Inspection on 08/03/06 for Millreed Lodge

This inspection was carried out on 8th March 2006.

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

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

Other inspections for this house

Millreed Lodge 21/07/08

Millreed Lodge 15/08/07

Millreed Lodge 12/09/06

Millreed Lodge 20/09/05

Millreed Lodge 22/11/04

Millreed Lodge 21/07/04

Millreed Lodge 04/03/04

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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 8th March 2006 09:30a 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.V265883.R01.S.doc Version 5.1 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.V265883.R01.S.doc Version 5.1 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.V265883.R01.S.doc Version 5.1 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 20th September 2005 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. More recently a new conservatory and reception area has been added 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.V265883.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk The last inspection of the home was unannounced and took place on 20 September 2005. This was an unannounced inspection carried out by two inspectors over 5 hours. The main purpose of the inspection was to make sure that the home provides a good standard of care for the people who live there. The methods used at this inspection included looking at care records, staff records, complaints log, records of money held for service users and health and safety records. A tour of the building took place and time was spent talking to service users, two visitors to the home and the registered manager. What the service does well: The home is friendly and visitors are made to feel welcome. Visitors to the home said the staff were very helpful and the home was always clean and odour free when they called. Residents said the staff were kind and helpful and staff and residents said they got on well together. Staff were respectful when they talked to residents and personal care was delivered discreetly. The staff offered choices of drinks, meals and desserts to everyone and obviously have a good understanding of what individuals like and dislike. The home is comfortably furnished and the sitting areas are bright. The bathing facilities have been improved over the past year. The health and safety records that are kept at the home are up to date and show that equipment is regularly serviced. Residents and their families are asked for their views on the service provided; the results are available from the home. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 6 The Responsible Individual visits the home regularly and reports to the Commission for Social Care Inspection each month on the conduct of the home in accordance with the Care Homes Regulations 2001. What has improved since the last inspection? What they could do better: Staff need to make sure they fully record information on all sections of the care plan format. The plans should clearly show how the care and support required by resident, is to be delivered. Some of the paintwork in the bedrooms needs attention where damage has been caused by wheelchairs. The record of activities needs to improve. If the small conservatory is intended to be used for activities, the area needs to be clean, warm and comfortable. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 7 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.V265883.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 All prospective residents are assessed before they move into the home. This makes sure that the staff are able to give people the support they need. EVIDENCE: Residents are assessed before they move into Millreed Lodge to make sure that their needs can be met at the home. Details of the assessments are held with the care plans. Assessment information provided by Calderdale Social Services in respect of a recently admitted resident was available on file. Prospective residents and their families are welcome to call at the home at any time to view the accommodation and to meet other residents and staff. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 10 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 The care plans at the home need to be improved. They need to contain more detail about the specific needs of individual residents and clearly show how these needs are to be met by staff. The introduction of a new care planning system should provide an ideal opportunity for staff to bring about this improvement. EVIDENCE: A new care planning format has been introduced recently. The format has the potential to assist staff to record valuable information about the health, personal and social care needs of all residents. A sample of care plans was examined relating to four residents who have moved into the home since January 2005. The amount of information gathered was disappointing. One person had lived at the home for over two weeks and no care plan was in place. On the other documents only parts of the format had been completed, there was insufficient information to give a picture of the Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 11 sort of lives that people had led and very little had been recorded about each persons interests and preferred daily routines. The format gives prompts for staff to record specific information. For example, for breakfast (the named resident) usually has… the format then goes on to prompt staff to record how and where the resident prefers to have breakfast eg. In bed on a tray, in the bedroom or dining room. Other parts of the plan require staff to identify and record when people like to get up, when they prefer to go to bed and how residents prefer to spend their time at various parts of the day. Much of this information had been left blank. There was insufficient information about the specific care needs of each person and about the action that staff must take to make sure that individual needs are met. For example, the plans require staff to ascertain whether individuals prefer a bath or shower and to identify what sort of assistance each person needs to bathe. Some records show preferences for baths over showers but do not go on to give details of the sort of support people need. It is important that this information is recorded in full in order that residents can receive care and support with consistency, in a way that suits them and allows them to feel comfortable. The plans do not reflect the work that care staff carry out. This same point was made in the last report. The new care planning format should be an ideal opportunity for staff to produce some detailed, personalised care plans that reflect the work that they do. This was discussed in detail with the manager in the feedback session at the end of the inspection. Progress on care plans will be followed up on the next inspection. On a positive note, there has been some improvement in the quality of the daily records. These were not as repetitive as found previously, they contained information about the care provided and offered some insight into the sort of day that individuals had experienced. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 12 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 There is no evidence of planned activity. The records do not show that people have been individually consulted about what they would like to do. There needs to be an improvement in this area. EVIDENCE: There is little recorded evidence of any progress in the area of activities. Previous reports note that preparations have been underway for eighteen months to use a small conservatory as an activities room. Difficulties were first encountered in making the area suitable for purpose and then in recruiting an activities organiser. At the last inspection the room was inadequately furnished and had been used for storage purposes. On this inspection it was noted that some more comfortable chairs had been placed in the room but it was still not suitable for use as an activities area. The sink in this room which is apparently used for hairdressing, was tea stained. There was a full ashtray on the table. The manager said that two members of staff have taken on responsibility for coordinating activities. The new care-planning format provides the facility for staff to find out and record what particular interests and hobbies residents have. There is scope to keep record what activities take place and to keep a record on each care plan showing individual involvement. Activities need not always be group exercises, each resident should be provided with opportunities Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 13 for stimulation through leisure and recreational activities which suit their personal preferences and individual capacities. On the day of inspection a visiting entertainer was singing and playing an organ in one of the lounges. A number of people were joining in and appeared to enjoy the session. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The complaints procedure is well publicised at the home. The recording of complaints/concerns could be improved. Measures are in place to protect residents from abuse. Staff recruitment measures have improved and staff receive training on adult protection issues. EVIDENCE: The complaints procedure is displayed on the notice board and in each bedroom. Prospective residents and their families are given written details of the complaints procedure when arrangements are being made for people to move into the home. The Social Services Department is investigating one complaint about the home. The complaint is about the standard of care received by a resident who was at the home for a short stay earlier in the year. The home has a complaints log but nothing had been recorded. Discussion took place with the manager about the need to record any complaints/concerns raised by residents and relatives. The records should indicate when the complaint/concern was made and who by, details should include what the complaint/concern was about and what action was taken to resolve the issue. Sixteen members of the team have recently taken part in adult protection training. Plans are in hand to deliver the training to the remaining members of the team. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 15 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): 19,20,23,26 The home is generally well maintained. The decoration in some of the bedrooms needs attention. EVIDENCE: A full tour of the building did not take place on this inspection. Some of the bedrooms that were seen would benefit from repainting. Wheelchairs have scuffed the paint and plaster in some of the entrances to the rooms. In other rooms the door handles have banged against the walls when the doors have been fully opened, damaging the decoration. Some of the carpets in bedrooms are uneven and could cause people to trip; this needs to be attended to. The laundry has a new floor covering which is an improvement. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 16 The small conservatory that was intended to be the activities room needs attention. The room is cold and not very inviting. The roof was leaking at the time of this inspection. The roof is also badly stained with nicotine as this area is used as the smoking area. The manager said that plans are in hand to replace the roof but these were hampered by the bad weather. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The home is appropriately staffed to meet the needs of residents. Recruitment practice has improved and more robust procedures are now in place. Improvements have commenced in the way staff files are maintained. The staff have a range of training opportunities available to them. EVIDENCE: Three staff files were examined; these included two files for containing records in respect of recently appointed staff. The records indicated that two references had been obtained and checks of the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register had been carried out before new staff started work at the home. Changes to the way in which staff records are held have begun; this is a positive improvement and should make it much easier to access information. A quick reference matrix is currently being set up. This will show details of all of the staff training that has been undertaken, details of planned training and where training updates are required. This is a positive improvement and can be used in conjunction with the more detailed information that is held on individual staff training files. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 18 Seven care staff have achieved their NVQ level 2 or 3 awards in care, this amounts to 40 of the care staff team. There are a further six members of the team who have enrolled for this training. There is a nurse on duty at the home at all times. In the mornings there are five care staff on duty and in the afternoons and evenings this reduces to four care staff. At night there is one nurse and two members of care staff on duty. The care staff are well supported by cooks, domestics and laundry staff. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. The registered manager is experienced in managing a care service for older people. Residents and their relatives are consulted about the service provided at the home. Health and safety records are up to date and indicate that the equipment used in the home is regularly serviced. Records indicate that residents’ money is managed appropriately. EVIDENCE: The registered manager is a qualified Registered Nurse. She had previous experience of working in a care home before she moved to Millreed Lodge in 1997. She became Deputy Manager of the home in December 2002 before taking over as “acting manager” in 2004. She was registered by the Commission for Social Care Inspection in 2005. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 20 She has undertaken various in-house training courses during the course of her employment at Millreed Lodge and gained the Registered Managers Award & NVQ Level 4 in September 2003. The manager holds some money for residents for safekeeping. Records of all transactions are maintained and receipts for all purchases are available. There is a written health and safety policy and risk assessments are in place for safe working practices. All of the service records for lifts, hoists, gas safety and small appliance tests were available and up to date. The electrical wiring certificate was not available; works are to be completed w.e. 18/3/06, following this the certificate will be issued. Moving and handling training for staff is ongoing and fourteen members of staff have completed updated training in 2005. The majority of staff attended fire safety training in November/ December 2005. There are nine appointed first aiders at the home, seven members of the team have food hygiene certificates and six members of the team have completed infection control training. The accident records showed that some residents had fallen several times in their bedrooms. These records need to be analysed to see if there is a pattern to the accidents, for example, do they occur at certain times of the day, are they always in the same part of the room. Falls risk assessments need to be carried out in each case to try to minimise the number of accidents occurring. In February 2006 residents and their families were asked to complete a satisfaction survey. Fifteen surveys were returned. The results indicate that people thought the staff were helpful and courteous. Respondents were satisfied with the accommodation; the results show that people were happy with their rooms and with the shared areas of the home. Comments on the food ranged from OK to very good, with the majority indicating that the quality, choice and variety of the meals was very good. There was also general consensus that the laundry service at the home was very good. The Responsible Individual for Millreed Lodge provides the Commission for Social Care Inspection with regular, detailed monthly reports on the conduct of the home. Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 2 X X 2 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 2 Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 22 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. Standard Regulation Requirement Timescale for action 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 OP7 OP12 Good Practice Recommendations Work needs to continue to fully implement the newly adopted care planning system. 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 planned work to the roof of the small conservatory needs to be carried out. This area needs to be improved if it is intended for use as an activities area. Records should be made of all complaints/concerns that are brought to the attention of staff. Plans need to be drawn up to improve the décor in some of the bedrooms. All accident reports should be analysed and appropriate preventative action taken to reduce the risk of falls. 3 OP20 4 5 6 OP16 OP23 OP38 Millreed Lodge DS0000057454.V265883.R01.S.doc Version 5.1 Page 23 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.V265883.R01.S.doc Version 5.1 Page 24 - 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!