Inspection on 16/08/06 for Millstream View

This inspection was carried out on 16th August 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Millstream View 29/04/10

Millstream View 17/09/08

Millstream View 24/09/07

Millstream View 06/03/06

Millstream View 26/10/05

Millstream View 21/02/05

Millstream View 26/08/04

Millstream View 29/05/03

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Millstream View Mill Lane Adwick Le Street Doncaster South Yorkshire DN6 7AG Lead Inspector Stuart Hannay Unannounced Inspection 16th August 2006 09:30 Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 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 Millstream View DS0000032073.V306822.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 Adults 18-65. 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. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millstream View Address Mill Lane Adwick Le Street Doncaster South Yorkshire DN6 7AG 01302 721408 NONE NONE 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) Doncaster Metropolitan Borough Council Pamela Hankinson Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users with challenging behaviour can only be accommodated in the 8 bedded unit. 6th March 2006 Date of last inspection Brief Description of the Service: Millstream View is a Care Home registered to provide accommodation, care and support to up to 13 young adults with a learning disability (18-65 years of age). The accommodation is offered within two separate units. One unit, which is located on the ground floor, provides care for up to 8 young adults with learning disabilities and challenging needs. The second unit is located in a part of the building where the accommodation has been arranged into 5 individual and separate flats. Both units have separate access. They have designated staff groups. The Home is situated on Mill Lane, in Adwick-Le-Street village, Doncaster. It is close to local amenities, including shops, a post office, and a church. The ‘Adwick Social Education Centre’ is situated next to the Home, and is attended by the majority of the service users of Millstream View. Millstream View is owned and managed by the Social Services Department of the Doncaster Council. There is a registered manager, Mrs. Pam Hankinson, who is responsible for the day- to- day running of the Home. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. The first visit lasted for approximately five hours and the second visit for two hours. It was not possible to formally interview all the service users present, however time was spent talking with most of the service users. Four service users were able to answer some of the questions about the service. Seven members of staff were spoken with over the two days, including the deputy manager, the senior on duty, four care officers and a care assistant. An inspection was made of the premises in both units and a range of records were checked; the service users’ care plans, the medication administration records (MAR) sheets, staffing rotas, the Statement of Purpose, fire safety records and fire training records. A check was made of the storage of the medication. The deputy manager had completed a pre inspection questionnaire and some of the information in the report is taken from this. The manager was not present on the day of the inspection but the inspector telephoned her on Monday 21st August to discuss some of the findings and her comments are included in the report. What the service does well: Although both the units were quite different in their layout, all the service users appeared relaxed and ‘at home’ in both areas. Those who were able to express an opinion said that they liked living at the home. A new admissions procedure was in place and service users were able to undertake planned visits to the home prior to moving in. Information for service users and potential service users had been revised and updated. Service users took part in a range of group and individual activities at the home and in the community and they all attended day services. The care plans contained lots of useful information about the service users and, for the most part, there were clear action plans in place. The care plans had been regularly reviewed. Medication was safely stored and good records kept of its administration. The building was clean and generally well maintained and decorated. Service users had been able to personalise their bedrooms to their taste and said that they were happy with their rooms. Staffing levels meant that there was usually a ratio of one staff member to two service users. Staff interviewed had undertaken a range of statutory training and training related to the needs of the service users. They felt that they worked well as a team and that senior staff generally listened to their thoughts about the care and took any concerns seriously. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 6 Fire alarm testing records were of a good standard and the system had been serviced annually. Regular fire drills were held at the home and a good response noted in the records of these. What has improved since the last inspection? What they could do better: There was insufficient guidance and training for staff on how to intervene to prevent service users harming themselves or others. Although the staffing to service user ratios were high, there was a strong feeling among some staff that a recent reduction in staffing levels placed some vulnerable service users at risk. They also felt that it was more difficult to do activities outside of the home as they did not always feel that it was safe to leave some service users without two staff present. The manager felt that the decision to reduce the staff numbers had primarily taken into account clinical as well as financial considerations and that extra staffing hours would be possible for trips if necessary; however there needs to be clearer written risk assessments regarding the safety of all the service users. Some staff had not had statutory training at the required frequency. Staff interviewed were aware of the fire procedures and could describe what they needed to do but there was no record of when staff had last had training, except for their induction training. One staff member said that he had not had manual handling training in the previous 18 months. The home was in the process of developing its training programme and the manager said that statutory training had been affected by sickness levels in the previous 12 months. Some handwritten entries on the medication sheets had not been signed by the staff member and countersigned by a witness to say they were an accurate record of the prescription label. The home’s Statement of Purpose needs to include information about fees and extra costs. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 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. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a Statement of Purpose which accurately described the service provided, ensuring potential service users could decide if the home was appropriate for them. The needs of potential users were assessed to make sure that these could be met. Potential service users were able to visit the home for a number of times to see if they liked it prior to moving in. EVIDENCE: The home’s Statement of Purpose had been revised and updated. It included information about the nature of the service and for whom it was intended. There was other information about the activities provided, the routines at the home and how to make complaints or raise concerns about the home. Pictorial information was included for service users who do not read. It did not include details of the fees charged. No new service users had been admitted to the home since the previous inspection. The home has devised a detailed admission procedure to ensure that the service is right for both the potential service user and for the existing people at the home. There was a potential service user visiting the home for a meal on the second day of the inspection; staff had obtained assessments about the service user and were in the process of making the decisions about their admission. Staff said that emergency admissions are avoided wherever possible. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each of the service users had a care plan, ensuring that their needs were identified. Generally, there was clear information in place to show how staff should meet these needs. The home is in the process of developing further ways of ascertaining information about what service users want from the service, ensuring that it can be more tailored to their needs. Risk assessments were in place, however more detail was needed in some to ensure that all activities in which they are involved are reasonably safe for them and for others. EVIDENCE: Three service users’ care plans were checked in detail. They contained a range of information about their personal, social and health care needs. Action plans had been drawn up to give staff clear guidance on what they needed to do to meet the service users’ identified needs. These had been regularly reviewed to ensure that they were still relevant. Contact with other healthcare professionals had been documented and any treatments recorded. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 11 Risk assessments were in place in the plans; these had been updated and reviewed. One of the three service user’s plan checked identified that this person could sometimes be aggressive towards other service users. Incidents of aggression had been recorded and reported to the Commission For Social Care Inspection . The care plan identified some strategies for reducing these incidents and gave information for staff on what to do should these incidents occur. However, staff interviewed felt that there was insufficient guidance on what to do in the event of the service users displaying aggressive or physically violent behaviour. They said that they had been told to use ‘minimum force’ if they had to intervene to prevent service users harming other service users or themselves. There was no definition of what ‘minimum force’ meant and the staff said that there was no clear policy in place. They said that they had had to intervene and physically separate service users on occasions and there were incident records to show that on occasions staff had been hit by service users. Some training had been organised on dealing with challenging behaviour for the day following the inspection, however it is clear that more training and more detailed policies and procedures are needed for staff to reduce the risk of harm to themselves and to service users. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to take part in social and educational activities to ensure they lead stimulating lives. They use local facilities with the assistance of staff and are supported in keeping in contact with their friends and families, ensuring that important links are maintained. Staff were keen to promote the rights of the service users. Service users said that they enjoyed the food, that were given a choice of meals and encouraged to eat healthily. EVIDENCE: All the service users attend day services throughout the week, most people using the neighbouring social and educational centre. Alternatives are provide for service users with more challenging behaviours. Two of the service users said that they liked going there and they liked the activities that they did with the staff outside of the home. Most of the service users were unable to verbalise their opinions about the day care and the activities but there was a record of regular activities occurring outside of the home. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 13 Some staff felt that the recent reduction in staffing levels would affect their ability to be able to do activities outside the home as staff would not feel confident about leaving certain service users at the home without a minimum number of staff present. The manager felt that it was generally safe and that extra staffing hours could be provided if required to ensure that activities could take place, however this needs to be clearly recorded in a written risk assessment with regard to staffing. Two service users interviewed were able to say that they were helped to keep in contact with their friends and their families. One of these used an external advocacy service. The service users who were interviewed felt that staff treated them well and with kindness. Other service users seemed relaxed in the company of the staff and their non-verbal actions indicated that they felt comfortable interacting with them. Staff sat with service users at the dining tables and in the lounges and there was generally a relaxed atmosphere. Some of the service users who did not verbalise appeared happy to sit with the inspector and, with the accompaniment of staff members, to show them their bedrooms. Staff appeared to be able to understand the needs and the wishes of people who used non-verbal communication to express themselves. Staff interviewed were strong advocates of the service users’ rights and understood the need to promote and maintain their independence, dignity and safety. They spoke of allowing and encouraging service users to lead interesting and fulfilling lives. Routines appeared to be flexible and service users appeared to have choice over how they spent their time at the home, being able to get up and go to bed when they want. Mealtime was observed in one of the units. The service users appeared to be enjoying it and a potential service user who was visiting the home said that it was ‘very nice’. Another service user interviewed said that the food was ‘really good’ and that she ‘liked chips best’ but said that the home encouraged her to eat ‘good things’ as well. There was information in the care plans about service users’ dietary needs. Several of the service users were on weight-reducing diets. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The action plans indicate how personal, emotional and health care needs could be met in a sensitive way that took into account the wishes of the service users. The medication system was generally well managed. EVIDENCE: The care plans detailed what care the service users needed. The identified interventions included information about their personal preferences, such as whether they would prefer male or female carers, or whether they would prefer a bath or a shower. The plans took into account the social and emotional needs of service users and what actions the staff needed to take to promote and maintain their skills in these areas. There was a record of contacts with other healthcare professionals. A check was made of the medication in the home. The medication trolleys were secured to the wall by chains in secure areas. The contents of one of the trolleys was checked. Prescription labels on boxes and bottles were clearly labelled and there was no overstocking of medicines. All the medications checked were for identified individuals living at the home. The Medication Administration Record sheets were checked. There were no omissions in the recordings, any refusal or withholding of medication was documented. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 15 Information was clear. There was one hand written entry for medication received between the regular deliveries. This was clearly recorded but needed to be signed by the person writing the information on the MAR sheet. It also needed a second person to check and sign to show that the copy was an accurate copy of the information on the prescription label. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a written complaints procedure, which service users, their advocates or staff can use to raise concerns about any aspect of care at the home. The home has adult protection procedures in place to ensure that vulnerable service users are protected. EVIDENCE: Procedures were in place and made available to service users and their advocates to enable them to make complaints. There were copies of these in the home and in the Statement of Purpose. There had been no complaints to the Commission For Social Care Inspection about the service in the previous 12 months and the deputy manager said that there were no ongoing complaints. Adult protection procedures were in place and had been invoked by the home when necessary. As identified in the ‘Individual Needs and Choices’ section of this report, clearer guidance and training on what constitutes appropriate intervention for staff when trying to prevent service users from harming themselves or others. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and free of unpleasant odours, providing a pleasant environment for the service users. They could personalise their rooms and have comfortable private space. The home needs to review the suitability of one piece of moving and handling equipment to ensure it meets the needs of the service users. EVIDENCE: The service is divided into two separate living sections. Both were pleasantly decorated and comfortably furnished. Due to the design of the building, one part of the home has a more ‘domestic’ appearance, with a smaller lounge and kitchen. All areas were clean and tidy with no trace of unpleasant odours. There is a large amount of communal space since the home has reduced the number of service users and the current resident group is able to access some of this, enabling them to have extra areas for privacy or group activities. The carpets in part of the home had been replaced but some of the windows in service users’ rooms still need to be replaced. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 18 Service users’ bedrooms were all decorated and furnished differently and had been personalised in line with their personal preferences. Four bedrooms were seen with the permission of the service users, two said that they liked their rooms and the others, who do not always express themselves verbally, were clearly very proud of their rooms and pointed out important details or photos in their rooms. Staff said that a chair hoist fitted in one bathroom did not work very well as the service users who needed it were now too large to fit comfortably in the bath. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff had a range of qualifications and had received training to help them understand and meet the service users’ needs, however not all required training had been provided at the required frequency. Staff to service ratios are high but risk assessments are needed to demonstrate that they are sufficient to meet the needs of the service users. EVIDENCE: Seven staff members were spoken with or interviewed during the days of the inspection. They had undertaken statutory training – such as moving and handling, food hygiene, health and safety and fire training. However, two people interviewed, although they could describe the fire procedures in detail, had not undertaken formal training in the previous 12 months. Staff had taken part in fire drills but no record was kept of when staff were last assessed as being competent in this area, except for the induction period. One staff member said that he had not had manual handling training after being at the home for over 18 months. Staff were aware of the needs of the service users, they had experience of working with this client group and some staff interviewed had achieved NVQ Levels II or III. They were sensitive to service users’ dignity, privacy and rights. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 20 Others said that the home was generally good at providing training but that in the previous 12 months it had been difficult to send staff on training, due to staff sickness. This was confirmed by the manager in the telephone interview. The deputy manager said that the home is in the process of developing an overview of the training required by staff. Some staff interviewed felt that it would be useful to have Makaton training to enhance communication with some of the service users. Staff received regular supervision where they could discuss training needs and work issues. The staff rotas showed that there were usually 5 staff on the morning and 5 staff on in the afternoon. These numbers included at least one senior in charge of the shift; however, the manager was also included in these numbers and did not always work as a ‘supernumerary’ staff member. Whilst it is acknowledged that if she were to work 9-5, Monday to Friday, she would have very little contact with service users, she should not generally be counted in the care staff numbers. The ratios at the time of the inspection worked out at 1 staff member to 2 service users. Staff said that the numbers on each day had recently been reduced by 1 since a service user, felt to be at potential risk from another service user, had moved to other accommodation. Staff were concerned that there was still potentially a risk to other service users and that the basic problem had not been resolved. It was clear from discussions with the senior staff and the manager that work is underway to ensure that this issue is addressed but the manager needs to complete a written risk assessment which takes into account the needs of the six service users in this part of the home. This needs to include how service users will be supervised over a 24 hour period in this part of the home, how many staff are needed on each shift and whether this impacts on staff being able to take service users out of the home if they wish to go on trips. Staff recruitment records could not be checked on the day of the inspection as these are stored at the organisation’s headquarters. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced and qualified in working with this client group; staff generally felt that senior staff were approachable and they could raise concerns on behalf of the service users and these would be treated seriously. It was clear that staff were keen to promote service users’ rights and interests. Staff training needs to be kept up to date to ensure that the everyday risks to service users are minimised. The monthly visits on behalf of the organisation need to be more detailed to show that the council is aware of issues affecting the home. EVIDENCE: Staff interviewed were generally positive about the managers at the home. 2 of the 7 staff members spoken with felt that managers had on occasion not respected their confidentiality when they had raised an issue privately. However, they felt that the managers were approachable and would deal with any care concerns raised in a responsive and professional way. Staff felt that they worked well as a team. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 22 It was clear from discussions with staff that they were knowledgeable about the service users’ needs and keen to promote their rights. They also felt that there was, on the whole, a relaxed atmosphere at the home. During the inspection of the premises, no obvious hazards were noted. There had been regular testing of the fire alarm system and regular drills. In the pre inspection statement, the deputy manager had stated that most of the major systems in the home had been regularly checked and serviced, including the fire alarm system, the lifts and the central heating. The pre inspection statement did not include dates for when the electrical wiring certificate was issued and when the emergency call systems were checked. As noted in the ‘Staffing’ section of this report, some staff needed to have some of their mandatory training updated. Two recent monthly visit (Regulation 26) reports were checked. These did not contain sufficient information to show that the Registered Owners were aware of all the current issues at the home, which is the purpose of the Regulation 26 report. For example there was no discussion of any accidents or incidents or issues identified in this report or details of discussions with the service users or the managers. The deputy manager felt that the line managers for the home were aware of issues at the home and had discussed them with the senior team. However, according to the reports, there did not seem to be any particular problems at the service. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 X X X 2 2 Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 5 Requirement The Service User Guide must include details of fees charged by the home. Risk assessments must be completed for each service user with clear guidance for staff on how to intervene to reduce the risk of service users harming themselves or others. These must include a clear description of what constitutes ‘minimum force’ as outlined in the home’s guidance. 3. YA20 13 (2) Handwritten entries on the MAR sheets must be signed by the person making the entry and by a witness to check the details are accurate. Staff must receive further training on the management of challenging behaviour. The windows in the service users’ bedrooms as identified, must be repaired or replaced. (Previous timescale of 24/02/06) 30/10/06 Timescale for action 30/12/06 2. YA9 13 (4) (b) and (7) 30/11/06 4. 5. YA23 YA24 13 (6) 12, 23 30/11/06 30/11/06 Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 25 6. YA29 23 (2) (n) 7. YA32 12, 18 The home must ensure that there is suitable equipment in place to assist service users to have a bath. A staff training and development programme must be developed in conjunction with staff, and implemented. The manager must provide a written risk assessment for staff, which includes: • the needs of the six service users in the main part of the home and how they will be supervised over a 24 hour period in this part of the home how many staff are needed on each shift and whether this impacts on service users being able to go on trips. 30/12/06 30/10/06 8. YA33 18 (a) 30/11/06 • 9. 10. YA35 YA35 18 (c) 18 (c) All staff must have updated moving and handling training. Records must be kept of when staff have updated fire safety training and this must take place regularly. An effective quality assurance and monitoring tool must be developed and must take into account the views of service users and their representatives, including advocates as appropriate. The monthly (Regulation 26) visits need to include more detail to demonstrate that the Responsible Individual is aware of any concerns about service users or staffing issues at the DS0000032073.V306822.R01.S.doc 30/11/06 30/10/06 11. YA39 12, 24 30/11/06 12. YA39 26 (4) 30/10/06 Millstream View Version 5.2 Page 26 home. 13. YA42 13 The home must provide evidence that the fixed electrical circuits have been checked within the previous 5 years. 30/11/06 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 Refer to Standard YA32 Good Practice Recommendations The manager should assess whether staff need to have MAKATON or similar training to enhance communication between service users and staff. Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 28 Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Millstream View DS0000032073.V306822.R01.S.doc Version 5.2 Page 29 - 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. 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