Inspection on 13/10/09 for Milliner House

This inspection was carried out on 13th October 2009.

CQC found this care home to be providing an Adequate 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

Milliner House 20/11/08

Milliner House 29/01/08

Milliner House 29/05/07

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Milliner House 23 - 29 Marsh Road Luton Beds LU3 2QS Lead Inspector Mrs Louise Trainor Key Unannounced Inspection 13th October 2009 09:50 DS0000066373.V377989.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Milliner House DS0000066373.V377989.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Milliner House DS0000066373.V377989.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Milliner House Address 23 - 29 Marsh Road Luton Beds LU3 2QS 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) 01582 490080 01582 491080 millinerhouse@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Manager post vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10) Milliner House DS0000066373.V377989.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Milliner House is situated on the Marsh Road in Luton within easy reach of the town centre amenities by car or public transport. The home is within walking distance of community resources, which include churches, shops, pubs and restaurants. An enclosed garden area is at the rear of the building alongside parking. The home provides personal care for up to 30 people over the age of 65 years who have dementia and 10 people over the age of 65 who have mental health needs. Accommodation is provided across two floors, there are 40 single rooms providing en suite facilities. The home consists of 4 unit areas, each area consisting of bedrooms, and lounge/dining facilities. The home has a rear garden which is accessible to people living in the home and car parking is also available. Access to the first floor is via a shaft lift or stairs. Various communal areas are located throughout the home. The manager at the home provided the following information on charges. The fees for this home vary from £490.00 per week, to £800.00 per week, depending on the funding source and assessed needs of the person. Additional charges are made for hairdressing and chiropody services. Milliner House DS0000066373.V377989.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 inspection was carried out in accordance with the Care Quality Commissions (CQC) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgments made within the main body of the report include information from this visit. This was the first Key Inspection for this year for this service. Regulatory Inspectors Mrs Louise Trainor carried it out on the 13th of October 2009 between the hours of 09:30 and 15:00 hours. The home Manager Miss Kelly Mullen was present throughout the visit to assist with any required information, and the Manager from a sister home was also present to give support. Verbal feedback was given periodically throughout the inspection and at the end of the visit. During the inspection the care of three people was case tracked. This involved reading their records and comparing what was documented to the care that was being provided. Documentation relating to: staff recruitment, training and supervision and medication administration, complaints, quality assurance and health and safety in the home were also examined. We also had a tour of the premises and spent some time in the communal areas of the home, talking to the residents and observing the care practices and interventions that were carried out during this five and a half hour inspection hour inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. Milliner House DS0000066373.V377989.R01.S.doc Version 5.2 Page 6 What the service does well: The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out so that prospective residents and their representatives can be sure their needs will be met. Medication records are generally in order, contain the required entries and are signed appropriately by staff. During this inspection we had the opportunity to speak with residents and in one case a visitor. Residents that were able to communicate told us that they were happy living at Milliner House, and one visitor told us. “This is the best care he could ever have, clean, tidy and food is always good”. The service has a recruitment procedure that meets statutory requirements and NMS, and there are records to support this. The activity organiser is working hard putting together memory books for the individual residents in this home, which are ideal for one to one work. She is also developing a wider range of activity equipment, such as a memory box with old coins, and a familiar smells recognition exercise. There is a well equipped sensory room in the home, and they have recently opened a bar on the first floor, which has television facilities and a dart board. The manager told us that a group of residents regularly meet there for a drink and a game of dominoes. The manager was able to demonstrate through discussion, her understanding of safeguarding procedures, and she liaises regularly with the local safeguarding team. All the staff files that we looked at, contained certificates confirming that safeguarding training is readily available and attended by staff as required. What has improved since the last inspection? The home has recently opened a bar on the first floor, which has television facilities and a dart board. The manager told us that a group of residents regularly meet there for a drink and a game of dominoes. Milliner House DS0000066373.V377989.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Milliner House DS0000066373.V377989.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 Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 People using the service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out so that prospective residents and their representatives can be sure their needs will be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a Service User Guide and a Statement of Purpose in place for this home. These are on display in the foyer of this home. This document is held electronically and reviewed at regular intervals, then issued to people as they enquire about the home. The document we were Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 10 shown had been reviewed recently and reflected the current management of the home, and the new contact details for the Care Quality Commission (CQC). These documents contained the full range of fees and facilities relating to the service. There are clear details of what is included in the fees, and what is provided at an additional cost, such as hairdressing and chiropody. These documents are available in audio version if required. The individual fees for each resident are also clearly identified within their contract of terms and conditions. Contracts were checked and were all signed and dated appropriately. We looked at the file of the three residents; the pre admission assessments had both been carried out in advance of the admission, and contained sufficient detail to ensure that staff would be able to meet his needs. This home does not provide intermediate care Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service experience adequate quality outcomes in this area. There are some gaps in documentation and in particular details about how care should be delivered are not always clear. Medication records are generally in order, contain the required entries and are signed appropriately by staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the case files of three residents. We chose these at random. These were generally tidy and well organised. Full physical and social assessments had been carried out on each individual, and care plans had been generated from this information. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 12 Personal profiles gave a clear picture of the individual, and included personal preferences and dislikes. For one resident it was clearly identified that they were a diabetic, skin condition was poor, they were prone to falls, had a mental health condition and other medical conditions to be aware of. The profile identified this individual’s religious denomination and identified how he preferred to worship. Food likes and dislikes were identified, as were rising and retiring times, and the importance of appearance for this resident. Risk assessments were in place to identify and minimise risks for all aspects of daily living, and were being regularly reviewed to reflect changing needs. For each medical condition information documents were in place with the care plan, providing a full summary of the medical condition in question and how it should be managed. We were however a little concerned that the care plan content and reviews were not always detailed sufficiently. For example, in a care plan for diabetes there was no information relating to blood sugar levels, except identifying that they should be checked once a week. The manager informed us that this is done by the district nurse, however this was not clear from the care plan and information relating to reading results was not present in the reviews or the daily logs. Similarly there was a care plan relating to seizures. This was very basic and did not give staff any specific instructions of how they should manage this situation. Nor was it clear when the last seizure had occurred. We found that lack of detail both in care plans and reviews, was apparent in all the files that we looked at. We discussed this with the manager who agreed further information should be included. During this inspection we had the opportunity to speak with several residents and in one case a visitor. Residents that were able to communicate told us that they were happy living at Milliner House, and one visitor told us. “This is the best care he could ever have, clean, tidy and food is always good”. We did however find the concept of bowel charts and ‘pad change’ charts hanging in residents’ doorways rather undignified, and suggested these should be more appropriately kept somewhere which was not in full view of everyone who passes the bedroom door. We were accompanied to look at the Medication Administration Record (MAR) sheets in ‘Beret House’ by the deputy manager. She told us that the MAR sheets are audited after every medication round, to ensure reconciliation is always correct, and any errors can be addressed immediately. There was a staff sample signature sheet present, and each resident had a photograph for ease of identification. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 13 The MAR sheets were tidy, and had been appropriately completed by staff with signatures or omission codes where necessary. Where variable does were prescribed, the dose given was always recorded. All the medication that we looked at reconciled correctly with the stocks remaining. The only criticism we had relating to the medication process is that where ‘as required’ medications are administered, or residents refuse medication, this is rarely recorded in the area provided on the reverse of the MAR charts. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience adequate quality outcomes in this area. Generally staff are aware of the need to support residents to develop and maintain their social, emotional and communication skills. Some residents are consulted regarding the choices of daily living; however this process could be improved. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home has an activity organiser in post. There is an activity programme on display in the entrance to the home, which identifies an array of activities such as, ‘memory lane’, ‘picture palace’, ‘tactile’, shopping trips and one to one sessions. External entertainers also visit this home periodically. The activity organiser is working hard putting together memory books for the individual residents in this home, which are ideal for one to one work. One that Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 15 we looked at even contained the residents’ birth certificate as well as photographs and other memory joggers. She is also developing a wider range of activity equipment, such as a memory box with old coins, and a familiar smells recognition exercise. There is a well equipped sensory room in the home, and they have recently opened a bar on the first floor, which has television facilities and a dart board. The manager told us that a group of residents regularly meet there for a drink and a game of dominoes. Overall we could see a lot of very positive work has gone into activities in this home, however on the morning of this inspection, although we observed two residents preparing to go out to the shops with staff, and we were aware that the activity organiser was working with clients on a 1:1 basis most of the day, we saw limited / no activities in progress for many residents. We spent some time in the main lounge on the ground floor during the morning. The television was on, and a programme on ‘breast examinations’ was showing, however none of the six residents in the lounge showed any interest in watching this programme, and unless residents requested assistance from staff there was very little interaction noted. Two residents that we spoke to in that lounge area told us they were bored with just sitting. Another resident we spoke to during this visit was very disappointed that for the second week running the hairdresser had cancelled, and she desperately wanted her hair done, and one resident in his room told us he was fed up and bored. We did see an improvement in the afternoon. Staff were more relaxed with residents, and a small group were playing dominoes in the courtyard. This home offers a wide variety of meals which are prepared and cooked on the premises. Each days’ menu offers a choice of two hot meals, and lighter bites and salads are available on request, as are ethnic and special diets. On the day of this inspection there was a choice of chicken casserole or pasties with salad or vegetables. Although records for individuals identify any food likes and dislikes, and residents are asked each morning what they would like for each meal, there was evidence to indicate that using visual choices would be more appropriate on the dementia floor. We sat with one gentleman prior to lunch being served, he told us how hungry he was and that he would love chicken, however as he had chosen a pasty earlier that day, that’s what he was served. Consequently he did not want his lunch when it arrived. This matter was eventually resolved by an understanding carer, however if visual choices were given at the point of service, this would have been avoided. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints policy, which is easily accessible to residents and visitors to the home. It details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We viewed the complaints files. The home had only received one complaint this year. There were letters of acknowledgement and resolution in the folder, however there was no documentation to support how the matter had been investigated and the outcome reached. In the entrance to the home there were framed letters of thanks and gratitude on display. One read. “Over the last 2 years you have given unwavering Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 17 thoughtful and loving care to my mother from the moment she arrived to her peaceful passing”. The manager was able to demonstrate through discussion, her understanding of safeguarding procedures, and she liaises regularly with the local safeguarding team. All the staff files that we looked at, contained certificates confirming that safeguarding training is readily available and attended by staff as required. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience adequate quality outcomes in this area. The home provides a physical environment which meets the needs of the residents who live there, and individual rooms are decorated and furnished to meet with personal choices, however the cleanliness of some areas of this home are in need of attention. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home operates over two floors, with twenty residents on each floor. Each floor is divided into two units. These are named in line with the town’s hat industry, such as ‘Beret’ and ‘Stetson’. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 19 The ground floor is occupied by residents that have a Mental Health disorder and the first floor by those with a diagnosis of dementia. The home is in the process of having some decorating done in the main corridors at present however we did notice that one of the dining rooms in particular was in desperate need of painting. The walls were badly marked where pictures had been taken down leaving marks from adhesive tape, and pieces of the old pictures still attached. This was not conducive to a pleasant environment for dining. We also noted an offensive odour throughout the building, which was reflective of poor continence management, although we appreciate that this odour may have been coming from the carpets. The communal lounges are spacious, and there are quiet areas such as ‘The Picture Palace’ and the sensory room where residents can go to relax more privately. Individual bedrooms are decorated to personal taste, and are furnished with photographs and ornaments which reflect the individual resident’s personal life history. There is a small courtyard, which was being utilised freely by residents on the day of the inspection however the surrounding garden area is rather limited. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience adequate quality outcomes in this area. The service has a recruitment procedure that meets statutory requirements and NMS, and there are records to support this. The training programme in this home meets with NMS and is person centred, however this is not always reflected in care delivery. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The present staffing levels in this home are four care staff per floor during the day time shifts. They are supported by cleaning and kitchen staff, and two care staff per floor at night. The manager works a 09:00 hour – 17:00 hours shift pattern. During this inspection we looked at three staff files. There was evidence that the recruitment policy is being followed appropriately. They all contained fully completed application forms, interview notes, health questionnaires, confirmation of Criminal Record Bureau (CRB) and POVA first checks, various forms of identification including birth certificates, driving Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 21 licenses, passports and utility bills, and at least two references from appropriate sources. Terms and conditions of employment were present and were signed and dated appropriately by staff. All the files that we looked at contained a variety of training certificates, including: SOVA, food hygiene, infection control, health and safety, fire, medication, care planning, bed rail safety, moving and handling ski sledge manoeuvres. There was a morning training session in wound care on the day of our inspection, and an afternoon session in dementia awareness. Both of these sessions were well attended. We observed care practices for short periods during this inspection, and it was evident that the level of the staffs skills and knowledge, particularly in the Mental Health Unit varied considerably. We observed two care staff, who were very competent and interacting well with the residents, however we also witnessed one member of staff in particular, who sat in the company of one resident who was verbally expressing some very negative feelings. No effort was made to acknowledge the content of this resident’s conversation, reassure her or intervene in an attempt to divert this person’s attention. We believe this was due to lack of skills, understanding and confidence. Consequently this resident became more agitated and other residents in the lounge that could not get up and walk away independently were left to listen to her. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, 37, 38 People using the service experience adequate quality outcomes in this area. The manager is aware of the importance of record keeping in the home. However gaps in documentation, indicate that auditing processes require improving. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager for this home is not yet registered with CQC, although she has been in post for approximately a year. She is very enthusiastic and is in the process of completing her NVQ level 4. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 23 There are auditing processes in place in this home, however particularly relating to care planning and reviews, these are not proving effective. We found care plans to be very basic in places and lacked specific care delivery details, we also found that reviews often just read “no change”, and did not reflect essential information relating to the need. Examples of this have been detailed in the Health and Personal outcome area of this report. Accidents and incidents are being recorded and reported appropriately, and where necessary safeguarding referrals are being submitted. Staff files that we looked at contained supervision documentation. However for one member of staff who started work at the home in January 09 only details of two supervision sessions could be found, indicating that it may not take place as regularly as it should. The management in this home monitors the quality assurance, by using questionnaires that are given to the residents and their representatives to complete. This is done by sending out to a given number of questionnaires each month, however the manager needs to look at how these can all be incorporated into an annual report, which reflects where improvements have been addressed. Resident’s personal money that is held within the home is all controlled electronically like a banking system by the administrator, with any monthly expenditures / withdrawals and credits being invoiced or sent to the individual resident or their representative in statement form each month. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 3 Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 25 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 OP7 Regulation 15 Requirement The care plans must give sufficient detail to ensure that staff know how to deliver the required care, and reviews must reflect any changes in individual needs. Timescale for action 30/11/09 2. OP16 17(2) 3. OP26 23(2)(d) 4. OP37 17 The registered person must 30/11/09 ensure that all records referred to in schedule 4 of the NMS for Care Homes for Older People – including those relating to how complaints outcomes are reached, are maintained within the home. The registered person must 30/11/09 ensure that all areas of the home are kept clean and reasonably decorated. The registered person must 30/11/09 ensure that all records specified in schedule 3 of the NMS for Care Homes for Older People, are appropriately reviewed and maintained within the home. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 26 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 OP30 Good Practice Recommendations The manager should consider further training for staff in caring for residents with Mental Health issues. Milliner House DS0000066373.V377989.R01.S.doc Version 5.3 Page 27 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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