Inspection on 25/01/06 for Millwater

This inspection was carried out on 25th January 2006.

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

The inspector 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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Millwater 03/03/10

Millwater 03/02/10

Millwater 01/12/09

Millwater 14/08/08

Millwater 23/08/07

Millwater 07/03/07

Millwater 08/07/05

Millwater 05/01/05

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

CARE HOME ADULTS 18-65 Millwater 164-168 Waterloo Road Hay Mills Yardley Birmingham B25 8LD Lead Inspector Sean Devine Unannounced Inspection 25th January 2006 10:40 Millwater DS0000063161.V280302.R01.S.doc Version 5.1 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 Millwater DS0000063161.V280302.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 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. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Millwater Address 164-168 Waterloo Road Hay Mills Yardley Birmingham B25 8LD 0121 706 3707 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) West Regent Ltd Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to accommodate 18 people who are in need of nursing care for reasons of mental health problems. (18 MD) In addition to the care manager and ancillary staff, minimum staffing levels are maintained to enable one first line nurse and three care assistants to be on duty during the waking day, 9am to 9pm. That minimum night waking staff levels of one first line and two care assistants are on duty between 9pm and 9am. That a registered manager is recruited and in post by 30 November 2005. That the service is transferred from Millwater Care Home to The Royd Nursing Home by January 2006. 8th July 2005 3. 4. 5. Date of last inspection Brief Description of the Service: Millwater Nursing Home has been registered to provide a temporary service for the residents of The Royd Nursing Home. Millwater will provide rehabilitative nursing care for 17 younger adults with mental health needs whilst The Royd is redeveloped and refurbished. The residents accommodation is single rooms with en-suite facilities, there is a large communal lounge and a small lounge/quiet area designated as the smoking area for service users. Dining facilities are available in two areas. The grounds are fully enclosed with access from inside the building only. There is a small area outside the main entrance for off road parking. The home is situated close to major bus routes in and out of Birmingham City Centre, local shops and amenities are within walking distance and the Swan Shopping Centre is approximately one mile away. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector conducted the inspection visit. It was conducted on an unannounced basis. At this visit records pertaining to care, health and safety and service delivery were sampled including two residents care plans. The inspector was able to meet with two residents, staff and the acting manager. It is recommended that the last inspection report dated the 8th July 2005 is considered in conjunction with this report. The inspector and a regulation manager have undertaken a visit to The Royd on the 19th January 2006. The building work and refurbishment is now completed and following delivery of some fittings and completion of minor building work the service will be able to return from Millwater to The Royd. The area manager informed the inspector that the timescale for this is towards the end of March 2006. The regional manager has informed the commission that it is the organisations intention on returning to The Royd to provide residential care and not nursing care. At present the care needs of residents are being reassessed by social workers to determine their care needs. What the service does well: The home ensures that residents are able to access all required community healthcare services and will provide extra support where needed, such as escorting residents to appointments. One resident commented that he is able to make his own arrangements to see his GP when needed. Recruitment of new staff is only completed when all required check have been undertaken, such as criminal records bureau, protection of vulnerable adults and professional references. Staff training is often undertaken for all roles, a recent focus has been upon safe working practices such as fire safety however support workers are also trained to support residents with mental illness and challenging behaviours. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: 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. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 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 Millwater DS0000063161.V280302.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Residents do have their needs prior to and following admission assessed, however these assessments are not subject to review or consultation with residents. Thus changing needs may not be identified and adequate care plans developed. EVIDENCE: Residents’ files include a very detailed assessment of need, including risk assessments to determine what measures can be taken to reduce level of risk. The assessments cover all activities of daily living and include a description of normal day care needs. This description is a form of care planning and needs to be reviewed on a regular basis along. Many of the assessments of need had not been reviewed and there was no available evidence that residents had been involved in the assessment process. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 9 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): Standards 6, 9, and 10 Care plans are descriptive and informative to enable the staff team to meet residents’ needs. Possible risks to residents are not always identified. Confidentiality and privacy is well managed to protect residents from risks. EVIDENCE: Care plans are informative and describe what staff and residents need to do in order to ensure the residents’ needs are met. Residents had signed their care plans and some areas of non-compliance as detailed in care plan reviews had been risk assessed, such as declining to have blood tests. However other areas identified in care plan reviews such as not attending health appointments had not been risk assessed. Care Programming Approach care plans and reviews must have the actions fully implemented or discussed with relevant keyworkers and residents, this was a concern at the last inspection. Care plans had been written on different formats, which is confusing to the reader and it is recommended that one format be used. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 10 Staff were observed to ensure that the confidentiality of residents was maintained, through ensuring records were safe and that privacy where needed was in place. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 11 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): Standard 14 and 17 The activity needs of residents are not fully met. The recordings of these events need to be improved to enable staff and residents to review and evaluate progress; residents are not provided with a clear and structured programme of activity. EVIDENCE: Residents’ files include a log of activity, one record seen had not been updated since July 2005 and another did not record the active lifestyle of one resident. Further information was available in daily records and included shopping and leisure pursuits. These records do reflect the information gathered in assessments, which for some residents are then developed into care plans. One resident confirmed he was able to join in activities within and external to the home and others were observed listening to music and watching television. A hazard analysis of critical control points is available and kitchen records indicate that at most times cleaning is completed, however records of cleaning and temperature recordings continue not to be recorded when the cook is not on duty. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 12 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): Standards 19 and 20. The health care needs of residents are adequately met by the home, however some improvement is needed to ensure medication is managed safely and residents are not put at risk. EVIDENCE: Daily records indicate that residents are supported by many community healthcare services such as their GP, hospital outpatient appointments, community mental health teams, social workers, opticians, dentists and chiropodists. One resident commented he was able to see the doctor as and when he needed and at the time of the inspection visit the acting manager had accompanied one resident to a health appointment. It is practice to weigh residents on a monthly basis, however weight records are not fully completed in line with this practice. Records identified an alarming weight loss for one resident and the acting manager was advised to investigate as a matter of urgency. Medication administration records are fully completed including when medicines are received at the home and also when medicine is administered to residents. Stock control appeared to be good, and there are adequate storage facilities for all medicines. The medicine fridge temperature is frequently too high to ensure that medicines are maintained safely. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 13 It is a concern that some nursing staff are not aware of a medicine policy, this is of particular concern for agency nurses who are not made aware of the policy. A controlled drug register was not available at the time of inspection. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 14 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): Standard 22 Residents and their representatives are not adequately supported to raise concerns in respect of their care and service provision and may anguish unnecessarily. EVIDENCE: A complaints policy is available in the home and included with the residents guide and statement of purpose. The acting manager confirmed that she had received informal concerns from residents’, these concerns along with actions taken had not been recorded within the complaints log. The complaints log had no entries and the commission have received no formal complaints about the service in the past 12 months. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 15 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): Standards in respect of the environment were not assessed. No judgement. EVIDENCE: Nil. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 16 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): Standards 33, 34 and 35 Staff training and recruitment is conducted to ensure that residents needs are met by well trained and fit to work members of staff. The hours worked by some staff may put the care of residents at risk. EVIDENCE: Staff files include details of training; those sampled included evidence of recent safe working practices training, abuse, communication and challenging behaviour. It was evident that criminal records bureau (CRB) checks are being completed prior to recruiting new staff members along with a full application form, interview and references. The acting manager confirmed that the CRB’s were at present being audited. It was evident from staff rotas that one trained nurse (RMN) is on duty day and night. The inspector was concerned that one nurse is working excessive hours that may be unsafe and place residents at possible risk. The acting manager and area manager were requested to address this concern as a matter of urgency. There are a minimum of two Support Workers at night, and a minimum of three during the day with often four in the morning. A permanent cook and a domestic are employed; an additional Support Worker is employed when the cook is not on duty. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 17 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): Standards 39 and 42 The home does not fully ensure that the management and the administration of the home is of a standard that will ensure the quality and safety of the service for the residents. EVIDENCE: One resident confirmed he had been consulted about the move back to The Royd, also other residents have been able to visit The Royd as part of the consultation, development and the refurbishment of the home. It is not evident that residents are consulted in respect of a quality assurance system, one resident was asked about this and stated, “I am not asked about what I like and do not like”. Risk assessments have been completed, some including the fire risk assessment require an annual review. Risk assessments are not available for the security of the building and for gas appliances. Fire drill records were not available, however some staff confirmed that they had personally attended a drill. Other records in respect of fire safety and training staff are available including regular servicing of the fire system. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 18 Fire alarm tests are not routinely completed on a weekly basis and records do not record the outcomes of the weekly fire alarm test. Accident records are routinely audited and there is no indication that there is an undue amount of accidents at the home, these records are well maintained. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 19 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X X X 1 X X 2 X Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 20 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 YA2 Regulation 14(1) Requirement The life histories of residents must be further developed to include positive experiences; this must be included within a care plan. Timescale for action 31/03/06 2 YA2 14(1) Previous timescale of 30/6/05 not met, this requirement is carried forward. Residents must be 31/03/06 involved in the assessment of need process. The normal day care needs developed from assessment must be regularly reviewed. Information gathered from 28/02/06 reviews such as Care Programming Approach meetings must be included within a written care plan and detail how the needs and goals are to be achieved. Previous timescale of 31/8/05 not met, this 3 YA6 15(1) Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 21 4 YA9 12(1), 13(4)(c) 5 YA14 15(1) requirement is carried forward. Risk assessments must be completed in consultation with residents in respect of not attending important health appointments. Accurate and upto date records of residents’ participation in leisure activity must be maintained. All residents must have a programme of activity. The home must maintain cleaning and records for cleaning in the kitchen at weekends. Records of probing food temperatures and daily fridge and freezer temperatures must be maintained at the weekends. Samples of food prepared at the home in line with the food hazard analysis must be maintained at weekends. Previous timescale of 31/5/05 not met, this requirement is carried forward. The weights of residents must be recorded monthly in line with management guidance. Previous timescale of 31/8/05 not met, this requirement is carried forward. Concerns in respect of 28/02/06 31/03/06 6 YA17 13(3), 23(2)(d) 28/02/06 7 YA19 12(1) 28/02/06 Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 22 8 YA20 13(2) excessive weight loss or gain must be fully investigated. All residents who have as required medicines must have a care plan devised that includes why, when, name, dosage, frequency and reasons for administering medicines, outcomes must be recorded. Residents must be involved in the development of the care plan. Not assessed and is carried forward. A medicine policy that reflects current practice at the home must be available. All staff involved in the management of medication must be aware of the policy. Previous timescale of 31/8/05 not met, this requirement is carried forward. A controlled drug register must be available at the home. The temperature of the medicine fridge must always be maintained at a safe level. All concerns and complaints raised by residents or their representatives must be recorded including subsequent actions to improve services, where needed. The home must revise DS0000063161.V280302.R01.S.doc 28/02/06 9 10 YA20 YA20 13(2) 13(2) 28/02/06 28/02/06 11 YA22 22 28/02/06 12 Millwater YA23 13(6) 31/03/06 Page 23 Version 5.1 adult protection procedures to ensure full compliance with the guidelines provided in No Secrets including Whistle Blowing policy. Previous timescale of 30/6/05 not met, this requirement is carried forward. The care manager must ensure that a minimum of 50 of the employed care staff achieve NVQ 2 in Care by 2005. Currently only 3 staff have NVQ 2 or above. Not assessed and is carried forward. Nursing staff must not work excessive hours that will unnecessarily put at risk the well-being and health of residents. All staff including qualified nurses must receive supervision at regular intervals and in line with National Minimum Standards. Qualified nurses must receive clinical supervision and be assisted with development needs in respect of their clinical practice. Not assessed and is carried forward. The home must have in post a qualified, competent and appropriately experienced manager that has been registered with the DS0000063161.V280302.R01.S.doc 13 YA32 18(1)(a), 18(1)c)(i) 31/03/06 14 YA33 18(1), 13(4)(c), 28/01/06 15 YA36 18(2), 12(1) 31/03/06 16 YA37 CSA 2000 Sec 24. 31/03/06 Millwater Version 5.1 Page 24 commission. Previous timescale of 30/11/05 not met, this requirement is carried forward. The acting manager must ensure that regular consultation, which is recorded is undertaken, to elicit its performance against the statement of purpose, aims and objectives. This must include residents, their representatives and stakeholders. An annual report must be made available to residents and interested parties. The home must further develop risk assessments at the home to include; gas and appliances and security at the home. Previous timescale of 30/9/05 not met, this requirement is carried forward. The homes’ risk assessments including fire must be reviewed annually or sooner if needed. Records of fire drills must be available at the home. All staff must attend at least two fire drills annually. Fire alarm tests must be completed weekly and outcomes recorded with adequate records maintained. 17 YA39 24 30/04/06 18 YA42 23(4) 30/04/06 19 YA42 23(4), 13(4) 30/04/06 20 YA42 23(4)(e), sch 4 (14) 28/02/06 21 YA42 23(4)(c)(i) 28/01/06 Millwater DS0000063161.V280302.R01.S.doc Version 5.1 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. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that care plans are only written upon one clear format. Millwater DS0000063161.V280302.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Millwater DS0000063161.V280302.R01.S.doc Version 5.1 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. 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