Inspection on 19/12/06 for Millview

This inspection was carried out on 19th December 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Millview 16/12/08

Millview 12/09/05

Millview 03/05/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Millview Millview 38 The Street Charlwood Horley Surrey RH6 0DF Lead Inspector Kenneth Dunn 19 th Unannounced Inspection December 2006 10:00 Millview DS0000059973.V316862.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 Millview DS0000059973.V316862.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. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millview Address 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) Millview 38 The Street Charlwood Horley Surrey RH6 0DF 01737 765800 Prospect Housing and Support Services Mrs Sarah Katherine DuMagnee Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 32 65 years. 3rd May 2005 Date of last inspection Brief Description of the Service: Millview is a large detached house situated in the village of Charlwood, with a large secluded and landscaped garden to the rear of the property. Car parking facilities are available to the side and front of the property. The home consists of five single bedrooms, which are decorated and furnished according to the service users’ choice. Ample bathroom and toileting facilities are situated on both floors. Communal accommodation is on the ground floor and consists of a wellequipped kitchen, dining room and lounge. A small pleasantly furnished conservatory is located to the side of the building with access from the lounge. The home owns a vehicle, which is used for service users to access community facilities and to participate in a wide range of outdoor activities. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over four hours. Mr. K Dunn Regulation Inspector carried out the visit and Mr. R Doogra acting manager represented the establishment. The registered manager is currently on a temporary seconded to another post within the organisation. A number of the service users have non-verbal communication therefore their direct views about their care could not be obtained. Observations of interactions and service user responses have been recorded in this report. A tour of the premises took place. Staff training records, staff files and policies and procedures were sampled. The inspector spoke to three members of staff. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: There is a need to carry out some remedial decoration throughout the home. The heating system must be fully functioning to meet the needs of the service users. The acting manager must ensure that the fly screen is returned to the kitchen window. Millview DS0000059973.V316862.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 7 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 Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide provide the current service users and prospective service users with the details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangements for assessing needs are strong ensuring service users need are assessed and identified prior to admission to the home. EVIDENCE: The statement of purpose and Service Users guide were reviewed by the inspector. These documents should be updated to ensure that all corrections are actioned to remove all pencil and pen corrections. The acting manager should always indicate that the documents are reviewed they should be signed and dated. There have been no admissions in the home since the previous site visit and currently there was one vacancy. The admissions procedures is well designed and ensure that any future potential service users will be assessed by a multi disciplinary team and allowed to trial run the home. Evidence was sampled for two individuals, which confirmed that assessments were, completed prior to admission to the home. Case tracking activity confirmed good practice pre-admission assessment procedures and admission procedures were followed. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 9 Millview DS0000059973.V316862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals. Service users are supported to make decisions about their lives with assistance. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The acting manager stated that the home offers the Service users flexible routines and choices. The structure of the service users daily lives were influenced and planned around their individual activities programmes. The inspector was informed that the activities were not “set in stone” and could be changed if and when the service user wanted. All service users have care plans, which included guidance for personal care, communication, safety, health and social skills. The inspector was informed that it is the responsibility of the key workers to conduct reviews and to keep the plans up to date. A review of the care plans clearly demonstrated that and all of the service users individual care plans have been reviewed regularly. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 11 Individual plans were person centred in their approach detailed and structured with clear objectives and goals. Each plan contained details of the individuals of strengths, needs, likes and dislikes. The acting manager informed the inspector that the service users were unable to participate in this process; observations confirmed that statement to be true all service users currently living at Millview have learning disabilities and limited speech. All service users has Health Action plans in place, containing impute from other health professionals giving clear guidance on the care needs of each individual. Because of the limited speech of the service users the staff base their decisions and reviews upon pre-existing knowledge of the service user. Observed assessments, risk assessments and care plans are signed on behalf of the service users. Risk assessments sampled are kept under review and included road safety and aggression. Millview DS0000059973.V316862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service uses are supported to take part in the local community. The rights and responsibilities of service users is respected. The home is able to demonstrate that service users are provided with a wellbalanced and nutritious diet. EVIDENCE: All service users have very active social lives and there was evidence of them going Buggy riding, swimming, Line Dancing, music, Sensory Room, going to the pub and aromatherapy. In addition the service has access to the Ellen Terry Centre in Reigate for their primary leisure facilities. Evidence was seen of the service users attending the theatre and going on holiday they have been to the Isle of Wight for a week and Centre Parks this year. In addition there is good evidence of the many and varied outing the Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 13 home has enjoyed over the last 12 months. On the day of the inspection the service had arranged to go to a local pub for their Christmas Meal. The service users benefit from the home having a relatively stable staff team who can use past knowledge and the ability to observe the reaction of he service users to see if they are enjoying an activity. The acting manager stated that it is a role of the staffs to assists the service users to maintain contact with any known relatives; the home had recently posted Christmas cards to relatives and friends of the service users. Millview DS0000059973.V316862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users physical and health needs are met. Service users are protected by the homes medication administration procedures. EVIDENCE: The personal and health care needs of service users were identified in their individual plans, which included the likes and dislikes of service users and their preferences. The individual files of two service users contained all relevant information required to allow the staff to offer appropriate and effective support and care. The files contained sufficient details of the service users in case of emergencies. Staff were observed to respect services users privacy when carrying out personal care by ensuring doors were shut. The homes medication administration systems were examined and records were adequately maintained. A list is maintained of staff authorised to administer medication and photographs of individuals were available with their medication card. All full time staff have received training in medication administration. Last pharmacy inspection 22nd of Aug 2006. Checks are undertaken on regulation 26 visits by the provider. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 15 Millview DS0000059973.V316862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. The local safeguarding adult procedure will ensure that service users rights and best interests will be fully safeguarded. EVIDENCE: The home has an accessible complaints procedure, which is in picture format and was seen on display in the home. Since the previous visit no complaints have been received. The organisation has a safeguarding adult and whistle blowing procedure and the local authority safeguarding adult procedures were available. Staff training records indicates that staff have been attending safeguarding adult training, which was confirmed by two members of staff spoken to. Millview DS0000059973.V316862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are several minor areas of improvement needed to ensure service users live in a well maintained, comfortable, homely and safe environment. However the home is clean and hygienic ensuring that service users have a pleasant home to live in. EVIDENCE: Exterior of the home was tidy with parking facilities to the front and at one side of the building and can cope with average use, on the day of the inspection this was very busy. Home very clean and significant efforts have been made by staff to create a homely, domestic atmosphere with quality, modern furniture and furnishings. The home was also fully decorated for Christmas. All bedrooms seen were personalised to reflect the individual service users tastes and interests. There is a maintenance/decorating programme in place however the bathroom on the ground floor was very cold, upon further investigating the radiator had Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 18 a faulty valve and would not heat up. In areas throughout the house overall decoration was requiring some basic remedial work to improve the environment. The inspector reviewed a recent Health and Safety audit completed by the registered manager before she started her secondment. This audit covered all areas of the home and contained detailed evaluations of areas within the home. A sample of health and safety certificates was seen and these were all current and in good order. Gas certificate, Fire Risk Assessment recently reviewed and Staff fire training took place recently fire evacuation procedures undertaken. It is essential that the fly screen over the kitchen window be replaced as soon as possible. Millview DS0000059973.V316862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the homes recruitment policy and practices and their needs are met by appropriately trained staff. EVIDENCE: During this visit there were three staff plus the manager on duty. The service has currently over 50 of its staff qualified to NVQ level 2 in care, and a further 2 working towards final completion. Three staff personal files were sampled all found to be well maintained and contained the required information. The training records and certificates were sampled for three members of staff, which concluded that staff have received up to date mandatory training in safeguarding adults, fire training, food hygiene and moving and handling. It was clear that that training completed actively supports the needs of service users which includes, health action planning, communication skills, person centred planning, communication skills, key workers roles, person centred and health action planning, The inspector was informed that staff supervision was carried out on a regular bases. The record s reviewed indicated that on average all staff receive supervision at least once a month. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 20 Millview DS0000059973.V316862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 40 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users benefit from a home, which is well run, and is designed to work in the best interests of the residents. The health safety and welfare of service uses is protected. EVIDENCE: The registered manager has been temporarily seconded to another post within the organisation, in her absence the home is run on a day-to-day bases by the deputy manager. The inspector was informed that the organisation is committed to ensuring that this temporary situation will not impact on the service users. In an effort to minimise possible problems the acting manager is supported by the Head of Learning Disabilities who informed the inspector that she is available for the acting manager at all times.. Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 22 The company has updated and reviewed their policies and procedures. The acting manager stated that they discuss any new policies and procedures at staff meetings to ensure that the staff understands the changes. Certificate of registration and employers liability certificate were displayed. (The insurance policy expiry 09/07) The responsible individual carries out monthly quality visits with a copy supplied to the Commission for Social Care Inspection. The regulation 26 visits audits have been incorporated within this report. Millview DS0000059973.V316862.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 3 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 x Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4, 5 & 6 Schedules 1, 4.1 & 4.2 Requirement All reviewed documents must be finalised and have there review or introduction date clearly marked. In addition the statement of purpose must reflect the current management arrangements. The manager must review the internal decoration of the home, and develop a timetable for any works to be carried out. The fly screen that should over the kitchen window must be replaced. Timescale for action 28/02/07 2 YA24 16(1), 23(1&2) 28/02/07 3 YA24 16(1), 23(1&2) 28/02/07 4 YA24 16(1), 23(1&2) The manager must ensure that the heating system is fully functioning and can meet the needs of the home. 28/02/07 Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 25 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 Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Millview DS0000059973.V316862.R01.S.doc Version 5.2 Page 27 - 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!