CARE HOMES FOR OLDER PEOPLE
Millreed Lodge 373 Rochdale Road Walsden Todmorden Lancashire OL14 6RH Lead Inspector
Liz Cuddington Key Unannounced Inspection 15th August 2007 12:15 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 Millreed Lodge DS0000057454.V343062.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. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Millreed Lodge Address 373 Rochdale Road Walsden Todmorden Lancashire OL14 6RH 01706 814918 01706 817919 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) Millreed Lodge Care Ltd Mrs Elizabeth Shufflebottom Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (2), Terminally ill (2), of places Terminally ill over 65 years of age (2) Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. To accommodate a maximum of two persons in category TI/TI(E) at any one time To accommodate a maximum of two persons aged under 65 years of age with a physical disability Two named persons over 60 years of age Date of last inspection 12th September 2006 Brief Description of the Service: Millreed Lodge is set in landscaped grounds alongside the Rochdale canal and Walsden Water, and is situated on the main Rochdale Road in Todmorden. Banks, a post office and shops are one mile away in the local town. The home provides care with nursing for up to thirty-three people The accommodation was created many years ago by the conversion of a textile mill. A conservatory and reception area has been added to the ground floor accommodation. All of the bedrooms have en suite toilets. There is a passenger lift that serves all floors. The fees at Millreed Lodge are between £443 and £405 nursing determination per week. Hairdressing, chiropody, newspapers and personal items are not included in the fees. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The last key inspection of the home took place on 12 September 2006. I have not made any further visits to the home. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Millreed Lodge. The methods I used to gather information included a visit to the home, conversations with the people who live there, their relatives and the staff, looking in detail at the care and records of three people, examining other records and looking around the home. I spent seven and a half hours at the home. Before visiting I sent out questionnaires for the people who live at the home and their relatives to complete. I received six back from people who live at the home and seven from their relatives. I also received surveys from two social care professionals who visit people at the home. Feedback from these surveys is included in this report. The manager also completed the home’s pre-inspection questionnaire. These questionnaires and surveys provide valuable information to help me form a judgement about the quality of the service offered at Millreed Lodge. Although there are still areas for development, the home continues to make improvements. I would like to thank the people who live at Millreed Lodge, their relatives and the staff, for their welcome and hospitality and for taking the time to talk to me during my visit and for completing the questionnaires. What the service does well:
People confirmed that the pre-admission procedures at Millreed Lodge are thorough. One person’s relative wrote that ‘we are really pleased to be involved with (the) care plan and was introduced to (the) keyworker…that was really important’. Staff support the people who live at the home to maintain their health and independence and to make choices about all aspects of their lives. All the people who completed questionnaires agreed the staff listen and act on what they say. One person wrote that the ‘…staff are informative and supportive’. Someone else commented that their relative ‘…is in very good hands…I am satisfied’.
Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 6 The staff treat people with respect and look after them in the way they prefer. Relatives and other visitors are welcomed to the home. Many people visited while I was there and contributed to the relaxed and friendly feel to the home. One relative commented that ‘Millreed has a lovely homely atmosphere’, another said the home provides a ‘….safe and happy environment’. Everyone said they always or usually enjoyed their meals. One person wrote in their questionnaire that ‘The meals are particularly good’. The home is clean and hygienic. One relative wrote that ‘The home is always clean and well cared for’. Most people felt that the staff provide good care and support. In their questionnaires one relative wrote that ‘The carers that I have met are excellent’, another said ‘The staff are friendly and helpful’. The manager promotes an open and inclusive atmosphere where everyone’s views are valued. One person’s relative commented ‘I am very impressed with the care that my (relative) gets’ and another said ‘…so far we are really pleased with (the) care’. One social care professional commented that, apart from activities, they are satisfied with all aspects of the care provided at Millreed Lodge. In the part of the questionnaire where people are asked how they think the home could improve one relative wrote ‘I can’t! Just keep up the good work’. What has improved since the last inspection? What they could do better:
Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 7 The care plans do not all show that the person, or their family, has been involved in developing and reviewing the plan and that they have agreed to what it says. Two plans I looked at did not have risk assessments where there was a clear need for these to have been completed. Staff need to make sure they keep accurate records of the support and assistance they offer to people, especially when they are following routines to promote good healthcare. Four relatives said they are always kept up to date with important issues and one said they usually are. However, one relative wrote that they are never informed and gave 2 examples of occasions when the family had not been told on either occasion of two accidents to their relative. The home needs to develop a wider programme of activities for people. Although activities are offered, one relative commented ‘I have never seen any stimulating activities….’. The medicines trolley should be either securely attached to a solid wall, or moved to a locked room, when not in use. Five of the people who live at the home said that staff are usually available when needed, one person said they sometimes are and felt that when they are not this is ‘…because they are somewhere else’. One relative wrote that ‘Many times there is not enough staff to properly care for clients. Specially at toileting times’. One person wrote in the questionnaire that ‘…sometimes due to lack of staff things aren’t done as quickly as I would like’. All staff need to have their mandatory training updated regularly, covering all health and safety subjects and adult protection, to make sure they are aware of current procedures and good practice. The quality assurance system may benefit from widening the scope of the people who are surveyed. Where people like to be able to keep their bedroom doors partly opened, safety door closures connected to the fire alarm system should be fitted. Currently wedges are being used, which is not safe in an emergency. To support the home’s overall improvement, the manager needs to have sufficient time and resources available to her. At present her time is limited by only having twenty hours each week to fulfil her management role. How this can be achieved is something the home and the organisation’s management should consider. Millreed Lodge DS0000057454.V343062.R01.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. Millreed Lodge DS0000057454.V343062.R01.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 Millreed Lodge DS0000057454.V343062.R01.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 Standard 6 does not apply People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A comprehensive pre-admission assessment is carried out before offering someone a place at the home, to make sure that their needs can be met. EVIDENCE: The care plans I looked at showed that comprehensive pre-admission assessments had been carried out before offering someone a place. This is to make sure that the home can meet the person’s needs. This assessment forms the basis of the person’s care plan. A senior member of staff visits the person at home or in hospital to discuss their care needs. Social Services’ assessments are also used to determine the care needs of the individual. People are welcome to visit the home before reaching a decision. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 11 Five people said they had enough information before moving to the home. One person did not, but said they received all the information needed by the end of the first week, which confirmed Millreed Lodge was the right place for them. One person wrote in their questionnaire that before reaching a decision they ‘Liaised with Social Services and made personal visit to the home’. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To maintain their health and well-being, people’s personal and healthcare needs are met. Care plans do not all show that the individual or their representative has agreed to the contents. Risk assessments are not always being completed. People are protected by the home’s medication systems. Medicines are stored safely and their administration is accurate. To maintain their dignity, the staff treat people with respect at all times. EVIDENCE: I looked at three care plans in detail, to make sure that people’s health and personal care needs are being met in the way each person prefers. The plans cover each area of the individual’s health and care needs in detail. One social care professional commented that she or he found ‘Written records not up to
Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 13 date. Care plan states needs to move position 2-4 hourly but written record in bedroom logged 0.45 & then 7.15am. …at 3pm and nothing further had been written’. Staff need to make sure that, when it is important that notes are kept of regular procedures such as this, they record what they have done each time. This is to confirm that the person is receiving the care the need, in accordance with their care plan, and that staff are following professional advice on the best care practices. Two people’s care plans showed that there are not always risk assessments in place, where needed, to show how potential risks can be minimised. This must be done for everyone, including people who are only staying at the home for a short period of time. Each person who needs assistance with his or her mobility, has a moving and handling plan. Details of visits by GPs and other healthcare professionals are kept. The plans show that people are being weighed each month. Three people said they always receive the medical support they need and two said they usually do. One person’s relative wrote that medical ‘….support is offered appropriately’. From my own observation, and comments made by the people who live at Millreed Lodge and the staff, it was clear that the staff are fully aware of each person’s needs and preferences. The staff make sure they provide the help people need in the way the person prefers. In the questionnaires one person said they always receive the care and support they need and five people said they usually do. Earlier in the year a social care professional witnessed someone being left for too long, despite staff knowing the person needed attention. The manager has since put measures in place to try and make sure people get the attention they need with minimal delay. However one relative I spoke with said that people are still being left for at least three hours and are not even being assisted to the toilet when they ask staff. The relative felt that this was mainly because there are not enough staff on duty at the busiest times of the day and evening. Wherever possible the care plans need to show that the person, or their relative or other representative, has agreed to the contents of the plan. The plans I looked at did not show that the individual or someone representing them has been involved in developing and reviewing the plan. The Medicines Administration Record (MAR) charts are kept up to date. Members of staff must sign the MAR charts each time they administer a dose of medicine. This was being done. Medicines are generally kept safe but the medicine trolley should either be bolted to the wall, or moved to a room that can be locked, when not in use. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 14 During my visit I noticed that all the staff treat people with respect. The people I spoke with during my visit said that they receive the care they need and are supported to maintain their independence for as long as they are able. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to maintain their independence and keep in contact with family and friends. Some leisure activities are provided, to try and meet people’s recreational needs. People are offered a good choice of meals, which meet their dietary needs and personal preferences. EVIDENCE: On the day I visited an entertainer came in the afternoon and played music and sang songs; he comes each month and many people seemed to enjoy the event. One person who visits regularly, confirmed that this was enjoyed by their relative. The care plans I looked at showed the type of activities people prefer. The home provides some activities such as nail care, conversation and bingo but the questionnaires I received did suggest that people would like there to be more. In the questionnaires one person said there are always activities
Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 16 available that they can take part in, one said there usually are, one person said only sometimes and two said there are never suitable activities. Two people said they are no longer able to take part in activities. One person commented that they would like there to be ‘More availability of magazines, newspapers, jigsaws….’. Another suggested the use of volunteers to do this type of individual interaction. The home’s management may like to explore ways of providing a wider range of activities that people will take part in and enjoy. Visitors are always made welcome and during my visit many relatives and friends called in. One relative wrote in the questionnaire that the staff ‘Make everyone welcome. Always cheerful’. Everyone was offered refreshments and the visitors contributed to the friendly atmosphere at Millreed Lodge. The staff treat each person as an individual, and their choices and wishes are respected. Everyone who commented said that the staff listen and act on what they say. One person wrote that the ‘…staff are informative and supportive’. Two people said in the questionnaires that their relative is always supported to live the life they choose and three said they usually are. Mealtimes are relaxed and sociable occasions and each person takes all the time they need to eat their meal. There is a good choice of dishes on the menu, and alternatives are offered if people wish. Special diets are catered for and the cooks and the rest of the staff are aware of people’s needs and preferences. The care plans confirm that people’s dietary needs are known and understood. Assistance is offered discreetly to people who are not able to manage to eat independently. All the people who commented during my visit, and on the questionnaires, said they enjoy their meals. One person commented that there is ‘Always a choice of menu’. Another said that ‘The meals are particularly good’. Drinks are always available when people want them and extra cold drinks are offered during the warm weather. Millreed Lodge DS0000057454.V343062.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 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most people living at the home, and their relatives, are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have not all received up to date adult protection training, which helps make sure that people living at the home are safe. EVIDENCE: The complaints procedure is clear and easily available. Most of the people who completed the questionnaires said they know how to make a complaint or raise a concern, if they need to. Three relatives of the people who live at Millreed Lodge said the home had responded appropriately when they or their relative had raised a concern. The staff have not yet had updated Adult Protection training. This needs to be arranged without further delay, to make sure the staff are fully aware of their role in protecting the people they support and care for. The relevant policies and procedures are up to date. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, comfortable, well-maintained and homely environment. EVIDENCE: A new ramp and handrails have been built between the car park and the main entrance, to make access to the house easier as well as to improve the appearance of this area. There are extensive plans to alter and improve the house, creating additional bedrooms to allow twin rooms to become single rooms and re-locating rooms, such as the kitchen and laundry, which will then give additional space for the people who live at the home to enjoy. There is an ongoing programme of re-decorating the house. The hall, stairs and landings have recently been painted. When I visited there were just four bedroom doors still to be fitted with locks.
Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 19 The garden is to be substantially improved to make it more attractive and provide safe, accessible paths so that people can use the garden. At present the paths are uneven and not considered safe enough for people to use. There is a balcony at the rear of the house, giving a sheltered place for people to sit out during the better weather. Some of the doors are being held open with wedges. This is not good practice, as they will not close in an emergency. The manager said there are plans to replace the wedges with self-closures, which will shut the door automatically if the fire alarm goes off. The house is clean and fresh and the staff follow good hygiene practices, as part of the home’s infection control measures. Most people who commented said the house is kept clean. One person wrote that the ‘Bedroom (is) usually tidied and cleaned’. Another said that ‘Sometimes small things like the wheelchairs look like they haven’t been cleaned’. One relative wrote in their questionnaire that ‘The home is always clean and well cared for’. Two people wrote that the lack of toilets on the ground floor means that residents have to wait at the busy times; which they believed can cause distress. Increasing the number of toilets on the ground floor may be something for the management to consider as part of the refurbishment plans. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet people’s needs. The people who live at Millreed Lodge are protected by the home’s recruitment procedures, which ensure that staff are suitable to work with older people. More than half of the care staff have a suitable NVQ award. Other training is provided; but more frequent updating is needed to make sure staff have all the skills and knowledge they require to help them to meet people’s needs. EVIDENCE: The staff rotas confirmed that there should be enough staff on duty to meet the needs of the people who live at Millreed Lodge. But as the home is now fully occupied, and many people need two staff to assist them, the staffing levels particularly at peak times of the day and evening need to be high enough to meet everyone’s needs in a timely way. The comments I have received suggest that the management should review the numbers and deployment of staff, to make sure there are always enough staff available to meet people’s needs. All staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA)
Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 21 register checks are obtained. New staff do not begin work until these checks have been completed satisfactorily. New care staff take the ‘Skills for Care’ induction and foundation training course and the home has a system where experienced staff mentor new staff. This basic training makes sure staff have a good understanding of their role and responsibilities, and provides a sound basis for NVQ study. Ten of the seventeen care staff have a relevant National Vocational Qualification (NVQ) at level 2 and four staff are working towards completing the award. Two more staff are enrolled to start the NVQ level 2 award. New care staff are encouraged to take the qualification. The home’s training records are completed adequately. The management needs to make sure all the staff have up to date training in all the mandatory areas, including health and safety, moving and handling and adult protection. The manager told me that training in health & safety, food hygiene, fire safety and adult protection is planned for the near future. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe and well managed and people who live and work at the home can contribute to the decision-making processes. EVIDENCE: The manager is a registered nurse and has the skills and experience to manage the home effectively. The manager is allowed twenty hours supernumerary time to carry out her management role and has support from a part-time administrator. The remainder of her time is spent as the nurse on duty. The manager has a wide range of responsibilities, including arranging and delivering staff training. To fulfil this role satisfactorily, and to support the home’s overall improvement, the manager needs to have sufficient time and
Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 23 resources available to her. How this can be achieved is something the home and the organisation’s management should consider. The home’s manager promotes an open and inclusive management style and everyone is involved in the decision-making processes. My own observations, and comments from other people, confirm that everyone’s views are valued and taken into account. The home has carried out a quality assurance survey of people’s relatives, in order to gain their views on the quality of care and support provided. The home’s manager plans to include health and social care professionals on the next occasion. A new quality audit tool has been purchased, to assist the manager to assess the quality of the service. The home looks after small amounts of people’s money, to pay for their dayto-day expenses. The records and monies are accurately kept and safely stored. Confidential information is now being stored securely in a locked filing cabinet in a room that can be locked, when not in use. The policies and procedures are kept up to date; this is to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. A recent Environmental Health Officer’s inspection gave the home a 3 star rating, with just a few recommendations for improvement. Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 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 Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 25 YES 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 OP7 Regulation 12(2)&(3) Requirement To confirm their agreement the care plans must show, wherever possible, that the individual, or their representative, has agreed to the plan. This is brought forward from the last inspection: dated31/03/07 For the safety and well-being of the people who live at the home and the staff, risk assessments must be completed where necessary to reflect each service user’s current care needs. This is brought forward from the last inspection: dated 31/12/06 In order to meet people’s care and support needs, there must be sufficient staff on duty at all times. For the safety and well-being of the people who live at the home, and the staff, essential staff training must be kept up to date. Timescale for action 31/12/07 2. OP8 13(4) 31/10/07 3. OP27 18(1)(a) 31/10/07 4. OP30 18(1)(c) (i) 31/12/07 Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP8 Good Practice Recommendations To confirm that people are receiving the health care they need, staff need to make sure they keep accurate records of the support and assistance they offer to people. For the safety of everyone, the medicine trolley should be secured to a solid wall or stored in a locked room when not in use. The home’s management should explore ways of providing a wider range of interesting and stimulating activities, to meet the social and recreational wishes of the people who live at the home. For the safety of everyone, closures connected to the fire alarm system should be fitted to doors which are left partly open. OP9 OP12 4. OP25 Millreed Lodge DS0000057454.V343062.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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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