staff, who are receiving appropriate training, to make sure residents’ needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the staff rotas. There were five care staff on the rota to be on duty each morning and four each afternoon/evening. Care staff are also assisted by the housekeeper who works as a care assistant from 8 a.m. to 9 a.m. each morning, and by the night staff who stay till 9 a.m. The manager said that from the following weekend there would be five care staff on duty for the afternoon/evening shift as well. We saw no evidence that there were not enough staff to meet the needs of the residents. Records of staff training have improved and showed that the all staff are given opportunities to receive sufficient training for them to be able to do their jobs well, and to ensure they have the skills and knowledge to offer good quality care to the residents. The majority of staff have received training in the mandatory topics (moving and handling; fire safety; food safety; infection
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 21 control; and first aid), and further training has been planned for the whole of 2007. Several staff have also received training in the care of people with dementia from a satisfactory source. The home has yet to achieve 50 of staff with a recognised qualification, but we were told that this is being addressed. We checked the personnel files of three staff and were satisfied that adequate checks had been undertaken (such as written references; Criminal Record Bureau check; POVA list check; and identification checks) to make sure the person was suitable to work at this home. An induction workbook was on the file of the most recently employed person, showing that a good induction had been undertaken. Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. Residents benefit from improved management of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The improvements we identified at this inspection show that the management of the home has improved greatly since the proprietor took on the role of registered manager on a full time basis. She and the staff team are to be commended on the hard work they have done to improve the quality of care offered to the residents.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 23 The manager said she has employed someone who is assisting her with this. She said she knows that there are still further improvements to be made but is pleased with what the whole staff team have achieved so far. Three of the four requirements made following this inspection are carried forward from previous inspections as they had not been fully met. The challenge for Millfield Lodge is to make sure the improvements made so far are maintained, and the home continues to move forwards. In November 2006 the manager carried out a survey of views of the care offered at the home. Questionnaires were given to residents, their relatives and visiting professionals. 19 out of 29 were returned. The questionnaire consisted of 13 questions, with 5 tick-boxes (ranging from very poor to excellent) and then space for written comments on “Like most about the home”, “Like least about the home”, and “Suggestions for improvement”. All of the responses were collated into a report which was honest about the findings: as well as comments on what people like most about the home, the report included the comments people had made about what they liked least, and showed that a few people had ticked the ‘very poor’ box (4 out of 219 ticks). 97 of the ticks were in the ‘excellent boxes’, with ‘Staff approach/helpful’ and ‘Feeling welcome’ scoring highest. The manager wrote that all the respondents said they would recommend the home to others. In her summary, the manager said that some people had preferred to respond at face-to-face meetings, and telephone interviews rather than complete a questionnaire. She wrote that “the overall satisfaction rate is 99 on the quality of care provided by the home”. She said that all the areas identified as in need of improvement will be included in the home’s improvement plan. Residents’ and relatives’ meetings are held regularly, are well supported and minutes are taken. One of the residents co-chairs the residents’ meetings. The home looks after a small amount of personal allowance for several residents. We checked the transaction records and cash for three people and all balanced correctly. We looked at some of the records relating to health and safety. Tests of the fire alarm and emergency lighting systems have been carried out as required, tests of the hoists, boilers and the electrical systems were all satisfactory, portable appliances were tested in May 2006, and temperatures of the hot water are recorded regularly. There was no door closer on one bedroom door, so it would not close automatically in the event of a fire, and we saw another bedroom door which did not close properly. In a telephone call as we were driving away from the home, the manager said the missing door closer had been re-fitted. We found nothing else which gave us any concerns regarding health and safety.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 24 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 X 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) Requirement Care plans must continue to improve to make sure that each service user’s needs are fully identified and that staff have clear guidance on the way each person’s needs will be met. This requirement is carried forward as it had not been fully met. Arrangements must be made for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Records of medication administration must be accurate. Security for the storage of medicines must be reviewed to ensure spare keys are available and medication can be held securely. This is a repeat requirement, previous timescales of 2/10/06 and 31/12/06 were not fully met.
Millfield Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 26 Timescale for action 31/05/07 2 OP9 13(2) 30/04/07 3 OP26 16(2)(k) All parts of the care home must be kept free of offensive odours. This requirement is carried forward from 31/07/06 and 02/10/06. The timescales were not met. All fire doors must close properly. 30/04/07 4 OP38 23(4)(c) 15/02/07 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 Lodge DS0000015176.V330848.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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
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