Inspection on 17/10/07 for Millington Springs

This inspection was carried out on 17th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Millington Springs 16/03/09

Millington Springs 25/03/08

Millington Springs 14/11/06

Millington Springs 10/02/06

Millington Springs 05/08/05

Millington Springs 10/01/05

Millington Springs 20/08/04

Millington Springs 18/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Millington Springs Portland Road Selston Nottinghamshire NG16 6AN Lead Inspector Susan Lewis Unannounced Inspection 17th October 2007 09:00 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 Millington Springs DS0000057365.V352272.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. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millington Springs Address Portland Road Selston Nottinghamshire NG16 6AN 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) 01773 581114 Elder Homes Midlands Ltd Tina Frances Kapp Care Home 42 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (42), Physical disability (5), Physical disability over 65 years of age (5) Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Millington Springs Care Home is registered to provide care with nursing to male and female service users whose primary care needs fall within the following categories:Physical Disability over the age of 50 years (PD) 5 Physical Disability over the age of 65 years PD(E) 5 No more than 5 persons falling within the categories PD or PD(E) should be accommodated in Millington Springs Care Home when there are already 5 persons accommodated in the individual or combined categories of PD or PD(E) Old age, not falling within any other category (OP) 42 Dementia - over the age of 55 years (DE) 10 Dementia - over the age of 65 years DE(E) 10 No more than 10 persons should be accommodated at Millington Springs in the DE or DE(E) category when there are already 10 persons accommodated in the individual or combined categories of DE or DE(E) The maximum number of persons to be accommodated at Millington Springs Care Home is 42 14th November 2006 2. 3. 4. Date of last inspection Brief Description of the Service: The manager said that the current weekly fees for the home are £301 residential care and £501 nursing care high dependency needs. Rates are dependant upon needs and are further discussed during the preadmission procedure. The fee does not cover the cost of hairdressing and chiropody. The most recent inspection report is available in the reception area. Millington Springs is a purpose built home with 32 bedrooms, sited on Portland Rd, Selston, Nottinghamshire. The home provides personal care with nursing for older people and the home can also cater for physically disabled people and ten people with dementia care needs. The home has 3 lounges, 5 bathrooms, all with shower facilities, 1 walk in shower facility and 14 WCs. One bedroom has en-suite facilities and one bedroom has a shower cubicle. A garden area is provided at the rear and adequate car parking facilities to the front of the building. The home was purchased by Elder Homes Midlands Ltd and has undergone some refurbishment. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 9 hours, including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive by speaking with them, observation, reading their records and asking staff about their needs. We were unable to effectively understand and communicate with some of the people living at the home, therefore some judgements in this report are drawn from our observation of staff and resident interactions. Two members of staff and four sets of relatives were spoken with as part of this inspection. In addition the views of two other residents who were not part of the “case tracking” were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. Relatives interviewed said they were given a brochure about the home. A review of the registration document took place to ensure that it was correct any amendments necessary will be made in due course. What the service does well: Residents are assured that the staff are able to meet their needs before moving to the home. The trained staff are good at recognising when residents need help from other Health care professionals to improve their health and well being. Residents are treated with respect and their dignity is maintained and able to choose how they spend their time. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 6 A range of activities are arranged that are suitable for all the residents. Complaints are documented, investigated and complainants are responded to, ensuring that their concerns are addressed. Residents live in a clean and well maintained home. Proper checks are done on all staff who come to work at the home to make sure they are suitable to work with vulnerable people The manager is qualified and was praised by residents and relatives as being kind, helpful and approachable The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected. What has improved since the last inspection? What they could do better: Care plans must reflect more accurately the needs of residents and where possible evidence that residents and their relatives are involved in their creation and review should be provided. The pre printed plans should be filled out correctly to ensure the complete picture of the residents needs is obtained. The arrangements for managing the medication for residents should be much safer to make sure that unnecessary risks are avoided and people get their medication as prescribed by their Doctor. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 7 Improvements should be made in the safe access to the garden and the Commission informed of the proposed timescale for the alterations to the property. 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. Millington Springs DS0000057365.V352272.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 Millington Springs DS0000057365.V352272.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): 3 and 6 Quality in this outcome area is good. Service users may be assured that their needs will be assessed and can be met prior to moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Intermediate care is not provided at this service. In discussion with the manager she said that she visits prospective residents in the community if necessary, and residents and families spoken with confirmed that the manger had visited them either in their own home or in hospital prior to them moving to the service. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 10 The manager also advised that prospective residents are able to spend time in the home prior to making their decision. Relatives spoken with said that they had looked round the service prior to the decision being made and had discussed it with their loved ones later. The pre admission assessment covers all aspects of the activities of daily living and this assessment is used to create the care plan. Where possible the manager also obtains the Community Care Assessment and this is also used to inform the care plan. One relative spoken with said that the manager assured her that the staff could care for her loved one and she felt confident that this was the case. Staff had been supportive of her and her loved one in the ‘settling in’ process. Millington Springs DS0000057365.V352272.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 and 10 Quality in this outcome area is poor. Residents’ personal and health care is not always consistent and may place them at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were “case tracked” to make sure that they contain enough detail about people’s needs to properly guide staff, this also included two plans where concerns had been raised regarding the care provided. The plans were pre printed sheets with the blanks filled out with the resident’s name. Although the detail was good for general care it gave the impression that all residents had the same needs and so lacked an element of individualised person centred care. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 12 Plans covered all aspects of the person’s daily life including how carer’s should provide personal hygiene, medical needs and social interests. In one resident’s plan some but not all plans had been reviewed but it did not always reflect the change in the persons situation. For example the plan for their mobility stated they could walk unaided, however diary notes showed it was clear the person was totally dependant on carers for all transfers. Some parts of the plans were not completed so for example a plan would say the person is at risk of falls due to…. No reason was in place as to the reason. Although the pre printed care plans could work well, if they are not completed or reviewed appropriately they could potentially place residents at risk of receiving inappropriate care. The plan also states that family should be involved in the review at least yearly the plan showed no evidence of this despite the person’s needs changing significantly. However in discussion with relatives they said that they had been involved in the creation and subsequent reviews of their loved one care. There was evidence in care plans that risk assessment take place for when bed rails are used and bumpers are also used to minimise the risk of a resident harming them selves due to trapping a limb. Staff spoken with said that they found care plans useful and they provided them with good information about how to care for residents. Diary notes showed that GP’s and other health care professionals were contacted regularly if concerns were raised about resident’s ill health. A visiting health care professional spoken with said that staff followed advise and provided appropriate support for residents with pressure care needs. Evidence was also seen during the visit of Continence Advisors visiting the home to provide support and advise regarding residents with continence needs. Relatives spoken with all said that they felt medical support was obtained quickly and they were kept informed if their loved one became ill. A medication round was observed during the inspection to check the systems in place are safe and protect residents. Temperature checks are taken daily on the drugs room to ensure that it does not go above the safe temperature to store medication, on three days it was Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 13 above 25°C but there was no evidence anything was done with this information to prevent it happening again. The drug trolley locked to wall in a locked room. In checking the Medication Administration Record sheet it showed a resident had received their medication as it was signed for, however on checking the medication dosette box it was clear that the person had not received any medication during that shift. This could place the person at some risk of ill health by not receiving prescribed medication. For another resident some of their medication did not add up and the audit system had not picked this up. Medication coming into the building had not been counted and checked as being correct. The nurse on duty said that the person who normally did medication was on holiday and it is usually done. Previous Medication Administration Record sheets were looked at and this was the case. Hand written entries were not all signed and countersigned, which could lead to potential errors in administration if the wrong amount is written down. Staff were observed throughout the day speaking respectfully to residents and residents spoken with said that staff were lovely and always treated them well. Relatives spoken with said that they thought staff were marvellous and very caring. Staff spoken with said that they had been instructed how to speak to residents during their induction and were able to say where they could find the policies on respect and dignity for residents in the office. Millington Springs DS0000057365.V352272.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 and 15 Quality in this outcome area is good. Residents have their lifestyle choices respected and are provided with activities to meet their needs. Meals are appetising and nutritious and provided by knowledgeable staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there were a variety of activities taking place and residents were able to choose to take part as they wished. Information about activities was seen on the notice board. The activities that were observed were suitable for the residents abilities and the activities coordinator ensured she spoke to all residents to ask if they wanted to take part, she was very keen and enthusiastic with residents. In discussion with relatives they were very positive about the activities that took place at the home. ‘There are a variety of activities’. ‘The Social Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 15 activities person is excellent. ‘She will liaise with me and let me know anything she is very involved with them’. ‘I come every day as I live locally, I am always made welcome and able to join in activities’. ‘A real strength’. Not everyone joins in but they choose what they want to do’. ‘There are lots of different things to do’. ‘Often a concert on Saturdays with outings. It is a zestful home, they get the enthusiasm up. They are very patient and helpful staff’ Care plans identified likes and dislikes cultural and spiritual needs and relatives said that they had been asked about their loved ones past history and hobbies or interests. Relatives also responded positively about the food. ‘The high spot is the food, it is very good’. ‘They are given plenty and it is good quality, also a vegetarian option’. ‘If they can’t feed themselves help is at hand it is always done nicely’. The midday meal was observed and it looked appetising, it was mashed potatoes, cauliflower, gammon and rice pudding or cod and tomato bake or macaroni cheese. The cook spoken with was aware of residents’ dietary needs and what was needed for people with diabetes as well as those who needed a soft diet or who had poor diets and needed fortified drinks. Staff spoken with had a good understanding of older persons dietary needs including the importance of the appearance of meals. The cook said they were awaiting moulds to serve pureed diets in. The puree is put in and turned in shape of the food. There was evidence of homemade cakes for residents’ tea. The kitchen was clean and well maintained, the fridge and freezer temperatures were taken regularly to ensure food was stored at the correct temperature. There was evidence of fresh fruit and vegetables to maintain a healthy diet for residents. Staff were observed providing assistance during the mealtime in a pleasant and discreet manner. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 16 Staff spoken with said that if residents wanted anything they could have it. Drinks were available throughout the day for residents ensuring their fluid intake was maintained. Rooms seen during the partial tour of the building were personalised and those residents who were able looked after their own money, where a resident was unable to relatives assisted in the process. This ensures where possible residents maintain control over their day to day live. Millington Springs DS0000057365.V352272.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 and 18 Quality in this outcome area is good. Residents and relatives feel able to complain and know they will be listened to. Residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaint had been received by the home and investigated by social services. Evidence was seen that the manager had attended strategy meetings and was carrying out improvement plans. Complaints records show the manager records and responds to all complaints received and there is clear guidance and outcomes for each complaint investigated. The area manager as well as the registered manager investigate all complaints. The complaints procedure is available around the home and residents spoken with said they knew whom to complaint to if not happy. In discussion with relatives one said that the manager had discussed the complaints procedure on admission. Another relative said that they did complain. Once it was brought to manager’s attention and was dealt with Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 18 promptly, as a result they now feel confident to complain and it would be dealt with. Another relative said ‘If you mention anything it is dealt with and the manager is approachable’. Staff spoken with said that they had been given training on the whistle blowing policy and evidence of this appeared in staff training records. Staff also said they received training on safeguarding adults which looks at the different types of abuse and what staff must do to protect residents from abuse. Evidence of further training was also seen in the training records. There was also evidence seen that a new safe guarding adults procedure has been produced that is in line with the new procedure created by the local authority. Finances records were viewed for a selected group of residents to show how they are protected from financial abuse and they were all in order and signed and countersigned by two staff. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. Residents live in a generally clean and well maintained home however the uneven patio area potentially places them at risk of falls. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In discussion with the manager she said that the provider has plans to extend the home and as such the patio area has not been refurbished it is still uneven and places residents at potential risk of falls due to its this surface. However this uneven surface has been like this for some time and there is no time scale as to when this is likely to be completed this does not ensure the ongoing safety of residents. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 20 Generally the home is well maintained internally with a maintenance person carrying out any minor repairs necessary. Staff said that any problems are dealt with promptly. The home was clean and odour free and cleaning staff were seen throughout the day. Relatives spoken with said that the home was generally clean The laundry met standards and was positioned so as to ensure that soiled line was not carried through where residents ate their meal or food was prepared. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. Recruitment procedures are robust and protect residents from people who may abuse them and the approach of staff is positive and shows that training is understood and put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with felt that usually enough staff on duty and it only becomes an issue if someone phones in sick but the manager deals with it either by ringing other staff or getting agency staff. Staff were employed from a wide range of cultural and ethnic backgrounds and the service had a equal opportunities policy to ensure employment was fair and equal. Relatives spoken with also said that they felt there were enough staff available to meet needs of residents. Staff rotas were viewed and showed that there are sufficient staff to meet the needs of residents. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 22 The staff files were inspected to make sure that they had all of the information and documentation to ensure that residents are properly protected from people who may harm or abuse them. The files were very well kept and contained all of the information and documents needed by Law in order to safeguard vulnerable people. Staff observed during the day showed that they had been given training on manual handling and when using the hoist ensured residents were safe and understood what was happening. Staff were polite and respectful to residents and ensured that their safety was maintained. Staff training is now provided by an organisation called Quantum Training. The manager provided a copy of the training matrix, which showed what training staff had completed in the last 12 months. This was a requirement at the last inspection and is now met. A list of proposed training for the next 12 months was also provided. Staff files also show what training staff have achieved in the last 12 months. This included dementia awareness training, challenging behaviour and all mandatory training including manual handling, fire safety training and first aid. All new staff undergo induction training and new staff spoken with confirmed that they had taken part in this training. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is good. The manager is a caring and approachable person and ensures that there are adequate systems in place to promote the smooth running of the home when she is not there. The home is run in the best interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was seen as approachable and supportive by staff, residents and relatives. She manages only one home ensuring she is able to focus on the needs of the service and undertakes regular training to maintain her knowledge and keep up to date with changes in the care of older people. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 24 The manager has developed a quality survey of all residents and relatives and is starting the process of sending it out to people no results are available as yet to this survey. There was evidence provided in posters and confirmed in discussion with staff that a residents meeting is due to be held at the end of October 2007. The area manager visits the home and carries out a quality audit of the service copies of this are sent to the Commission for our information. Residents’ money is stored securely in the safe and all records are correct and procedures are followed to maintain the safety of residents’ finances. The records of Health and Safety servicing and checks were inspected to ensure that residents’ are properly protected. These were all up to date and well recorded. The staff have all completed their statutory training courses and they confirmed that their health and safety is promoted and protected by the provision of training and equipment. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X 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 X X 3 Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 26 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 (1)(b) Requirement Where a resident needs change significantly care plans should be kept under review and changes made to ensure needs are met appropriately. The management of medication must improve as follows: • Residents must be given their medication according to their prescription. Timescale for action 01/12/07 2 OP9 13(2) 01/12/07 3 OP19 23(o) There must be an accurate record of medication held by the home to ensure that these are being administered safely and according to the residents’ prescription. Residents must have safe access 31/12/07 to the grounds. A time scale must be provided to the Commission to show when the proposed alterations are likely to take place and when access to the garden will be made safe. • Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 27 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 2 3 Refer to Standard OP7 OP7 OP9 Good Practice Recommendations Provide evidence when families and residents are involved in reviews. If using pre printed care plans ensure they are completed correctly. Where Medication Administration Records are hand written sign and countersign to minimise risk of errors. Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Millington Springs DS0000057365.V352272.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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