Inspection on 30/05/08 for Millfield Nursing And Residential Home

This inspection was carried out on 30th May 2008.

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

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

Other inspections for this house

Millfield Nursing And... 13/09/07

Millfield Nursing And... 09/10/06

Millfield Nursing And... 10/11/05

Millfield Nursing And... 04/05/05

Millfield Nursing And... 07/01/05

Millfield Nursing And... 17/08/04

Millfield Nursing And... 12/02/04

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Byars Care Home

St Marys Nursing Home

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Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Millfield Nursing And Residential Home Cedar Park Drive Bolsover Chesterfield Derbyshire S44 6XP Lead Inspector Rob Cooper Unannounced Inspection 30th May 2008 11:10 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 Nursing And Residential Home DS0000002065.V366699.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 Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millfield Nursing And Residential Home Address Cedar Park Drive Bolsover Chesterfield Derbyshire S44 6XP 01246 825959 01246 825923 millfield@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Care Management Limited 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) Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2007 Brief Description of the Service: Millfield is a purpose built care home set within a residential area in the market town of Bolsover, which lies approximately seven miles east of Chesterfield town centre. The home provides nursing and personal care for up to forty older persons. Accommodation is provided over two floors, with all bedrooms having single room occupancy each with an en suite facility. There is disabled access throughout with a variety of environmental aids, adaptations and equipment to assist those who may have physical and/or sight disabilities, including a shaft lift and a nurse call system throughout. There is a choice of lounge and dining areas located on each floor, including a small smoking lounge and there is level access to an enclosed outdoor courtyard area with seating provided. A separate hair dressing room is also provided. People are provided with care and support from a team of nursing, care and hotel services staff, including an activities co-ordinator who organised a variety of activities for people both in and outside the home. The registered manager has worked at the home for a number of years, being well established and provided with support via external management arrangements. A copy of the most recent inspection report is available in the home’s ‘Welcome Pack’, a supply of which are openly available in the main reception area. The range of weekly fees charged by the home are as follows: Privately funded £472.87 for personal care only and for nursing care £671.00 nursing care - minus the free nursing care payment determined by the PCT. Local authority funded - £345.52 for personal care only (mid band) to £498.30 for nursing care (high band). Millfield Nursing And Residential Home DS0000002065.V366699.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 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit as part of the key inspection process – so that no one at Millfield knew that the inspection visit was going to take place. The visit took approximately six hours through the middle of the day, with two inspectors present. One of the inspectors was a specialist pharmacy inspector who looked at the medication systems and procedures in depth. The methods used during this key inspection and visit were to visit Millfield, where a method called case tracking was used; this involved identifying four people who live at Millfield and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour of Millfield, looking at the activities on offer, and talking to three residents, and three members of staff about the quality of the service, and their experiences of living and working at Millfield. During 2007 the Commission for Social care inspection introduced an Annual Quality Assurance Assessment (known as an AQAA) as part of the inspection methodology, this allows care homes like Millfield to self assess their service. Information provided by Millfield helped to form the judgements in this report. We also sent out ten surveys asking for views and information to people who live at the home, five to relatives and five to staff. Of these we received two surveys from people living at the home, one surveys from a relative and one from a member of staff, which also helped with the judgements that we made. The registered manager post is currently vacant, and much of the information during this key inspection visit was provided by a project manager. On the day of this inspection there were thirty-six people living at Millfield. People who might want to live at Millfield can obtain information about the home direct from them, and this would include seeing previous inspection reports prepared by the Commission for Social Care Inspection. In addition information about Millfield and the services it provides can be found at the following web site: www.ashbournesl.co.uk. Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Two statutory requirements have been made as a result of this inspection visit, both relate to medication, and the records kept at the home relating to medication. If the issues raised are addressed it will lead to people living at Millfield being safer. In addition three good practice recommendations have been made, one again relating to medication, one about trip hazards in the new courtyard and the third about regular supervision sessions for the staff. The issues raised will again lead to people being safer, but will also lead to a better quality of life for individuals within the care home. Millfield Nursing And Residential Home DS0000002065.V366699.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 Nursing And Residential Home DS0000002065.V366699.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 Nursing And Residential Home DS0000002065.V366699.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): 123&6 Quality in this outcome area is good this judgement has been made using available evidence including a visit to this service. People, who live at Millfield, and those who would want to, have access to detailed information about the services on offer. People have contracts or a service agreement and they receive a comprehensive assessment of their needs, which allows the people to make an informed decision about whether the home can meet their needs. EVIDENCE: Both the statement of purpose and service user guide for Millfield were seen. Both documents contained detailed information about the care home, and provide people living at Millfield and those who would want to live there with enough information to be able to make an informed choice about living at the home. Discussions with three residents showed that they had been given copies of the service user guide, and copies were seen in several bedrooms. The foyer at Millfield has a great deal of information on display, including the Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 10 last inspection report, and notice boards for relatives and visitors. In addition people can visit Millfield’s parent company’s web site at: www.ashbournesl.co.uk, which also gives details of the services on offer, and has a link to the latest inspection report. Copies of different types of contracts, privately funded, social services funded, and nursing contracts were seen, as well as copies of the terms and conditions of residence. Each file seen contained a formal assessment of need. Two of the files contained assessments that had been completed by social workers; and all four also contained internal assessments, completed by Millfield’s staff. People’s files showed evidence that care plans had been produced from the information within the assessments. In their AQAA Millfield said: “We always receive a Care Management assessment and a copy of a social services care plan before an individual is admitted to the home, but we also do our own assessment.” Millfield does not offer intermediate care, and therefore this National Minimum Standard was not assessed. Millfield Nursing And Residential Home DS0000002065.V366699.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 & 11 Quality in this outcome area is adequate this judgement has been made using available evidence including a visit to this service. People have their personal care given in a professional and caring manner by the staff. People in the home are given the opportunity to be responsible for their own medicines, and support is offered if required. Poor practice in the handling of medicines means that people may not always protected. EVIDENCE: Each person’s file that was seen contained a clear plan of care, which had been produced from the assessments and identified personal goals and needs and how to meet them. Care plans were being reviewed regularly, and the files also contained risk assessments to accompany care plans for identified individual risks. In their AQAA Millfield stated: “We complete comprehensive care plans for each individual coming into the home, and these are based on Roper, Logan and Tierney’s activities of daily living, long term goals and information given from the care management assessment.” Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 12 All of the files contained care plans related to people’s health care needs, and these were clear and detailed. Three people were asked about seeing the doctor, and they all said that there was not a problem, as staff would contact the doctor if they were unwell, and the doctor would come to see them at the home in necessary. In addition a chiropodist visits on a regular basis to tend to people’s feet, while an optician comes in to test eyes, and sort out prescriptions for new spectacles. Documentation within the files relating to health issues was clear and detailed. The home has a medicine policy that clearly describes procedures for medicine management. Records of the receipt and disposal of medicines are kept. The previous month’s completed medication administration records (MARs) were examined by the pharmacist inspector. A total of three “gaps” in administration records were seen. However, one person’s MAR indicated that a double dose of a “sleeping” tablet had been given on four nights. A stock check showed that the correct number of tablets were left, indicating that the correct dose had been given and an incorrect record made. The lunchtime medicine round was observed: The home’s procedure for medicine administration was not followed. It was noted that the MARs of five people in the home had not been signed that morning: The nurse stated that she had given these medicines to four individuals (the fifth person being unwell) but not signed the MARs. During the medicine round a small number of MARs were signed before the nurse witnessed the person take their medication. Eye drops were administered in a public area. Medicines belonging to a gentleman staying at the home for respite care were given from an unlabelled compliance aid. A tablet in the lunchtime compartment of this container was not recorded on the MAR; the nurse gave the tablet and amended the MAR. Medicine storage facilities were clean and well organised. Medicines (apart from controlled drugs) no longer required were stored in a separate, locked cupboard before being “checked out” and removed by a licensed waste carrier. Controlled drugs were stored in a CD cabinet that complied with the Misuse of Drugs (Safe Custody) regulations. A stock check was performed and stock balances were correct. However, the wrong stock balance was recorded on one page due to a subtraction mistake the day before. Regular stock checks of controlled drugs were not carried out. The cupboard contained controlled drugs awaiting disposal. There were records to show that regular medicine audits were carried out, the most recent audit being on 15th May 2008. Records also demonstrated that all staff involved in administering medication had received training from an external provider, and an assessment of their competency from the home’s manager. Discussions with two people who live at Millfield, and observation of the staff working generally showed that the staff treated people with respect and dignity. This included observing staff knocking on doors before entering, and Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 13 speaking to people in a respectful manner. Among the comments received from relatives in the surveys was the following: “ … They (the staff) also have an excellent habit of letting us know positive things, such as mum interacting with them, which is very difficult for her.” Each person’s file identified their wishes at the time of the death, including telephone contacts, and undertakers details. Millfield Nursing And Residential Home DS0000002065.V366699.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 good; this judgement has been made using available evidence including a visit to this service. People have a lifestyle that reflects their cultural, social and religious interests, and needs, and there is clear evidence that their social care needs are being met. EVIDENCE: A programme of activities was on display at Millfield, and discussions with two people living at the home identified that there were activities arranged, usually of the tabletop games and puzzles type. In their AQAA Millfield said: “We promote the individuals preferences on daily living and activities. It is documented in their individual care plans about which activities and social contacts they wish to join in with.” The two surveys received from people living at the home asked if there were activities arranged for the individual to take part in: one person said “always” and the other “sometimes” adding the comment: “There appears to be a shortage of carers to take us out. I am a widow with no family, so I don’t get out much.” Millfield also has a mini bar to try and recreate a pub atmosphere, and give people a social activity room, and there is also a library book service, which people can use. Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 15 One relative who was visiting was spoken with. This relative said that they found the staff very welcoming, and they were able to visit easily. There is a notice board for visitors, and the staff are very good at making information available, and keeping relatives and visitors up to speed with what is happening at the home. In a survey returned by a relative the following comments were made: “ … There is good communication with residents and with relatives, via the notice boards which are changed quite often. Also, staff encourage us to leave notes in mum’s room if we wish to, and they are very skilled at giving us time even when they are busy.” During the course of the inspection visit staff were observed to see how they interacted with the people living at Millfield, and whether choices were offered. There were a number of positive choices being offered particularly around drinks and food. Discussions with the kitchen staff identified how choices were made at meal times, with choices being made and recorded in the morning. Discussions with two service users, indicated that they both thought they had the opportunity to make choices through the day, and that the staff asked them about a range of different activities and refreshments. Among the comments received from relatives in the surveys was the following: “It is a fantastic reflection on these staff that they work so hard to ensure that people with dementia, like mum, can and do make choices albeit very simple ones. For example, they have realised when she does not like certain food and provide an alternative, they know what sort of music and TV programmes she enjoys and so on.” The dining room was spacious and attractively laid out with tablecloths, and menus on the tables, as well as the menu being written in larger print on a whiteboard on the wall, for those with difficulty reading smaller print. The tables also had cruets (salt & pepper) and flowers, to make the dining experience more pleasurable. Discussions with staff in the kitchen showed that people’s preferences, and likes and dislikes in relation to food were recorded. Comments from two people living at Millfield in relation to food were: “The food is really good, I get plenty to eat, and we always get a good meal” and “It’s lovely, really enjoyable.” Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 16 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. People are safe, as a result of the policies, procedures and systems that are in place, and those people and their relatives are confident that their complaints will be taken seriously and dealt with. EVIDENCE: Millfield has received ten complaints since the last key inspection in September 2007. A review of the complaints folder showed that the complaints had been dealt with in line with the home’s complaints procedure, which is on display in the foyer, and also forms part of the service user guide. Discussions with two people who live at the home indicated that they knew who to complain to, and how to complain, although both said that they had never felt the need. Since the last key inspection a number of safeguarding (safety) issues had been referred to social services, and these were reviewed and discussed with senior staff at the home. Action plans drawn up by Southern Cross, and the measures put into place to address the issues indicated that appropriate action had been taken, and issues had been dealt with satisfactorily. A review of the staff training records in relation to safeguarding adults showed that courses had taken place in November 2007 and May 2008, and thirtythree staff members had undertaken this training. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering service users greater protection against abusive practice, Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 17 while also making sure that the staff understand the correct policy and procedure to follow if and when abusive practice is found. Millfield Nursing And Residential Home DS0000002065.V366699.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 & 26 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People live in a safe, clean, well maintained and comfortable home, with their personal possessions around them, this means that people are living in ‘homely’ surroundings that meet their needs. EVIDENCE: A partial tour of Millfield showed that it was comfortable and well maintained. Discussions with two people who live there showed that they were happy with the care home, with among their comments: “I’ve got a lovely bedroom, really comfortable, and they keep it very nice and clean”, “it’s very nice, very comfortable” and “I like it very much.” In their AQAA Millfield said: “The environment is always kept clean, safe and comfortable, and well maintained.” Since the last key inspection visit Millfield have had a courtyard installed with raised beds, a water feature, and very attractive seating areas. This is a super addition to the home’s facilities, and makes a real focal point. However some Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 19 of the wooden sleepers used to form the raised beds do pose a trip hazard, as they are only a few inches above ground level. This was discussed with senior staff at the home, and the workmen who installed the courtyard have been asked to return, staff should ensure that the courtyard is safe for all people to use. Domestic staff were seen cleaning in different parts of Millfield during the inspection visit, and discussions with a domestic member of staff indicated that there were good systems in place for cleaning, and that the care home has a good range and supply of cleaning materials. The building was found to be clean, and smelt fresh. Millfield Nursing And Residential Home DS0000002065.V366699.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; this judgement has been made using available evidence including a visit to this service. Staff have been recruited professionally, and are competent and trained to do their jobs, which means that the people who live at the care home are safe, and have staff who are able to meet their needs. EVIDENCE: The staffing rota and staffing levels for Millfield were reviewed and this showed that there was enough staff currently employed to meet people’s needs. In their AQAA Millfield said: “We always ensure there are enough staff on shift to meet the needs of the residents and conform to the guidance from the department of health. We have retained staff to ensure continuity of care for the residents. The staff are of different ages and experience which shows a real balance.” The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the staff training records showed that currently there are twenty seven care staff at Millfield, of whom there are thirteen staff with NVQ level II qualifications and one more currently studying for their NVQ level II. In addition nine people have their NVQ level III qualification, and two more are currently studying for that qualification. Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 21 The files of four members of staff were seen, to check that they contained all of the information that would show that staff at Millfield had been recruited in a safe manner – namely that applicants had filled out an application form, provided two written references and had had a Criminal Records Bureau check. The documentation showed that Millfield’s recruitment policy and procedure had worked to protect people living at the home. Discussions with three members of staff about their recruitment showed that they had gone through all of the pre-employment checks, and had not started working until those checks had been completed. The staff training records showed that there is a training plan for staff, and that staff training is given a high priority by Southern Cross. The training records showed that staff were receiving the training to be able to do their jobs. Discussions with three staff members showed the sort of training courses they had attended, and this was supported by records in the training file. In the AQAA Millfield said: “We have a very comprehensive training programme within the home. We offer training specific to the residents needs and staff are given the opportunity to attend training they feel will develop their role.” Millfield Nursing And Residential Home DS0000002065.V366699.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 36 & 38 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Millfield is a safe, well-managed care home with good systems for ensuring it’s quality in place, which means that people living at the home have good management systems in place to ensure their needs are being met. EVIDENCE: Millfield does not currently have a registered manager, although the current acting manager has applied to the Commission for registration, and is awaiting the outcome of that application. The care home has a quality assurance system, which relies on questionnaires being filled in by people who live at the care home and their relatives and visitors. Evidence was seen that questionnaires were sent out in March, and Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 23 responses are currently being evaluated. Evidence was also seen that there are regular meetings for the people who live there, where they can raise issues, and have a formal voice in the running of the home. Copies of Regulation 26 visits were seen – these are monthly visits to the home by representatives of the owners to carry out a management inspection and report. People living at the home have a system for their cash needs. This is operated on behalf of some people by the staff (dependent on choice and ability to manage the money), and four people’s finances were checked at random. All of the cash tallied with the records, and receipts were seen, which enabled a clear audit trail of service user’s expenditure to be seen. Millfield has a system in place for supervising its staff. This relies on staff receiving formal supervision, either with the manager or with one of the other senior members of staff. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. The records together with discussions with three members of staff indicated that there is a system in place, but that it is not yet running consistently, so that staff are not receiving regular formal supervision. Many different health & safety records were seen, including the fire safety records – weekly tests, emergency lighting tests and extinguisher maintenance records, and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up-to-date. Millfield Nursing And Residential Home DS0000002065.V366699.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Millfield Nursing And Residential Home DS0000002065.V366699.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 OP9 Regulation Requirement Timescale for action 30/06/08 2. OP9 Regulation Gaps in recording relating to the 13(2) administration of medicines to any person must not be left unaccounted for. Administration records must always be fully completed to ensure best and safest practise in accordance with recognised guidance concerned with the administration of medicines. Regulation Entries of medicine names and 13(2) dose instructions on medication administration records (MARs) must accurately record the person’s current prescription. 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Prescribed controlled drugs that are no longer required should be destroyed promptly to reduce the risk of DS0000002065.V366699.R01.S.doc Version 5.2 Page 26 Millfield Nursing And Residential Home 2. 3. OP19 OP36 incorrect use. Destruction should be witnessed by a senior person in the home, to ensure good governance. Regular stock checks of controlled drugs should be carried out and recorded. Efforts should be taken to ensure that the new courtyard does not pose any risks to people living at Millfield, in relation to trip hazards. Every member of staff should receive formal supervision a minimum of six times a year. Millfield Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team 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 © 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 Nursing And Residential Home DS0000002065.V366699.R01.S.doc Version 5.2 Page 28 - 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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