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Inspection on 17/01/06 for Millview Nursing Home

Also see our care home review for Millview Nursing Home for more information

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continues to provide appropriate care and accommodation for a wide range of service users. Of the 6 units at the home 2 specialise in EMI nursing care, 2 in general nursing care, and 2 in personal or `residential` care. Residents and their relatives spoke very positively in respect of the care and accommodation provided at the home.

What has improved since the last inspection?

The wide ranging staff training programme has been extended to place more emphasis on the individual needs of staff and the specialised needs of the residents on the various units of the home. Clearly this has a very positive impact on improving the quality of care residents can expect from the home.

What the care home could do better:

Whilst the environment is generally maintained to a very high standard a small number of issues were identified as being in need of attention and are detailed in the body of this report. Also whilst the general standard of the maintenance of residents care and medication administration records 2 issues were identified as being in need of remedying and are detailed in the body of this report.

CARE HOMES FOR OLDER PEOPLE Millview Nursing Home Bridgeman Street Bolton Lancashire BL3 6SA Lead Inspector Mike Murphy Unannounced Inspection 17th January 2006 09:30 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 Millview Nursing Home DS0000005689.V271129.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. Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Millview Nursing Home Address Bridgeman Street Bolton Lancashire BL3 6SA 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) 01204 391211 01204 363246 www.bupa.com BUPA Care Homes (CFHCare) Limited Kathryn Bebbington Care Home 180 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (120), of places Physical disability (10) Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 120 OP, up to 60 DE(E) and up to 10 PD The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 25t of August 2005 Date of last inspection Brief Description of the Service: Millview is a Care Home providing nursing and personal care for mainly older people. It is situated in Great Lever about half a mile from Bolton town centre. It is close to main bus routes, the local railway station and the motorway network. The home is purpose-built, single storey and comprises of six separate houses, each with 30 single bedrooms. There is plenty of car parking to the front of the home and there are garden areas around each unit for residents to sit out in. All the houses allow level access for wheelchair users and people who have problems climbing steps. Each house has a large lounge, a designated smoking area and a dining room. The toilets and bathrooms have aids to assist any resident with a disability or mobility problem. The home is registered to provide care for up to 180 residents with a variety of nursing and residential needs. These include general nursing and physical disabilities, palliative care and dementia care. Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of 2 statutory inspections conducted at Millview during the inspection year 2005 – 2006. The inspection was conducted by two CSCI inspectors. For a complete overview of the home the reports produced following both inspections should be read. What the service does well: What has improved since the last inspection? What they could do better: Whilst the environment is generally maintained to a very high standard a small number of issues were identified as being in need of attention and are detailed in the body of this report. Also whilst the general standard of the maintenance of residents care and medication administration records 2 issues were identified as being in need of remedying and are detailed in the body of this report. Millview Nursing Home DS0000005689.V271129.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. Millview Nursing Home DS0000005689.V271129.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 Millview Nursing Home DS0000005689.V271129.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): 3,4,5. Standard 6 does not apply to this service. The home ensures that all prospective residents are appropriately assessed prior to admission to the home. This is essential to ensure that the home is able to meet the health and social care needs of prospective residents. Standards 1 and 2 were not inspected on this occasion. EVIDENCE: The residential, general nursing and EMI units all adopt a pre admission assessment process that is designed to assess the particular specialised needs of prospective residents who require the services of a particular unit at the home. Senior staff are responsible for the assessment of prospective residents to their particular unit. In the case of the general nursing unit qualified general nurses conduct the assessments, in the case of the EMI units the clinical care manager who is a qualified psychiatric nurse conducts them, and in the case of the residential units the unit care managers are responsible. The pre admission assessment conducted by the home supplement those conducted by other health and social care professionals prior to the admission of resident’s to the home. Residents are encouraged to visit the home prior to admission where Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 9 possible, all admissions are for a trial period and all placements are formally reviewed – usually about 6 weeks after admission. Discussion with a large number of residents and their relatives throughout the home indicated that they were generally very satisfied that the home was meeting the needs of residents. Where concerns or issues were raised in this area both residents and their relatives who were spoken to reported that when such concerns or issues were raised with senior staff or the home manager they were promptly responded to. Comments made to the inspectors throughout the home included ‘ a nurse came to see me in hospital before I came to the home to make sure they could look after me’, ‘before I came here I was allowed to come for a couple of times to make sure I liked it’, ‘we had a review with the social worker and staff a few weeks after mum was admitted to see if things were ok, which was good as mum’s opinion was what mattered,’ Its good here because my mother-in-law originally was on a residential unit but then needed to go on a general nursing unit as her condition deteriorated and was able to do so without moving to another home as that service is also provided at Millview’, ‘there were a few problems at first but the staff in charge eventually sorted them out and things are fine now’. Millview Nursing Home DS0000005689.V271129.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): 7,8,9,10,11. The health, personal and social care needs of residents, throughout the home, were being addressed appropriately. A couple of issued were identified in respect of record keeping are identified below. EVIDENCE: Martin and Rutland units (EMI provision) The management of residents health and personal and social care needs on both these units is provided by the clinical care manager (who is a qualified psychiatric nurse) and his team of qualified nurses. Both units provide nursing care for elderly male and female residents who have been medically diagnosed as suffering from dementia. This can include the management of occasional significantly challenging behaviour – this is particularly the case on Rutland unit where the residents tend to be in the earlier stages of their condition compared to those residents on Martin unit. Both units provide a safe and secure environment that seek to protect the well being of residents. 8 resident’s care records were inspected on this occasion – 4 on each unit. Care plans inspected were detailed, appropriate to the specialist needs of this group of residents, were initially based on a detailed and appropriate pre admission assessment, and were formally evaluated at least monthly. Care plans Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 11 reflected the health, personal and social care needs of residents were being met appropriately. Risk assessments, that seek to protect resident’s health and safety were also recorded in respect of residents skin integrity, mobility, and nutrition (including weight monitoring) and other relevant areas e.g. where the use of bed rails is deemed to be appropriate and were also evaluated at least monthly. Where risk assessments identify a problem e.g. a resident was experiencing weight loss then appropriate action was taken to deal with that problem – including referral of the resident to other health care professionals such as their and the dietician. All residents were registered with a local GP and discussions with relatives and staff as well as inspection of care records indicated that residents were accessing appropriate health care services according to need including the services of opticians, chiropodists and dentists. Also residents were supported in accessing specialist medical services such as those provided by psychiatrists and community psychiatric nurses. Clearly the provisions described above seek to ensure that residents receive the care and treatment they require to meet their individual needs, including their mental health needs which is of particular importance on Martin and Rutland units. The arrangements for the management of resident’s medicines were found to be secure and appropriately documented. The new system for disposing of unwanted medicines appears to be working well. However it was observed that not all handwritten transcriptions on the medicine administration records were signed by 2 people – it is recommended that they are checked and signed by 2 staff. The staff on Martin and Rutland units, assisted and cared for residents sensitively and appropriately on the day of inspection. Residents appeared well cared for and were appropriately groomed and dressed. Dove and Victoria units Both these units provide care for elderly and up to 10 younger adult residents who require general nursing care. The management of residents health, personal and social care on these units is managed by qualified nurses who are led by a senior nursing sister on each unit. 6 resident’s care records were inspected on this occasion – 3 from each unit. Both units care for residents who have in some cases very complex physical nursing needs. Care plans inspected were detailed and specific to identified general nursing needs and were initially based on the pre admission assessment. Care plans were formally evaluated at least monthly. It was clear to the inspector that the quality of the care plans indicated that care was being planned appropriately and sought to address the needs (including those specific to being cared for sensitively and properly when dying) of residents and the support of their supporters on both Dove and Victoria units. Risk assessments, that seek to protect resident’s health and safety were in the main recorded in respect of residents skin integrity, mobility, and nutrition (including weight monitoring) and other relevant areas e.g. where the use of bed rails is deemed to be appropriate and were also in the main evaluated at least monthly. However it was noted that the recording of nutritional risk assessments on Dove unit was erratic. This needs to be rectified and was discussed with the nurse in charge of the unit Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 12 during the inspection. All residents were registered with a local GP and discussions with relatives and staff as well as inspection of care records indicated that residents were accessing appropriate health care services according to need including the services of opticians, chiropodists and dentists. Also residents were supported in accessing specialist medical services such as those provided by medical specialists and nursing specialists such as the tissue viability nurse. Clearly the provisions described above seek to ensure that residents receive the care and treatment they require to meet their individual needs, including their complex general nursing needs which is of particular importance on Dove and Victoria units. The arrangements for the management of resident’s medicines were found to be secure and appropriately documented. The new system for disposing of unwanted medicines appears to be working well. However it was observed that not all handwritten transcriptions on the medicine administration records were signed by 2 people – it is recommended that they are checked and signed by 2 staff. The staff on Dove and Victoria units, assisted and cared for residents sensitively and appropriately on the day of inspection. Residents appeared well cared for and were appropriately groomed and dressed. Albion and Atlas units Both these units provide elderly residents with personal care or ‘residential’ care and who do not require a nursing care placement. The care records of six residents were inspected over the two units. These records contained care plans that addressed the assessed needs of the residents. They were detailed, regularly reviewed on a monthly basis and consistent in the information that they contained. Appropriate assessments in relation to risk, pressure care, nutrition and moving and handling detailed how staff were to deliver care and support residents. Other appropriate assessments such as wheelchair and bed side rails assessments were contained within other individual plans where they were required. On Albion unit there was a service user who required pressure care management. The notes were available in the visiting professionals file of the treatment they had received, but was not in the individuals personal care file. Communication needs to be improved and records kept in the individuals care plan so that care staff are aware of any changes that have taken place in the management of the residents pressure sores. Medication was appropriately managed, stored and disposed of. The responsibility of the administration of medication was the responsibility of the unit manager and senior care staff. All had received appropriate training. One resident who was responsible for administering his own medication had an appropriate risk assessment in his records and lockable storage facilities in his bedroom in line with the homes policy and procedure Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents at the home are supported in addressing and meeting their social needs though a diverse activities and outings programme, and being enabled to retain contact with their relatives and the local community. They are also provided with a balanced and varied diet. EVIDENCE: 3 activity co-ordinators are employed at the home providing a service to all the 6 units at the home. This provision was well planned, appropriate to residents needs/interests/abilities, and accessible to all residents. A programme of activities was prominently displayed on all units of the home. This programme was very varied and included games, entertainment, arts/crafts, and outings. On the day of inspection on the residential units activities on offer included a Music Quiz, Therapeutic Care, Prize Bingo, a trip to the Olympus ‘Chippy’. One resident spoken with said that she had just booked a trip out in a couple of weeks to have lunch out at a restaurant in Bolton. Community links continue to be an important aspect of activities engaged in by Residents, for example with schools in the area and other community groups who are involved in a variety of ongoing projects with the home. Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 14 Discussions with residents and their relatives throughout the home revealed that there are no unreasonable restrictions on visiting residents at the home. Residents may be visited in the privacy of their own bedroom or in quieter lounge areas. Relatives stated that they were made to feel welcome when they visited and were encouraged to attend social events held at the home. Residents also reported that they were actively encouraged to retain as much independence as possible and where possible make decisions for themselves. Certainly the daily routines within the units of the home were as flexible as possible within a communal living setting. Where residents are unable (due to their medical problems) to make individual choices staff strive to establish from relatives what residents likes/dislikes and pattern of life was previously so that their wishes can be respected as much as possible. Resident’s meals are prepared on site in an appropriately staffed and equipped kitchen. Menus are varied, nutritionally balanced, provide a reasonable choice and are changed seasonally. The views of residents throughout the home were sought in respect of the meals provided. The general consensus was that meals were of a good standard and that if there was a problem or another choice was desired then chef and his team would respond to such issues positively and quickly. The home manager and chef regularly monitor residents views on food provision and take such views into account in their assessments of quality assurance in the home. One resident commented ‘‘we meet with the chef at residents meetings and tell him what food we like to eat. He cooks a lot of fresh food’’. Lunch was observed on two of the units during the inspection. This meal was a hot, substantial and well presented meal. Resident’s nutritional needs were taken into account and special/medical diets were provided if required. Staff served and assisted resident’s sensitively and appropriately with their meals. Each unit has an appropriate dining area that provides an appropriate environment for residents to take their meals. Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 15 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): 16,17,18. Appropriate measures have been taken in the home as a whole to provide an environment where residents and their supporters feel comfortable with making a complaint if necessary, and to prevent residents becoming victims of abuse. These are important areas that are crucial to the protection of resident’s in a care home, many of whom are extremely vulnerable. EVIDENCE: Discussion with resident’s relatives indicated that there was a general awareness and information provided that enabled people to make a complaint if they desired. A detailed and accessible complaints procedure was in place and prominently displayed in the home, which included details of how complainants could contact the CSCI if desired. Inspection of policies and procedures operated at the home and discussion with staff throughout the home indicated that staff were aware of the importance of protecting resident’s from potential abuse and how to communicate any concerns they may have in this area. Staff are enabled to attend protection of vulnerable people training that is organised and provided by Bolton Social services. Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 16 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): 19,24,26. The home is structurally well maintained and each unit provides a suitable environment for the group of residents who live there. All resident’s private accommodation throughout the home is provided in single bedrooms. All units are single story buildings. Standards 20, 21,22,23 and 25 were not inspected on this occasion as they were inspected satisfactorily at the last inspection in August 2005. EVIDENCE: Martin and Rutland units Both units provide accommodation to residents who require EMI nursing care. These units were found to provide an environment that seeks to provide a safe and secure home for residents whilst maximising their ability to move about freely. Martin and Rutland units benefit from large well maintained secure gardens that are accessible to residents in clement weather. Generally the décor on both units was satisfactory – apart from the corridors on Rutland that were seen to be in need of redecoration with some walls having been subject to much wear and tear. Both units were very clean and any malodours were Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 17 well managed. 4 resident’s bedrooms (in each unit) were inspected at random. These rooms were clean, warm, appropriately furnished/equipped, and some were very personalised. Dove and Victoria units Both units provide accommodation for residents who require general nursing care. These units provided an appropriate environment for such care to be delivered. All areas of the units designated for resident’s use were accessible to them. Dove unit was decorated to a satisfactory standard. The inspector was informed that Victoria is schedule for redecoration/refurbishment in the near future. Both units were very clean and free of malodour. 3 resident’s bedrooms (in each unit) were inspected at random. These rooms were clean, warm, appropriately furnished/equipped and adapted, and personalised. Albion and Atlas units Both units provide accommodation for residents who require persona or ‘residential’ care. These units provide an appropriate environment for such care to be delivered. All areas of the units designated for resident’s use were accessible to them. The bedrooms of four residents were inspected and these were highly personalised with their own possessions. They were all clean and tidy. The house keeping staff interacted positively with the residents and were seen to respect their privacy and dignity whilst undertaking their duties. The communal areas were appropriately and adequately furnished and a new smoking rooms have been built within the main communal areas. The carpets in the corridors on both units and in the office on Atlas unit whilst clean are quite marked in places require either attention as they detract from otherwise very well maintained environments. Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 18 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. Staffing arrangements throughout the home were appropriately managed and suitable to meet the assessed care needs of residents. EVIDENCE: Martin and Rutland units Inspection of staffing arrangements for Martin and Rutland units indicated that staffing provision on the unit was adequate and appropriate. The clinical care manager responsible for the 2 EMI units at the home, who is a qualified psychiatric nurse, was of the view that EMI resident’s needs were being appropriately met by staff. Dove and Victoria units Inspection of staffing arrangements for Dove and Victoria units indicated that staffing provision on the unit was adequate and appropriate. The qualified nursing staff responsible for the 2 general nursing units at the home were of the view that the general nursing resident’s needs were being appropriately met by staff. Albion and Atlas units Inspection of staffing rotas indicated that staffing provision for the units complied with the current minimum requirements that apply to care homes for older people. Discussion with senior staff on duty at the home indicated that Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 19 they were of the view that staffing levels were appropriate to meet the dependency levels of resident’s who require residential but not nursing care. Inspection of 3 recently employed staff personnel files revealed that these contained an application form (including health declaration), 2 written references, a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity and evidence of induction training. Inspection of training records demonstrated that staff at the home were provided with appropriate training in care and related issues – including NVQ training (64.5 of the care staff currently hold an NVQ2 qualification or above and this training is offered to all care staff employed at the home). Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 20 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): 31,32,33,34,35,36,37,38. The home continues to be managed very effectively and efficiently by the registered manager. The management structure is appropriate to ensure the 6 units of the home are appropriately managed on a day to day basis. EVIDENCE: The registered home manager is a very experienced registered nurse and has completed an NVQ4 in management. Discussions with residents, their relatives, and staff employed at the home revealed that the manager has adopted a management approach that is accessible, supportive, positive and inclusive. The manager is supported in her role by a clinical care manager and senior nursing sisters and senior care staff at unit level. Millview Nursing Home DS0000005689.V271129.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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X 3 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 3 3 3 3 3 3 3 Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 22 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 OP19 Regulation 23 Requirement Timescale for action 31/03/06 2 3 OP20 OP8 16 12(1)(a) That a written action plan is submitted to the CSCI detailing the proposed schedule – including time frames - for the redecoration of the corridors on Martin unit and the proposed refurbishment of Victoria unit That the corridor carpets on the 31/03/06 2 residential units are deep cleaned or replaced as necessary That Nutritional risk assessments 31/03/06 must be undertaken on all residents 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 9 Good Practice Recommendations That all hand written transcriptions to residents medication administration records are witnessed and signed by 2 members of staff Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 23 Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Millview Nursing Home DS0000005689.V271129.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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