Inspection on 20/09/05 for Millreed Lodge

This inspection was carried out on 20th September 2005.

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

Millreed Lodge 21/07/08

Millreed Lodge 15/08/07

Millreed Lodge 12/09/06

Millreed Lodge 08/03/06

Millreed Lodge 22/11/04

Millreed Lodge 21/07/04

Millreed Lodge 04/03/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Millreed Lodge 373 Rochdale Road Walsden Todmorden Lancashire OL14 6RH Lead Inspector Lynda Jones Unannounced Inspection 20th September 2005 10:00 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 Millreed Lodge DS0000057454.V250680.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. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 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.V250680.R01.S.doc Version 5.0 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 22nd November 2004 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, post office and shops are one mile away in the local town. The home provides care with nursing for a total of thirty-three people in the following categories: Old age, not falling within any other category (31), Physical disability (2), Terminally ill (2), Terminally ill over 65 years of age (2) The accommodation was created many years ago by the conversion of a textile mill. The home has recently been extended, adding a new conservatory and reception area to the ground floor accommodation. All of the bedrooms have en suite toilet facilities. There is a passenger lift that serves all floors. The fees at Millreed Lodge include care and accommodation, food, drink, heating and lighting, laundry and some toiletries. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by two inspectors and took place over six hours. Seven residents, two visiting relatives and five members of staff were spoken to. Care plans and staff records were inspected and a tour of the building took place although not all bedrooms were seen. Ownership of the home has changed since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 6 Staff recruitment procedures need to be improved to ensure that residents are fully protected and that suitable people are employed to work at the home. Training records should be improved so that there is a quick way of identifying what training has taken place and when updated training is required. Care plans need to contain more detail so that they include clear information about the needs of residents and of the action staff must take to meet these needs. The format that is used is restrictive and does not encourage detailed recording. There needs to be evidence of an improvement in the range, frequency and recording of the activities that take place. The activities area should be made more comfortable and inviting, it should not be used as a store room. 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. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 7 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.V250680.R01.S.doc Version 5.0 Page 8 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): None of these standards were assessed. EVIDENCE: Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 9 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): 7,9,10. The care plans do not indicate how the needs of residents are to be met. Records lack detail. Reviews of plans are often repetitive. EVIDENCE: There is a care plan in place for every person living in the home but the documents provide minimal information about residents. Very little information is recorded about life experiences and interests, or about the families and friends of residents. Useful information that is provided by social workers as part of their assessments is often not incorporated in the care plan. The care plans do not outline the sort of action the staff must take to meet the needs of residents. Examples of this were found in the personal hygiene section of plans where the notes stated “full assistance required” and “requires full assistance of one” but with no accompanying explanation of what this meant. From speaking to staff it appears that details about the individual needs of residents are communicated amongst the team by word of mouth. The records do not do justice to the care they provide. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 10 Daily recording tends to be repetitive, it does not reflect the sort of day residents have had, there is little information about the sort of routines people prefer or whether they have had visitors. The daily records made in respect of a resident who recently moved into the home contained some detailed information during the first couple of days, after this the recording was minimal. Monthly reviews of the care plans also tend to be repetitive. Verbal information provided about the appetite of one resident conflicted directly with the information recorded in the monthly reviews. Verbal information indicated that this individual had a poor appetite, the records for the previous three months suggested a good appetite. Other records for this individual showed evidence of weight loss. There was little information on individual files to show that detailed moving and handling assessments had been carried out. Moving and handling equipment is available in the home & was being used by staff on the day of inspection. Records could not be found to show what training the staff had received to ensure that safe moving and handling practices were followed. Medication administration records were checked. These were accurately completed and the stock of medication balanced with the records. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 11 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): 12,13,15 There has been a lack of progress in organising a variety of meaningful activities for residents and in using the activities area. The food is good and the menus offer plenty of choice. EVIDENCE: Preparations have been underway for the past eighteen months to use a small conservatory as an activities area. Difficulties were encountered in making the area suitable for purpose and then in recruiting an activities organiser. Building work was completed several months ago and the manager said that a senior care worker had just been appointed to oversee activities but as yet no programme had been established. It was disappointing to see the activities area. It contained several footrests and a number of spare parts for wheelchairs, old newspapers and some old shoes in a plastic rack. Of the three seats in the room, one was ripped, one was a commode. There was a full ashtray on the table. The manager said the room was also used for hairdressing, although no mirror was available and it did not appear to be particularly comfortable and relaxing for this activity. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 12 A sign on the notice board in the entrance to the home indicated that “Active Minds” visit every two weeks to provide some therapeutic activities and that entertainers are periodically booked to perform at the home. The recording of activities needs to be improved to reflect what actually takes place. From examination of some of the individual plans it appears that activities occur only spasmodically, contrary to what was reported by staff. One care plan indicated that a particular resident would “participate in activities with encouragement” the records went on to show that this individual had taken part in activities on two occasions in August and once so far in September. It is not clear whether the records reflect the total number of activities that were on offer or the number of times that staff were successful in encouraging and engaging the resident. It is possible that participation was not always recorded. Visiting relatives said they were always made to feel welcome and could call at the home at any time. Residents said the food was good. The midday meal looked appetizing and was served hot. Afterwards people said they had enjoyed their meal. Most people ate in the dining room, some people had their meal on a tray in the lounge. Six people were assisted by staff. It is important that there is clear guidance in the care plans about who needs assistance with their meals. One person who could eat unaided showed little interest in the meal, this could have been overlooked but for the vigilance of one member of the team. There were no instructions in the care plan for staff to provide assistance to this individual. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 13 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): 18 Staff recruitment procedures need to be improved to protect people from abuse. EVIDENCE: See section on staffing for details. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 14 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): 19,20,21,26 The home is well maintained. There has been continued progress in improving facilities in the home. EVIDENCE: Since the last inspection there has been a big improvement in one of the upstairs bathrooms and shower room. These are now safer and much more pleasant for residents to use. The manager said the homes central heating system had been upgraded and work had been completed on the roof one of the conservatories to prevent the room becoming too hot when the sun is shining. The home is well maintained and repairs are promptly dealt with. The home was noted to be clean and tidy throughout. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 15 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): 29,30 The procedures for recruiting staff are not thorough enough to ensure that residents are properly protected. Training records need to be improved. EVIDENCE: Records relating to two recently appointed staff were examined. There was evidence that employment histories had not been explored as periods of time were unaccounted for and dates of past employment were not fully recorded on the application forms. There was evidence that past and present staff from Millreed Lodge had provided references for staff, instead of past employers. Another reference was seven years old and addressed to “whom it may concern”. This had been provided by the applicant. In one case there was no evidence that a CRB check had been carried out. Training records need to be reviewed. It was not possible to see what training had been undertaken and when this had taken place. It would be useful if a training matrix was used and a training record held on individual staff files. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 16 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): 38 The floor in the laundry needs attention. EVIDENCE: The floor covering in the laundry in front of the washing machines is cracked. This has been repaired once but the crack is evident again. As this is potentially hazardous for staff working in the laundry, it should be attended to. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 3 3 3 X X X X 3 STAFFING Standard No Score 27 X 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 1 Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The care plan must detail the action that needs to be taken by staff to ensure that all aspects of health, personal and social care needs are met. All new staff must have all the necessary checks completed before they start work in the home. At the very least two written references must be obtained, one must be from the last employer. Checks must be made with the Criminal Records Bureau and of the Protection of Vulnerable Adults register. Records must be available to show that appropriate training has been provided for all staff. The flooring in the laundry must be repaired. Timescale for action 30/10/05 2 OP29 19 20/09/05 3 4 OP30 OP38 18 23 30/11/05 30/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 19 No. 1 2 Refer to Standard OP12 OP12 Good Practice Recommendations Residents should be given the opportunity to take part in stimulating leisure and recreational activities which suit their needs. Details of activities should be recorded. The activities room should not be used as a storage area. Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Millreed Lodge DS0000057454.V250680.R01.S.doc Version 5.0 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!