Inspection on 07/03/07 for Millwater

This inspection was carried out on 7th March 2007.

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 no outstanding requirements from the previous inspection report, but made 20 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 25/01/06

Millwater 08/07/05

Millwater 05/01/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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 Key Unannounced Inspection 7th March 2007 10:00 Millwater DS0000063161.V330970.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 Millwater DS0000063161.V330970.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. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millwater Address 164-168 Waterloo Road Hay Mills Yardley Birmingham B25 8LD 0121 706 3707 0121 765 5536 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 – Active Care Miss Sarah Jayne Owen Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 8 residents who have a learning disability aged 18 to 65 years of age only. 25th January 2006 Date of last inspection Brief Description of the Service: Millwater Care Home has been registered to provide a learning disability service for up to 8 younger adults. The residents’ accommodation is single rooms with en-suite facilities; there is a large communal lounge and a small lounge/ quiet area/ activity room for the residents. Dining facilities are available. There is a kitchen and a laundry. 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. Current fees for this service range between £800 and £2243.84 each week. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was visited on a Wednesday; it was an unannounced visit by two regulation inspectors. Prior to the inspection two residents had returned completed surveys to the Commission about life at the home. The inspector was able to meet four of the five residents who live at the home, and able to have discussions with two. There were some residents who were not able to have a verbal discussion but who could communicate using body language and some could use symbols. At the time of the key inspection there were five residents receiving a residential service. How the service provides support and care for two of the residents was fully assessed, including their health and lifestyle and what it is like for the two residents to live in the home. Records about the support and care offered to the residents were seen and staff were at times observed supporting the residents. Records about management such as health and safety practices and quality of the care were also looked at. The inspector had a look at communal areas of the home and one of the residents’ rooms. Complaints records maintained at the home were seen, there have been no complaints made to the home in the past 12 months. What the service does well: To help residents make the right choice of home; they encourage prospective residents to visit, sometimes for overnight stays. The residents that live at the home told the inspector that they make many of their own decisions about what they do with their day, some comments included “I do make decisions, and sometimes I go to college on set days”. Other residents at the home said they have the frequent support from their families and friends and often go out shopping with staff, comments included “I go home to my moms at weekends”, “I like shopping, especially for clothes”, “but I’m going shopping to buy my mom a card because its her birthday”. The home provides a safe keeping service for the money and valuables of the residents who live there; this was seen to be managed safely. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 6 The décor and furnishings are very new and the residents who live their indicated that they like it. The two residents who returned surveys indicated that the staff do treat them well, that they do listen and act upon what they say. The staff are only recruited following checks on their experience, character and backgrounds. The home asks the residents who live there and other residents who visit what they think of the home, what they do well and what they do not do well. What has improved since the last inspection? What they could do better: The home needs to ensure that any residents who may wish to come and live at the home only do so following a full needs assessments. The home needs to ensure that residents have written care plans that are detailed and provide the care staff with clear instructions with how to meet residents’ needs, this needs to include their chosen way of life, how to manage challenging behaviours and to regularly revisit these care plans with the residents. Everyday life at the home must include staff spending more time with residents who do have problems with communication. The home must keep records up to date that are required to check on the healthcare of the residents. There needs to be better management of the residents’ medicine to ensure they do have their medicine as the doctor has prescribed it. The home and the manager where needed must be involved in meetings about keeping residents safe. The staff must have further training, which will provide them with the skills to meet the needs of the residents. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 7 Residents, who do not or cannot leave the building in an emergency such as fire, need to have plans to maintain their safety. 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. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that it had the ability to ensure that residents are supported to choose a home that can meet their needs and expectations. This may lead to residents choices not being considered and they may therefore be inappropriately placed. EVIDENCE: The residents surveys indicate that they were asked if they wished to move into the home and that they were provided with enough information about the home before they moved in, which helped them make a decision. One resident spent a lot of time talking to the inspectors and was pleased about moving into the home and advised that she did come and visit before she moved in, this resident confirmed that moving in was made easier by the good staff. There were some recordings confirming prospective residents had been to visit and staff had recorded what had happened during the visit. From the records seen it appears that many initial assessments are undertaken after the resident has moved in, including dependency assessments. On the residents files there was some evidence of pre admission Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 10 assessments for example pre admission draft care plans (not dated) and important contacts such as family, psychiatrist and community nurses. For one resident a social worker had supplied written information that identified many needs and risks prior to the admission The home does have a statement of purpose and service users guide. It was not evident that this information is available to assist some residents with understanding; being available in a range of suitable formats for residents such as audio cassette, DVDs, pictures, symbols, Braille, community languages. At the time of the inspection the manager provided a contract for each resident containing most required information. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 11 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): Standards 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated that it has the ability to involve the residents in making decisions about their lives and has not consider their spiritual, psychological and emotional needs. This will lead to residents needs not being met, they may be unhappy and could become unwell. EVIDENCE: The two residents who returned there surveys confirmed that they are able to make decisions about what they do each day and some comments included “I do make decisions, as sometimes I go to college on set days”. There was little evidence that residents are involved in planning their care, or reviewing their care. There were no life histories or person centred plans that involve residents in planning their care. Two residents both had some written care plans and risk assessments. These has been written to address needs and risks identified in the initial Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 12 assessments. Some were confusing as there was more than one for the same need or risk. Some of the care plans and risk assessments were clear and concise and provided good instruction for staff in how to meet needs. Some care plans were not dated, similarly with some care plan reviews and risk assessments. There were no management strategies in place to guide staff should they need to manage aggression or challenging behaviours of residents. It was evident that all needs and risks did not have a care plan or risk assessment, such as for personal care and some of the risk assessments were written a considerable time after the social worker had highlighted concerns in a care plan, such as a high risk of falls. Most care plans were focussed upon the physical needs of residents. There were some good care plans promoting privacy and dignity and also to encourage maintaining abilities and life skills; these care plans were focused upon personal care needs. There were few care plans about social activities, but there was an individual activity programme. There were no care plans about family and friends, relationships, culture, religion, occupation or education. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 13 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): Standards 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated that it does have the ability to meet the varied individual lifestyle needs of the residents, there is not enough person centred planning and practice which gives way to more communal and task orientated practices. This may have a negative impact on the well being of residents. EVIDENCE: At the time of inspection one resident was waiting to go to the shops with staff, and another was also keen to go but had to wait until the first resident returned, however this resident was keen to talk with inspectors and neither resident went to the shops for up to two hours. Residents comments about daily activities included “I go home to my moms at weekends”, “I like shopping, especially for clothes”, “but I’m going shopping Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 14 buy my mom a card because its her birthday”, this resident confirmed she liked listening to music, goes to college and particularly enjoys her course on care of animals and also attends a course on creative card making. Each resident had an activity programme, these do not appear to be individual, as they included such events as watching a film, playing cards with other residents, activity with other residents and feeding the ducks. There was little evidence in the daily records that this plan is achieved. There is an activity room, staff advised that besides using the room for arts and crafts it is often used for snacks. Another resident was seen to spend long periods of time seated in the large lounge area, without regular attention from staff, other residents did not approach her. This resident’s activity programme recorded Monday, read magazines; Tuesday, pub for tea and Sunday going to the cinema. The residents’ communication assessment identified significant impairment and to aid communication pictures and symbols are used. This resident has a care plan that says she enjoys being spoken to and particularly enjoyed a hug; this was not seen to happen. The care also described how daily clothes are chosen. One appropriately trained member of staff is identified to cook the main meal each day, although this was not recorded on the rota. A resident who has a special diet did have appropriate food available, which is prescribed by the GP. There are no individualised food records, this is important for some residents who have a need surrounding food and nutrition. There is a weekly menu, staff advised that residents do help plan it and shop. Shopping is often two to three times a week. There were good stocks of food. One resident informed the inspectors that she did not have any breakfast and that staff had asked many times whether she wanted something. Concerns had been raised by the relative of one resident that since moving in she had spent much of her time in her room and was lonely, the inspectors were able to meet and talk with this resident who had no concerns about spending sometime in her room as she would often watch television, play computer games or listen to music. She also enjoyed spending sometime in the communal areas of the home and particularly liked the staff. Evidence in this area is also recorded under individual needs and choices. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 15 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): Standards 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated that it has the ability to meet the personal and healthcare needs of the residents. There are some poor practices that put the health and welfare of the residents at risk. EVIDENCE: Two residents who returned surveys confirmed that staff listen and act on what they say, this was further confirmed by another who described in conversation that if she is not well the staff arrange appointments for her and that one member of staff will go with her. At the time of inspection the residents presented very individually in dress and hairstyles. Staff do assist to some varying degrees each resident with elements of their personal care, whether this is monitoring or if its full assistance. There are good care plans that do describe how to care for each resident and what the residents do for themselves. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 16 There have been some concerns that a resident did not have her immediate healthcare needs met following an accident, records confirm that a resident did have an injury but refused to go to hospital, yet a day later the resident was escorted to hospital and treatment was given. There were also some concerns that this resident was at risk of choking and had been left at risk; the care plan to help manage this need was not adequate and the home had been alerted to this risk by a social worker. For the same resident there were concerns about damage to the skin, and there was a care plan to instruct staff about skin care. Yet the care plan did not detail adequately what they must do and it had not been adequately reviewed. These concerns led to a meeting of concerned health and social care professionals under local authority adult protection procedures including a vulnerable persons police officer. Each resident had a record of appointments with healthcare professionals. This included regular input from a district nurse for the resident with skin care needs. There were records where required of GP and psychiatric support including medication reviews. There were records of contact with social workers and for one resident a speech therapist had been involved due to weight loss, staff gave contact details of the previous care provider for the speech therapist to contact. The home should have had this information as part of the pre admission and initial assessments of need and risk. For one resident nutritional intake records are required, for the first seven days of March these had not been completed and prior to this records were not fully descriptive of intake. There were some Essential Life Planning records. Residents did not have a health action plan. Medication is supplied by a local chemist using a monitored dosage system. The manager explained the initial difficulty of acquiring a GP service for the residents and needed to involve PCT. The management of medicines for two residents was assessed. There were concerns in recording including not recording medication received into the home, gaps on records when medication has not been administered to residents; the manager advised this was normally when a certain resident had refused yet this was not coded on the record. Staff were seen to have signed records for medication that had no longer been prescribed. There is some medication that is prescribed, as when needed, there is no guidance or protocol for staff to follow to administer this medication. The staff do not regularly audit the stock and keep records of their findings and or actions. The training records for staff confirm they have completed medication training. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 17 Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 18 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): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that it has the ability to act in the best interests of residents and has failed in areas to ensure their safety and protection. This may mean that the staff team do not recognise their role in protecting residents and may leave the residents at risk. EVIDENCE: The two residents who returned their surveys indicated that they had no complaints and that if they did they could speak to staff or a named member of staff. The home does maintain a log for complaints and this was found to have no entries. The Commission has not received any complaints since the homes registration last year. The home does provide the residents with a safe to keep money and valuables in. Balances of money were found to correspond with current records. Where staff purchase items for residents they ensure a receipt is taken. However all transactions are completed by one member of staff and they are not witnessed, there are some entries on records that do not describe event, for example “money in” does not describe who from or what for. There are some Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 19 residents who do not have any money and the manager advised that she has made contact with their social workers. The Commission had been informed that there was to be an Adult Protection strategy meeting about the care of one named resident. This involved the vulnerable persons police officer and social care and health. The inspector has been advised that the outcomes are pending, yet actions have been taken to ensure the resident is safe. The Commission has been informed that a representative from the home failed to attend this strategy meeting. The staff training records indicate that the staff team do receive Protection of Vulnerable Adults training. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 20 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): Standards 24, 25, 26, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated that it provides an environment to the residents that are fully accessible and safe. This may mean that residents are restricted and have a negative effect on their health and well-being. EVIDENCE: The two residents who returned surveys indicated that the home was always kept clean and tidy. A report completed by the Commission about the homes registration requested that at this key inspection we should assess whether a call alarm had been installed in the ground floor en-suite level access shower and installation of a suitable ramp from the lounge to the dining room. This was assessed and found not have been addressed. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 21 A tour of some communal areas was undertaken and most areas were found to be well maintained, pleasantly decorated and some residents’ rooms were seen to be personalised. Improvements needed included offering additional furniture to residents in their rooms to meet National Minimum Standards, ensuring where wheelchair access is needed that doors have appropriate mechanism to be retained in the open position and are not wedged open and improving infection practices to ensure all high risk areas such as communal toilets have good hand washing and drying facilities. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 22 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): Standards 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to ensure that residents are supported by staff who have been safely recruited, well trained in health and safety and who are regularly supervised. This will help meet the needs of the residents and reduce elements of risk. EVIDENCE: The two residents who returned surveys indicated that the staff do treat them well, that they do listen and act upon what they say. The staffing rotas seen at the visit and the number of staff actually on duty are adequate, yet must be closely monitored to meet the regularly changing needs of residents and what is agreed with Commissioners of the service. There are four to five staff on duty during the day and three at night. The manager is supernumerary and there are no dedicated ancillary staff. The recruitment files for three staff were seen, one for the newest staff member who did have a protection of vulnerable adults (POVA) check, Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 23 interview, completed application form and two written references; one being from the most recent employer. All required recruitment records were available for the other staff. Records of staff training were seen for the three staff. The newest staff member had commenced an induction at the home. Training records for other staff indicated that mandatory training such as moving and handling, fire and food safety is undertaken and refreshers / updates are available. There is evidence that staff do undertake some training specific to the needs of residents such as POVA, safe handling of medicines and autism awareness. However no records were seen on these files for NVQ and Learning Disabilities Award Framework. There were no records seen to confirm that the staff attend courses on managing challenging behaviour, awareness of epilepsy and physical interventions. There were records available that confirmed staff do have regular supervision from the manager. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 24 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): Standards 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that it has the ability to ensure that the conduct of the management in the home is effective to meet the needs of the residents. This will mean that the residents’ health and welfare is put at unnecessary risk. EVIDENCE: The manager was available at the time of the inspection and was able to give a good overview of how the home had been commissioned and opened including teething problems. It was evident that in some areas she was determined to succeed, such as providing a GP for the residents and developing a good staff team. The manager was able to discuss the presenting needs of the residents and gave some background information. The manager was registered with the Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 25 Commission in December 2006. There were concerns raised at the time of the visit as one resident was being cared for in a part of the building that is unregistered, this was discussed with the manager and her senior manager, who advised that, they thought as long as they did not exceed registered numbers the supportive living side of the building could be used. Arrangements were made by the manager after discussions with the residents’ social worker for the resident to return to the registered care home side of the building. The home does have a quality assurance system, where regular auditing and monitoring of standards takes place. The residents and relatives are involved and their views and opinions about quality are included. There was not a report available for residents and other interested parties about the overall findings of the auditing. The manager had the findings of recent audits she had completed including accidents in the home, medication and pressure sores. It was a concern that issues identified earlier in the report about poor care planning for pressure sores and poor medication practices were not fully identified and addressed. The maintenance of the home, including health and safety tests and servicing was assessed. The fire system is well maintained most equipment is tested and serviced. The staff attend fire safety training and fire drills. Records indicate that some residents do not always respond to the fire alarm and they require individual fire risk assessments to guide them and staff about what they need to do to maintain safety. At the time of the visit the manager could not find evidence that the emergency lights had been serviced. There is a general fire risk assessment, which is due for review in September 2007. Utilities including gas, water and electric are regularly serviced and certified safe for use. Other examples of servicing include, the emergency call system in residents’ rooms and communal areas, visual safety checks and servicing of wheelchairs and lift examinations. An environmental health officer visited the home on the 20/2/07, the report reflected on good cleanliness and hygienic standards. There are no HACCP records to promote food safety, such as fridge and refrigerator temperatures. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 26 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 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 X 2 X 3 X X 2 X Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 14(1) Requirement Timescale for action 04/05/07 2 YA6 15(1) 3 YA6 15(1) 4 YA6 15(2) The registered person must ensure that new residents are only admitted on the basis of a full needs assessment this will ensure that the home can make a decision on whether they have the ability to meet the residents needs. The registered person must 11/05/07 ensure that residents have written care plans that are clear and concise in detail and that provide information to staff about what they must do to meet the needs of residents. The registered person must 11/05/07 ensure that where possible written care plans are completed after consultation with residents or their representative, which enable their personal choices and preferences to be considered and included. The registered person must 11/05/07 ensure that the residents written care plans in consultation with the resident or their representative are kept under review, this will ensure how effective or otherwise the care DS0000063161.V330970.R01.S.doc Version 5.2 Millwater Page 28 5 YA6 12(1) 15(1) 13(4)(c) 6 YA6 15(1) 16(2)(m) (n) plan has been can be discussed with the resident and any changes agreed. The registered person must ensure that all residents where required have written management strategies to ensure their challenging behaviours will be appropriately managed. The registered person must ensure that residents have individual programmes of activities or a written care plan detailing how their choices, preferences and diversity needs are to be met. This will help maintain an individual and fulfilling lifestyle. This must include their assessed needs in respect of family and friends, relationships, culture, religion, occupation and education. The registered person must ensure that risks identified during the pre admission assessments or there after have a risk management plan written and regularly reviewed in consultation with the resident or their representative. This will ensure that proportionate plans to reduce risks to residents can be made, and the choices and preferences of the residents can be considered. The registered person must ensure that residents are given regular opportunity to develop socially and emotionally and that staff positively and regularly communicate with them. This will improve their abilities and increase their self-esteem. The registered person must ensure that residents are able to DS0000063161.V330970.R01.S.doc 11/05/07 31/05/07 7 YA9 12(1) 13(4)(c) 15(1) 11/05/07 8 YA11 12(1)(a) 18(1)(a) 11/05/07 9 YA14 16(2)(m) (n) 11/05/07 Millwater Version 5.2 Page 29 10 YA19 12(1) 13(4)(c) 11 YA19 12(1)(a) 13(4)(c) 12 YA19 12(1) 13 YA20 13(2) 14 YA20 13(2) 15 YA23 13(6) take part in their chosen recreational and leisure activities, and record this adequately. This will ensure that residents have opportunity to maintain their chosen lifestyles. The registered person must ensure that staff follow well written and detailed care plans and risk assessments to ensure the health needs of residents are met. The registered person must ensure that the nutritional intake records are fully maintained that are required for any resident who needs their intake to be closely monitored for health reasons. The registered person must ensure that all residents have a health action plan, which details what the person with a learning disability can do to be healthy. The registered person must ensure that medication administration records are fully completed including when medicines are received into the home and when they are administered, omitted or refused by residents. This will ensure a full audit of medication can be completed and the health of residents properly monitored. The registered person must ensure that any resident who is administered “when required” medication has a written guidance “protocol” to advise what it should be given for, how much should be given and how often and when to report to the GP or psychiatrist. The registered person must ensure that money kept in safe keeping belonging to residents has any transactions in and out DS0000063161.V330970.R01.S.doc 11/05/07 11/05/07 31/05/07 11/05/07 31/05/07 11/05/07 Millwater Version 5.2 Page 30 16 YA23 13(6) 17 YA29 23(2)(a) (n) of the account signed by at least two persons, one where possible being the resident to help prevent any unnecessary risks of financial abuse. The registered person must ensure that when required a representative of the Active Care Partnerships attend any adult protection strategy meetings. This will enable the multi agencies lead by the local authority to effectively manage the safety of residents; this is in line with the provider’s policy. The registered person must ensure that a call alarm be installed in the ground floor ensuite level access shower and the installation of a suitable ramp from the lounge to the dining room. This will enable staff to respond to urgent situations and improve any restrictions on residents in the home. These improvements were discussed with the home during the registration visit in October 2006. The registered person must ensure that wheelchair users are not reliant on staff to hold open doors or wedge them open to enable them to roll the wheelchair through, other means such as automatic or selfretaining doors must be considered. The registered person must ensure that must ensure that staff are provided with training so they gain competencies in meeting the specific needs of the residents. This must include National Vocational DS0000063161.V330970.R01.S.doc 04/05/07 30/06/07 18 YA35 18(1)(a) 30/06/07 Millwater Version 5.2 Page 31 19 YA42 13(4)(c) 23(4)(c) (iii) 20 YA42 23(4)(b) (c)(iii) Qualifications, Learning Disabilities Award Framework, managing challenging behaviour, awareness of epilepsy and appropriate training for staff who must make physical interventions. The registered person must ensure for the safety and welfare of residents that if they do not respond to the fire alarm that an individual risk assessment is written and shared with the residents and staff advising of the management plan and what the staff will do. The registered person must ensure that to aid evacuation in the case of an emergency that the emergency lights are regularly serviced. 18/05/07 18/05/07 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. 2 Refer to Standard YA30 YA37 Good Practice Recommendations It is recommended that the hand washing and drying facilities in higher risk areas such as toilets be improved. It is recommended that the manager diligently monitor audits about the quality of service and other audits such as medication and take actions to make improvements for the benefit and safety of residents. Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Millwater DS0000063161.V330970.R01.S.doc Version 5.2 Page 33 - 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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