CARE HOMES FOR OLDER PEOPLE
Millpond View Care Home 11 Millpond Avenue Hayle Cornwall TR27 4HX Lead Inspector
Diana Penrose Key Unannounced Inspection 12th June 2008 09:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Millpond View Care Home DS0000063981.V362552.R02.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. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Millpond View Care Home Address 11 Millpond Avenue Hayle Cornwall TR27 4HX 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) 01736 754635 01736 754635 tredinnick@millpondcarehome.wanadoo.co.uk 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.V362552.R02.S.doc Version 5.2 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 29th June 2006 Brief Description of the Service: Millpond View is a care home providing nursing and personal care for up to 32 elderly people. 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 building. Access for residents is restricted in certain areas for safety reasons. Ramps and handrails are for dependent residents to access the home and sit outside weather permitting. Throughout the home aids and adaptations are provided to make life easier for residents. There are thirty bedrooms spread over two floors, two bedrooms are registered doubles and five rooms have en-suite facilities. Communal toilets and bathrooms are situated near to all rooms. There is a shaft lift that serves ground to first floor. A disabled vehicle suitable for wheelchairs is provided for appointments in the community and is free to residents. Information about the home is available in the form of a statement of purpose and service user guide; copies can be supplied to enquirers on request. Fees are £540 per week; this information was supplied to the Commission on the day of inspection. There are additional charges made for hairdressing, chiropody and newspapers. Millpond View Care Home DS0000063981.V362552.R02.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.
An Inspector visited Millpond View Nursing Home on 13 June 2008 and spent almost eight hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection twenty-seven people were living in the home. The methods used to undertake the inspection were to meet with people using the service, staff and the registered persons to gain their views on the services offered by the home. Records, policies and procedures were examined and the inspector toured the building. The registered manager has returned a completed Annual Quality Assurance Assessment, which has informed this inspection. Also CSCI surveys have been returned in respect of 5 residents, 12 relatives, 11 staff and 7 professionals, these have also informed this inspection. This report summarises the findings of this key inspection. The people using this service expressed a high satisfaction with the care and services provided at the home and said they were treated with kindness and respect by staff, manager and owners of the home. Some regulations have been breached and these have been discussed with the registered persons who have agreed to address the issues, recommendations have been set on this occasion. What the service does well:
The home provides a comfortable homely environment that is clean and safe for residents, staff and visitors. There is sufficient communal space and suitable washing and toilet facilities. People say they are happy living in the home and they say the staff are very kind and caring. They say their independence is respected and they can choose how to live their lives with their choices and preferences being respected. New people are only admitted to the home following a comprehensive assessment, of their health, personal and social care needs. Information is also sought from relevant external agencies. A detailed written care plan is
Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 6 compiled from the initial assessment to inform and direct staff on the care provision. The plans are agreed and signed by the resident or their representative. There is a suitable policy and system in place for the use of medicines in the home and a Registered Nurse administers all medication. Social activities, events and trips out are organised by a recreational therapist and people said they enjoy the activities provided. A programme of activities is displayed and there are records and photographs of previous events. The menu shows that a nutritious diet is on offer with choices available, homemade cakes, fresh fruit and vegetables are included. People said the food is good and they can choose what they have to eat each mealtime. There are appropriate complaints and abuse policies in place to safeguard people and staff receive relevant training regarding what to do should there be an abuse allegation. The rotas show that a suitable number of staff are on duty at all times. There is little staff turnover and agency staff are not employed which ensures a consistent team of workers. There is a registered nurse on duty at all times and 52 of care staff have achieved an NVQ qualification to at least level 2, in care. The home has quality assurance systems in place to monitor and improve the services provided. People are encouraged to air their views through surveys and various meetings. The registered providers visit very regularly and talk to staff, residents and relatives during their visits. The registered persons are committed to ensuring the health and safety of residents, staff and visitors. There is an active health and safety committee, appropriate fire precautions, a planned maintenance programme and services and equipment are checked regularly. What has improved since the last inspection?
The registered providers are continually improving the environment, replacing furniture and upgrading rooms. Bathing facilities are under review and a wet room shower has been provided. A stair lift is being considered for the main staircase and some moving and handling equipment has been replaced. A new call system has been installed and the fire precaution upgrading work has been done according to the fire authority’s specifications. New flooring has been fitted in the main corridor, kitchen and bathrooms, new carpet in the downstairs lounge, new windows in the original house. New equipment has been purchased for the kitchen. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 7 The information pack for the people using the service has been revised and more work is being done to this for example a sample menu has been included, an updated sample contract, information about fees and a dignity charter. Primary nursing has been implemented and is working well, supervision arrangements for staff have been incorporated. The Gold Standard Framework and Liverpool Care Pathway are being introduced and staff are receiving training in this area. Relatives are being encouraged to have more input to the care plans. New menus have been produced and a great deal of work has been done regarding food provision in the home including nutritional research. Nutritional assessments take place monthly. The registered manager said they have also improved on the provision of parties and celebrations in the home for residents and relatives. Further meetings have been introduced and the registered manager said that work has been done to improve communications in the home. Work has commenced towards the Investors in People Award. An infection control audit is to be undertaken. What they could do better:
The medicine administration record charts need to be monitored to ensure that all medicines administered are signed for or a reason given for omission. Also to help avoid errors, when handwriting instructions on the charts, they should be witnessed with two signatures recorded. Care plans should include relevant information regarding medicines, for example the use of ‘as required’ medicines. Level 1 training for care staff needs to be formalised and included in the induction programme. Not all staff have received abuse training and the records are incomplete to evidence who has done the training. Staff spoken with said they do regular statutory training as well but the records and certificates do not show this; they have not been kept up to date for over a year. The recruitment records required by legislation have not all been kept in staff files. Some checks such as references and CRB checks are missing. Induction records were not kept in the personnel files inspected. The registered provider said this would be rectified. The policy for the management of people’s money does not include the actual procedures used in the home. The processes in place need to be reviewed to ensure that people’s money is safe and that data protection issues are addressed.
Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 (N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following a full healthcare assessment, which ensures that staff are able to meet their personal, health and social care needs. EVIDENCE: The registered manager explained the assessment process for prospective residents. Three people’s files were examined and the assessment information is very detailed, it covers all aspects of health and social cares needs. There is information from external agencies in the files but the registered manager stated that it is often difficult to obtain information from hospital staff. People using the service said that the registered manager visited them prior to admission. This home does not provide an intermediate care service. Millpond View Care Home DS0000063981.V362552.R02.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 good. This judgement has been made using available evidence including a visit to this service. Each person using the service has a detailed written care plan that enables staff to ensure that healthcare needs are met. There is an appropriate system for the use of medicines in the home however recording on the charts needs to be monitored. EVIDENCE: The care files for three people were inspected and they hold very comprehensive information about health and social care needs. The care plans are concise and detailed to inform and direct staff. There are no plans at present for social needs or specific plans for medicines; for example the use of ‘as required’ medicines. The registered manager said she would include these. The plans are reviewed at least monthly and it is clear they are updated, the resident or their representative signs to agree the care plan. Relevant risk assessments were seen and they are also reviewed and updated. The nurses write daily records and care staff said they inform the nurses if they need anything to be recorded. Care staff have their own paperwork to complete
Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 12 each day regarding personal care. There are photographs of residents in their files. The registered manager said she has established good links with local healthcare professionals and the care plans include records completed by professionals when they visit. The registered manager said that one nurse is a tissue viability link nurse and other nurses have specific areas of expertise. People said that doctor’s visit and one was visiting during the inspection. People spoken with said their healthcare needs are met. “If I am ill they arrange a doctor straight away”, is a comment on a CSCI resident’s survey form. Primary nursing has been introduced and the Gold Standard Framework is being implemented. Some staff have received training on the framework and the Liverpool Care Pathway, which is a care plan for dying and death. There is a suitable medicines policy and the registered manager has a copy of the most recent Nursing and Midwifery Council guidelines for the use of medicines. There are reference books for staff to use and the patient information leaflets are kept to inform staff and residents as necessary. The medicines system was inspected with the assistance of a senior nurse and was found to be appropriate. A registered nurse administers all medicines. Handwritten instructions on the medicine administration record charts were not signed or witnessed. There were a few gaps where the charts had not been signed so there was no indication that the medicine had been given or a reason for it being omitted. There are no care plans for medicines such as those to be taken ‘as required’, the registered manager said she will incorporate these in the care files. Level 1 medicines training for care staff is informal at the moment however the registered manager said this could be formalised and included in the induction process. Petty cash is at present stored in the controlled drugs cupboard but the registered provider stated that an alternative arrangement would be made. We saw that residents’ privacy was respected during the inspection and they were free to move around the home according to their wishes and ability. People said they are treated with respect and their privacy is maintained at all times. They said they receive their post unopened and the telephone arrangements in the home are satisfactory Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of activities and social events are provided, visitors are welcomed and residents are encouraged to live a life of their preference. EVIDENCE: There is a recreational therapist employed, four days a week, to organise and initiate social activities and events for the people using the service and their relatives. She was very keen and passionate in her role and interacted well with everyone. Records are maintained of all activities undertaken by the people using the service and the recreational therapist said she compiles a monthly report for the registered manager. As well as the records kept by the recreational therapist individual records were seen in the care files. A programme of events is displayed along with photographs of events that have taken place. People spoke about an imminent trip to Bird Paradise, which is an annual event at the home, and they were all looking forward to it. One resident said, “it is a lovely day out and we all have a picnic organised by the cook”. An art exhibition is being organised in the home and the recreational therapist explained what the residents have been doing to contribute to this. The
Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 14 registered manager said they are also entering an art competition. Several people mentioned the art class with enthusiasm. Other activities include the compilation of life story books, hand massage, one to one chats, singing and a favourite appeared to be bingo. Relatives are included in some events and the registered manager said there have been birthday parties in the home with family and friends. One person said she is organising her own party in the home. The visitor’s records show that people come to the home regularly. Everyone spoken with said there are no restrictions on visiting times and the telephone arrangements are good with direct lines available. One relative survey comment included “the telephone is used with the help of a carer”. All people spoken with said their individual preferences are respected and they are supported to maintain their independence. They said they get up and go to bed when they like and are free to move around the home as they wish. They said they choose what they do and can to go out if they wish; one person said she sits outside when the weather is nice. All residents have their own belongings in their rooms including furniture. The menu shows that a nutritious diet is on offer with choices available, homemade cakes, fresh fruit and vegetables are included. People were seen to have different things to eat at lunchtime. People ate in their rooms or in the lounge with individual tables in front of their armchairs. The dining room was set for people to use if they wished. Staff support during the observed mealtime was good. One person said she did not like the corned beef hash but she thought she would try it. She said “there will be plenty of choice at tea time, there is always a good choice and we never go short of food”. Everyone spoken with said the food is good and they can choose what they have to eat. Nutritional needs are assessed and documented in the care files. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. There are suitable policies in place for complaints and adult protection to ensure that people using the service are safeguarded. EVIDENCE: The home has a suitable complaints procedure and a method for recording complaints, however the registered manager said she is looking to modify this, as it does not allow documentation to be included easily. There has been one minor complaint to the home since the last inspection and the registered manager has dealt with this. There is a suitable adult protection policy for staff to follow should the need arise. The registered manager said that most staff have undertaken training in respect of abuse. Some have attended external courses, and courses, using packs from a training company, take place in the home. Some staff told us that they have done abuse training and they are aware of procedures. The registered manager said a lot of informal discussion regarding abuse takes place with staff. Training of staff and recruitment are covered in the staffing and management sections of this report. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, decorated and furnished to a good standard with no unpleasant odours making it a pleasant place to live in. The building and grounds are well maintained; there is an improvement plan in place. EVIDENCE: It is evident from the people using the service, staff and survey comments that the registered providers are steadily improving the environment to provide a safe, comfortable home for people to live and work in. The home is clean, warm and comfortably furnished, it is decorated tastefully and refurbishment is ongoing. The grounds are tidy with colourful flowerbeds. The people using the service said they feel safe and comfortable in the home. A stair lift for the main staircase is being considered. The bathing facilities are being reviewed and work was being done in one bathroom during this inspection. Adjustable nursing beds are in use and there are several electric
Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 17 beds in use. A new call system has been installed that includes a display of the calls and a facility to monitor the time taken to respond to calls. A maintenance manager is employed to ensure that repairs are done and safety checks are carried out regularly. Laundry facilities are adequate with two washers and two tumble driers. The washer disinfector for cleaning the bedpans and urinals was not in use as the room was used for storage. The registered manager said that staff were scrubbing the bedpans and so on in the sluice. The importance of using the disinfector was discussed with the registered manager and registered providers who said the room would be cleared so that the washer could be used. There is information and written procedures to guide staff on the control of infection and they are provided with training in this respect by one of the nurses. Staff were observed to wear plastic aprons and gloves and there were soap dispensers and paper towels provided at every hand basin. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are suitable staffing levels for the number of residents and evidence that staff hold nursing and NVQ qualifications. Training records and certificates have not been kept up to date for over a year so do not evidence that staff are up to date with the knowledge and skills for their work. Recruitment procedures are not robust and may not safeguard the people using the service. EVIDENCE: The staffing rota shows that a qualified nurse is on duty at all times and sometimes two to cover daytime shifts on weekdays. The home is divided into two areas that are staffed separately. There appears to be a sufficient number of staff on each shift. Staff spoken with felt the numbers were satisfactory to enable them to meet people’s needs. CSCI staff surveys include the comments “Staffing levels maybe low due to sickness but individual needs of the people are met”, “We maybe short staffed because of sickness and holidays but we help each other out” and “We are a good staff team”. Staff seemed happy in their work and interacted well with the people using the service. Residents said the staff are kind and caring and they are looked after well. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 19 The registered manager stated that 52 of care staff have achieved an NVQ qualification to at least level 2, in care. Four others are working towards level 2 and one towards level 3. The registered manager said the staff turnover is low and a lot of people have worked in the home for many years. She said that agency staff have not been employed for five years. Five staff files were inspected including some for the most recent employees. Not all of the documents required by legislation were in the files. There were no interview records although we were shown a new form to record these in future. Issues in respect of recruitment checks are detailed in the management section of this report. There is an induction programme for new employees, which the registered manager said, complies with the ‘skills for care’ standards. She spoke about a translator who has helped in the induction of a Polish employee. There were no completed induction documents in the personnel files inspected. There was some evidence of staff training in the form of certificates of attendance but most were dated 2006. The individual records for staff have not been kept up to date and the registered manager admitted that she was behind with these. The compilation of a training matrix was discussed with the registered manager along with keeping the copies of certificates up to date. Staff said they receive regular mandatory training in respect of moving and handling, fire and infection control, for example. Staff survey results were generally positive regarding training. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is competent in running the home and systems are in place to monitor and improve the service for residents and staff. The management of people’s money does not ensure that people’s finances are safeguarded and the system needs to be reviewed. Statutory training records do not show that staff are kept up to date and recruitment records do not show that relevant checks have been carried out prior to the employment of staff, which could put people using the service at risk. EVIDENCE: The registered manager is a Registered General Nurse (RGN) with a wealth of experience in the healthcare sector. She has achieved the Registered Managers Award and a Masters degree in Business Administration (MBA); she is also a Registered Nurse Teacher (RNT). Staff and people using the service said the
Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 21 home is well run and the owners visit very regularly. One of the owners is a Chartered Accountant (FCA FCCA) in public practice. There is an atmosphere of openness in the home and people said the management team listen to everyone and hold meetings on a regular basis. Survey comments include “Overall the home is very well run and we have got a good team of workers, the carers are very happy”, “The manager is always available to discuss how I am working and give support” and “The owner and manager are very supportive hence little staff turnover”. Some staff files lack references and some CRB checks do not indicate that the check was done before the person started work; POVA first checks were not available for inspection. The registered manager told us that there was some information due to be filed by the deputy manager but this was not available for inspection. The registered manager has not ensured that staff training records are kept up to date or that personnel records are in order. These areas have not been managed well and were mentioned with recommendations in the last inspection report. The home has quality assurance systems in place to monitor and improve the services provided. The registered manager has completed an Annual Quality Assurance Assessment for the Commission that is detailed. It includes references to evidence her text and areas identified for improvement. There has been an independent report produced on the quality of care in the home, which is positive. A comprehensive quality assurance survey is undertaken with the relatives of people using the service annually. A report is then compiled, distributed to relatives and stakeholders and included in the information pack. The AQAA states that problems are discussed with individuals or at the resident’s forum meetings. The providers complete a monthly regulation 26 report that reports on the conduct of the home. The home is working towards the Investors in People Award. Meetings are held with staff, residents and relatives. The minutes of various meetings were seen and they indicate that people can air their views and action is taken. No formal audits are done at the moment but the registered manager said she has various formats for doing audits. Money is held for several people who use the service in a non-interest bearing bank account; individual electronic records of transactions are maintained. Some people’s records show a negative balance, which means that money is being borrowed between people in the account. This is not good practice and alternative arrangements were discussed with the registered provider and administrator responsible for dealing with resident’s monies. One person in particular has a substantial amount of money held on her behalf; as recommended in the last inspection report this money should be invested so that interest can be accrued for her. This was discussed with the registered provider and will be pursued further.
Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 22 The recreational therapist does the resident’s personal shopping and is refunded with a cheque from the resident’s account. Receipts are held but must be individualised and not have several people’s names on one receipt, to comply with data protection legislation. There is a policy for the safekeeping of resident’s money it does not include the actual processes carried out in the home, for example who hold the keys to the safe, what happens out of office hours if a person wants some money. The policy also includes the names of individual people so does not comply with data protection legislation. There is a health and safety policy and a health and safety committee, which the registered manager said, is very active and the members have all received level 2 health and safety training. She said that some people have undertaken risk assessment and the Control of Substances Hazardous to Health (COSHH) training. Documentation shows that equipment and services are regularly serviced and maintained to ensure they are safe. A schedule of planned maintenance was seen and shows when work is in progress or completed. There is a file for fire documentation and records. The fire training records are not up to date and do not show regular training for all staff. The registered manager talked about recent fire training and showed us a fire leaflet produced in Polish for employees. Other statutory training records are also not up to date. Accident reports are maintained and accidents are also recorded in the daily records. There are eleven reports for May and three reports for June. Accidents are audited informally there are no written audit records, the registered manager was able to verbalise which people are prone to falls and actions that have been taken to prevent falls. Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 23 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 3 8 3 9 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 24 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 OP9 Regulation 13(2) Requirement Arrangements must be made to ensure that all medicines are stored in accordance with the current regulations. The staff files must contain the documents specified in Schedule 4 and relevant CRB information must be maintained for all staff. This will ensure robust recruitment for the safeguarding of vulnerable people. Timescale for action 01/08/08 2 OP29 19 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP30 Good Practice Recommendations The registered manager should monitor the medicine administration record charts regularly to ensure that everything is recorded appropriately. The registered manager should ensure that staff training records are up to date to show that training has taken place to keep staff up to date.
DS0000063981.V362552.R02.S.doc Version 5.2 Page 25 Millpond View Care Home 3 4 5 OP30 OP35 OP35 It is recommended that a training matrix be compiled to easily evidence who has done training and when The policy and process used for managing the residents’ personal money must be reviewed to ensure monies are safeguarded and to comply with data protection. Individual interest accounts should be established; two signatures for withdrawal of service users’ money should be in place Millpond View Care Home DS0000063981.V362552.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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