Inspection on 11/01/06 for Millpond View Care Home

This inspection was carried out on 11th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Millpond View Care Home 12/06/08

Millpond View Care Home 29/06/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Millpond View Care Home Millpond View Care Home 11 Millpond Avenue Hayle Cornwall TR27 4HX Lead Inspector Stephen Baber Announced Inspection 11th January 2006 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 Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 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. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Millpond View Care Home Address Millpond View Care Home 11 Millpond Avenue Hayle Cornwall TR27 4HX 01736 754635 01736 754635 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) Omar Farook Thauoos Joyceleen Wendy Lissenburg Mrs Maureen Tredinnick Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (5), Terminally ill (5) of places Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users to include up to 5 adults with a physical disability aged 60 years and over on admission. Service Users to include up to 5 adults with a terminal illness aged 60 years and over on admission. Total number of service users not to exceed 32. Date of last inspection First Inspection for New Providers. Brief Description of the Service: Millpond View is a care home providing nursing and personal care to 32 people who experience old age, physical disability or terminal illness. The home is situated on the outskirts of Hayle and has views of the millpond from the front of the property, which are enjoyed by the residents. The home comprises of a two storey Georgian house with an extension to the rear. The layout of the home has two distinct areas that are interconnected. The home has gardens to the front and rear that are well maintained with parking to the sides of the home. Access for residents is restricted in certain areas but ramps and handrails are provided in some areas for dependent residents to access the home and sit outside weather permitting. There are thirty bedrooms spread out over two floors, two of the bedrooms are registered doubles and five rooms have ensuite facilities. Communal toilets and bathrooms are situated near to all rooms. There is a shaft lift that serves ground to first floor. Throughout the home aids and adaptations are provided to make life easier for the more dependent residents. A disabled vehicle suitable for a wheelchair is provided for appointments in the community and is free to residents. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Millpond View was registered under the Care Standards Act 2000 in November 2005. This was the first initial bench mark announced inspection as part of the home’s annual inspection programme on 11th January 2006 commencing at 8:45 am and ending on the 12th January at 5:30pm. A pre-inspection questionnaire was completed prior to the inspection and the following activities were carried out whilst at the home: 1. Inspection of records, including assessment information and care plans 2. Discussion with the new providers, registered manager of the home on how it operates on a day-to-day basis 3. Inspection of the building 4. Interviews with a relatives and members of staff 5. Individual discussion with residents. 6. Observation of the daily life of the home. The inspector would like to thank everyone who was involved in this inspection, including the providers, registered manager, staff and residents, for their helpful manner and kind assistance on the day. What the service does well: I spent a considerable amount of time talking with relatives who asked to see me. The relatives were unanimous in their praise of the very good care that their relatives receive from management and staff. The residents I spoke with said that they were very satisfied with the care and comfort they receive although there was some negative comments from residents who said that the food is sometimes not to their liking. The Commission received 18 comment cards back from the residents and 13 comment cards back from relatives. This was an excellent response and overall the comments backed up the good care, good communication from the manager and nurses, staff who treated the residents with kindness and respect. Prospective residents and their relatives or representatives are able to visit the care home to look at the services and facilities. The visiting arrangements are flexible and residents and relatives commented that every effort was made by the staff to be hospitable and helpful. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 6 The new providers Mr Farook Thauoos and Ms Joy Lissenburg are committed to continuous improvement and facilities, which assure a good quality of life and health for the residents. Since taking over the home there was evidence throughout the home of emphasis on results for residents with, facilities policies activities and services of the home lead to positive outcomes for and the inclusion of residents. The manager and staff work hard to raise money by way of fetes, for trips out and improving the comforts of the residents. What has improved since the last inspection? What they could do better: Management were well prepared for the inspection and looked at it as a positive experience for the benefit of the home. The inspection identified that the providers and manager should now address the issue of the fragmentation in some areas of their responsibilities and work towards full compliance with the national minimum standards. Areas such as the regulations and standards, which highlight the importance of consulting with residents and their representatives about their care plan, could be improved on. The fragmentation applies to the policies and procedures inspected on the day of the inspection that must enable staff to do their jobs well and to protect and safeguard the well being of residents. Ongoing training should be provided. Supervision for staff needs to be addressed and reviews and updating should be evidenced. The manager must undertake a ‘POVA first’ check before a new member of staff is employed at the home. The current arrangements to assess risk management and control need to be developed and the records about the Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 7 management of risk and control require improvement. This will make sure that staff are fully informed of the action needed to minimise potential risks to residents and their wellbeing. 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. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 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 Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4. Prospective residents are provided with written information about the home and are able to visit and spend time in the home before they make a decision about living there. This helps the person to make an informed choice about where they wish to live. The needs of residents are assessed so that they can be assured that the home can provide adequate care. EVIDENCE: The manager has in place an informative statement of purpose and service users guide that details the facilities and services provided. The manager to ensure residents needs can be met and where appropriate the views of other professionals are obtained and recorded assesses new residents. Agreement should be reached on the care to be given by evidencing that the information has been shared with the residents or their representative. Prospective residents and their relatives or representatives also have the opportunity to visit the care home to help decide if this is a suitable place for them to live. The home has a flexible approach about the visiting Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 10 arrangements. The relatives confirmed that they were encouraged to visit the home and some said they turned up without an appointment to make enquiries and were invited to look around the home and were given hospitality. They said they observed what was going on and were made to feel welcome. They said that they felt the care was very good but more upgrading work could be done to the home. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9. Detailed written care plans direct and inform staff about how to meet the residents’ health, personal and social care needs. Monthly summaries are carried out to update the care plan so that the changing needs of the residents are met. The arrangements for the management of medicines protect residents. EVIDENCE: The three residents’ records case tracked all had written care plans. The manager draws up an individual care plan for each care need, activity and risk assessment including clinical assessments that meet relevant guidelines. The plans include personal, health and social care needs. Each plan sets out a stated goal, the action to be taken and regular dated reviews. To further develop the care plans, residents or their representative should sign their care plans, and there should be evidence of their participation in agreement for Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 12 frequency of checks at night. Nursing and care staff record consistent daily and nightly notes, which were factual, legible and signed. Care plans and daily records provide evidence that residents are registered with local surgeries and the manager and nursing team are very good at utilising the full range of community healthcare professionals with the aim of providing a high standard of health care. Residents discussed the arrangements for chiropodists, dentists, and opticians. The providers have purchased three new beds and equipment for pressure relief. The manager has compiled a medication policy and procedure which all staff are familiarised with from induction. There is a medical room where medication is stored. The home operates a monitored dosage system. Storage, administration, recording and disposal of medication satisfies the guidance stipulated by legislation and regulation. A physical count and check at the time of inspection also confirmed the security and safety of all prescribed medication to be satisfactory. The pharmacist regularly visits the home and offers support and guidance to the nursing team. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. The providers and the manager are reviewing the meals provided to reflect the choices and preferences of residents. Also the providers are continuing to improve the kitchen facilities in the next year so that the kitchen operation is professional and meets the needs of the residents. EVIDENCE: The Environmental Health Officer inspected the kitchen on the 12th January 2006 and reported that he was very pleased with the improvement made so far and the overall standards of the kitchen. Residents’ feedback to me was variable with 50 of the residents saying that sometimes they are not satisfied with the meals. The providers and manager have taken this on board and are currently reviewing the kitchen operation & a substantial improvement has already been made. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The home has a detailed complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements in place to protect service users from abuse. EVIDENCE: The complaints procedure complies with the standard. No formal complaints have been recorded in the last year. The providers and manager actively consult residents individually and obtain their views about the services provided. The residents and relatives who spoke to me were very satisfied with the service and none had felt the need to make a complaint. The home’s policy and procedure on the prevention of abuse complies in general with the standard. The reference to the Social Services Procedure needs to be amended to refer to the recently launched revised Local Multiagency Code of Practice for the Protection of Vulnerable Adults. It is recommended that the manager obtain a copy of the code of practice from the Department for Adult Social Care ex (Social Services). Staff do not receive training in the protection of vulnerable adults despite covering this unit when they undertake NVQ training. The manager reported that she had experienced difficulties in obtaining places for staff on the multi-agency ‘alerter’s training’, which is in great demand. The manager needs to review the provision of training for staff Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 15 Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26.. Millpond View could be improved both internally and externally to provide a good standard of décor and furnishings creating a comfortable and safe environment for those living there and visiting. EVIDENCE: Millpond View has not had the luxury of continued investment to improve the home both internally and externally. Since taking over the home as new providers they have made lots of improvements. New flooring, three new hospital beds, kitchen equipment and commercial Bain Marie, redecoration to some parts of the home, new furnishings have been purchased. This is in addition to servicing and testing of equipment and the replacing of old equipment such as smoke for heat detectors throughout the home. The standards would be better assessed when the providers have been in post for longer and therefore at the next inspection I would like to present a better picture of improvements that have taken place Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 17 Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staffing levels generally meet the needs of residents. The recruitment processes carried out for staff do not fully protect residents. Staff must be trained in policies and practices that develop their knowledge, skills and competence in all required areas. The number of staff on duty each day and night is satisfactory to meets the needs of the residents. All staff at the care home should be given the opportunities to attend training courses. The staff have achieved 50 trained staff to NVQ level2 thus ensuring that the residents are in safe hands at all times. EVIDENCE: The records show that the staffing levels required have been provided and meet the needs of the resdients. A minimum of one qualified nurse is on duty for waking hours and overnight. The nurses play a lead role in the day-to-day coordination of the services and facilities provided. Residents and relative said staff were competent and that they were very satisfied with the staff and felt confident in the care they provide. Comments made in the comment cards said that their relatives are treated like their own family but one relative thought some care staff behaved above their position. The manager is required to evidence that staff are employed on the basis of fair, safe and effective recruitment policies and practices to ensure that they are suitable to work with vulnerable residents. A very big improvement has been made in the cleanliness of the home.A team of staff undertake the domestic duties of the home and a staff member is on duty each day of the week. All staff have undergone enhanced CRB checks Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 19 prior to their starting work in the home. POVA first was discussed with manager and this must be carried out before employment is offered to prospective staff. There was a lack of full evidence, however that recruitment of staff is fair, safe and effective, in the form of interview records. Individual records of staff training have improved but there is still no training and development plan. Staff must evidence training in key areas such as fire safety, health and safety, emergency first aid, basic food hygiene and multiagency training in the protection of vulnerable adults from abuse. Also supervision and annual appraisal must take place. The home has achieved the National Minimum Standards in that a minimum of 50 of the care staff has achieved NVQ level 2. Residents and relative said staff were competent and that they were very satisfied with the staff and felt confident in the care they provide. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. Residents live in a home, which is run and managed, by a person who discharges her duties professionally and responsibly. There are systems for seeking the views of residents with a development plan recorded as a result of this exercise to ensure that there are positive outcomes for residents. There are arrangements in place to protect and promote the health, safety and welfare of residents but improvements are needed particularly in the area of ongoing training. The arrangements to supervise and meet with staff need to be improved. EVIDENCE: The manager has many years experience as a qualified nurse and numerous positions have been held in management The residents benefit from her ability Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 21 to manage the home appropriately and discharge her duties fully for the benefit of the residents. Her management style is open and transparent. A yearly quality assurance and quality control exercise has been completed and will now be produced as an annual development plan. Staff must receive regular supervision with detailed records maintained. I discussed the finances with the providers who are accountants and for some residents personal allowance is held in a non-interest account. The providers explained if an interest account is set up then the individual would have to submit tax returns. The Health and Safety policies and procedures must be linked into staff training from induction. The head of maintenance has enrolled on a three-night course to qualify to test all portable and electrical appliances. Staff said they have access to reliable advice and guidance from the manager on a day-to-day basis. The providers have complied with the requirement to submit a regular monthly regulation 26 report on the conduct of the home. The providers and manager’s ‘Health and Safety Policy’ sets out the responsibilities of the employer and employees, and the arrangements for managing health and safety. There are hazard analyses and risk assessments for a range of activities and equipment. The current arrangements to assess risk management and control need to be developed and the records about the management of risk and control require improvement. This will ensure that staff are fully informed of the action needed to minimise potential risks to residents and their wellbeing. Staff felt that the manager paid satisfactory attention to health and safety matters but more evidence is required to substantiate this. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 1 3 2 Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? 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 OP18 Regulation 13(6) Requirement Timescale for action 07/07/06 2 OP29 19 3 4 OP36 OP38 18 13(4) The Adult Protection policies and procedures must be reviewed to reflect current pratice and all staff must receive ongoing training to protect residents from harm The recruitment and selection 07/07/06 vetting arragements must comprehensively comply with the regualtions. All staff must recive bi-monthly 07/07/06 supervision with detailed records maintained. In the area of health and safety 07/07/06 and training for staff management must provide ongoing training which must be recorded RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 24 1 2 3 OP3 OP15 OP38 Assessments and care plans should involve the residents or their representatives and agreement should be reached on the care to be given. A review should take place of the catering arrangements to reflect resident’s preferences and choices. The current arrangements to assess risk management and control need to be developed and the records about the management of risk and control require improvement. This will make sure that staff are fully informed of the action needed to minimise potential risks to residents and their wellbeing. Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 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 Millpond View Care Home DS0000063981.V268763.R01.S.doc Version 5.0 Page 26 - 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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