Inspection on 23/01/06 for Mills Meadow

This inspection was carried out on 23rd January 2006.

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

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

Other inspections for this house

Mills Meadow 16/09/08

Mills Meadow 17/09/07

Mills Meadow 25/08/06

Mills Meadow 10/08/05

Mills Meadow 21/03/05

Mills Meadow 03/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mills Meadow Fore Street Framlingham Suffolk IP13 9DF Lead Inspector John Goodship Unannounced Inspection 23rd January 2006 12:10 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 Mills Meadow DS0000038816.V275448.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. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mills Meadow Address Fore Street Framlingham Suffolk IP13 9DF 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) 01728 724580 01728 724959 lucy.roughley@socservsuffolkcc.gov.uk Suffolk County Council Mrs Lucy Roughley Care Home 35 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (35) of places Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: Mills Meadow Framlingham is a residential care home for older people, which is owned and managed by Suffolk County Council, Department of Social Care. The home has a total of 35 registered care beds - 20 of which are for residential care and 15 of which are for dementia care. Included in both categories are short-term care beds. The home is situated in the centre of Framlingham, a small market town in rural Suffolk. As such, the home is close to shops, and other community facilities and resources. It also benefits from having its own transport, used for outings, appointments, and activities. The home is all single storey, divided into a number of Hamlets - self-contained units providing residential care. Poppy Hamlet accommodates 15 service users with dementia / special needs. Rose, Viola and Iris Hamlets each accommodate 6 residential service users. Iris Hamlet is also used to accommodate some respite care service users. These are used to support people who require a short-term focused admission to improve their confidence, capabilities, and skills, towards living more independently in the community. There is also a 20 place Day Centre which is not subject to inspection. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection in this inspection year and the third within the last twelve months. The manager was present, and, for part of the time, the Locality Manager. A site visit to inspect three new rooms was undertaken at the same time. A sample of records were examined, and a tour of the building was undertaken. Several residents were spoken to, all of whom said they were happy in the home and that staff were caring and kind. The previous inspection in August 2005 covered most of the national minimum standards. This inspection covered all but one of those remaining and checked that others were still being met. What the service does well: What has improved since the last inspection? What they could do better: There were no requirements or recommendations from this inspection needed to meet the national minimum standards. The home has to agree an annual business plan with the department which includes local developments and maintenance programmes. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 6 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. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 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 Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 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): 3,6. Residents can be confident that their needs have been fully assessed upon entering the home to make sure that the home can meet their needs. The home no longer provides intermediate care. EVIDENCE: From a sample of care plans, which are kept on the relevant hamlet, it was confirmed that all prospective admissions had a pre-admission assessment by the manager or a team leader. These included those destined for a short-term care placement. The night team leader was responsible for starting the care plan from the assessment information, ready for the next day’s admission. Two intermediate care rooms had ceased to be required. Together with an adjacent meeting room, they had been converted to three en-suite rooms for older people with dementia. There were increasing referrals to the home for this category of accommodation. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 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): 9. Residents are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Following the discovery of a medication error in October 2005 (an underdosage), the manager had taken steps to reduce the likely interruptions to staff dispensing medication. She had also arranged for all staff responsible for administering medication to complete a survey form asking for comments on the current systems and procedures. The results of these forms had been discussed at a Team meeting and some procedures had been changed. Risk assessments had been completed for controlled drugs and a copy was attached to the controlled drugs book. The manager was also exploring the “Safe Handling of Medicines” distance learning course run by a local college. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 10 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): None of these standards were inspected. They were all covered at the last inspection. EVIDENCE: Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 11 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. Residents can expect their complaints, and those of their relatives to be dealt with within the County Council’s procedure, and action taken as necessary. EVIDENCE: Two complaints had been received in the home from relatives since the previous inspection: both concerned the content of letters sent to all residents, one about access to the day centre on site, and one about medication. Both had been dealt with within the time set out in the home’s policy. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 12 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. Residents admitted to the new rooms can expect them to meet current standards of facilities and safety. EVIDENCE: Two intermediate care rooms and a meeting room had been altered to provide three new en-suite rooms for older people with dementia. Two of the rooms had level-access showers. These had been registered by the Commission on 30 January 2006 to provide a total of 15 beds for this category of resident. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 13 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): 27,29. Residents can expect to be cared for by sufficient staff, who are appointed according the required safeguards. EVIDENCE: Staffing levels in the special needs unit had been revised for the three additional residents. The number of care assistants had been increased on days from two full-time and one part-time, to three full-time. The records of two recently appointed members of staff had been examined. Both contained the required pre-employment checks and documentation. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38. Residents can be confident that the home is managed by a competent person, with their views being sought regularly about the running of the home. Other mechanisms, and proper records, ensure that the home is run in the residents’ best interests. Health and safety measures are constantly updated to protect the residents. EVIDENCE: The registered manager had recently returned from maternity leave. She wished to work part-time. The other half of the week was being covered by the deputy who was applying to the Commission to be the other registered manager. The manager described how the two of them would share all duties, and would use a message book to assist their mid-week handover. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 15 The home had a good record of consulting residents through surveys and residents’ meetings. Catering was a perennial topic. Some of the changes introduced from residents’ comments included the introduction of pasta dishes and a cooked breakfast offered everyday. Other means of testing the quality of the home included monthly visits from the Locality Manager, and from the manager of another home, regular care plan reviews, appraisal and supervision of staff and Personal Development reviews. Questionnaires had also been sent to GPs and District Nurses. These had led to improved communication, for example, providing a summary record to take with residents to an appointment. All doors had now been fitted with automatic door closers linked to the fire alarm. Each door could be held open at any point in its travel. Entry to the home was by a swipe card system for staff. All other visitors had to ring the bell and be admitted by a member of staff. A button had to be pressed to release the door for going out. All records examined were up-to-date and complete. All policies were based on those issued by Suffolk County Council. Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 16 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? NONE 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. Refer to Standard Good Practice Recommendations Mills Meadow DS0000038816.V275448.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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