This inspection was carried out on 18th October 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
The Old Mill House 99 Pall Mall Chorley Lancashire PR7 3LT Lead Inspector
Della Lovell Unannounced Inspection 18th October 2005 10:00 The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 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 The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 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. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Old Mill House Address 99 Pall Mall Chorley Lancashire PR7 3LT 01257 274678 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) dalesview@tiscali.co.uk Dalesview Partnership Miss Lisa Warburton Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The home is registered for a maximum of 6 service users to include: Up to 6 service users in the category LD (Learning Disability). The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 14th March 2005 4. Date of last inspection Brief Description of the Service: The Old Mill House is currently registered to accommodate six service users with a learning disability. It has been home to the current service users for the past fourteen years. Within the home there are five bedrooms, two single and one shared room on the ground floor, and two single rooms on the first. Bathrooms and toilets are located on both floors and a single room on the ground floor has en-suite facilities. The homes kitchen/diner is located at the rear of the building and the lounge at the front overlooks the road. There is a garden to the side of the home which currently houses a vegetable plot, this is maintained by one of the service users. The home is situated on Pall Mall which is one of the main roads leading into Chorley town centre. The town offers a range of leisure and shopping facilities which service users are supported to access. The home is one of a number owned by the Dalesview Partnership and is currently managed by Lisa Warburton. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in October 2005. The inspection involved discussion with the staff, registered manager and the observation of three service users who lived at the home. The inspector examined records, policies and procedures and toured the premises. What the service does well: What has improved since the last inspection? What they could do better:
The home must ensure that a thorough pre-admission assessment of needs is undertaken and a copy of a local authority assessment obtained. The home must ensure that all needs are recorded on the individual care plan and how these needs are to be met or monitored. Each service user had a comprehensive file which contained many records /charts. These documents provide good tools to monitor service users specific needs however not all service users identified needs require these tools. It is The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 6 recommended that these tools are only kept on file if identified at the initial assessment or if certain care needs change following a review. Environmental risk assessments should be undertaken for windows without restrictors and action taken to minimise any identified risk. Information must be kept at the care home of all staffing staff working there and information required by law available for inspection at all times. The home will need to set a programme of training in place to ensure that 50 of care staff are trained in an NVQ Award. 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 Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 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 The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 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): 2 The home had documentation in place to undertake pre admission assessments. However this was not thorough enough to ensure that all individual needs where identified. EVIDENCE: Although the home had a good admission procedure and documentation for undertaking pre admission assessments there was no assessment or local authority assessment on three service users files examined by the inspector. The registered manager informed the inspector that this information may be held at the head office. One service users file did not contain information relating to a health care need and how these needs were to be met. Discussion with the manager confirmed that the needs were being met even though there was a lack of information. This approach is dependent on management and staff’s knowledge of the service user. If these informal systems break down the service users would be at risk of not having their needs met. Service users in the home were relaxed and were able to communicate effectively with the staff on duty. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 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): 6 and 7 Each service user had an individual care plan. More attention and detail is needed to ensure that service user needs are fully identified and met. Service users are assisted to make decisions about their lives which ensures service users rights are up held. EVIDENCE: Each service user had an individual plan of care, which sets out in detail the action that is needed to be taken by the care staff to meet their needs. Each service user had a number of daily record sheets, which recorded the care given, any significant events and activities undertaken. Care plans are reviewed on a regular basis and service users and their families are invited to be involved in the process. The files of two service users were viewed in detail as part of the inspection process. Each service users file contained various documentation for recording any assistance or health care intervention. However some records were seen as blank, due to the fact that this had not been identified as an assessed need. The inspector discussed with the management team the opportunity to keep these records on file only if required and therefore reduce the amount of paper work held on files. On the day of the visit one-service users file did not contain information relating to a health care need and on going investigations into
The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 10 their health. Discussion with the manager confirmed that both the service users needs were being met. This will need to be documented. Service user were seen on the day making decisions with regards to their daily living. All staff were able to communicate effectively with service users and communication needs were identified on the care plan. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 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): 12 and 13 The home arranged a variety of activities that met the service users needs and ensured that service users are involved in the local community. EVIDENCE: The service users files contained details of service users interests. “Person Centred Planning” was not in place at The Old Mill House, however training had been arranged for staff and the home is to undertake this approach once all staff are trained. There was a timetable of activities and events for service users each day and service user had a daily choice available to them. It was recognised that service users make their own choices and staff are there to support that decision. On the day of the visit a number of service users were attending a day centre and other services users where using services in the local community. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 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): 20 The homes policy and procedures for the administration and control of medication protects service users. EVIDENCE: At the time of the inspection no service users were administering their own medication and consent had been obtained from either the service users or their G.P. for staff to administer the medication. The home had a policy and procedure in place and all staff were provided with training and certificates were seen on staff files. A drug record was kept up to date and a record was kept of all drugs leaving the home. The registered manager had obtained sample signatures from staff and copies of all prescription were also kept. The registered manager was advised on the day to record the number of drugs leaving the home for home visits and the number of drugs returned. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home had a complaints procedure, which ensures that all complaints would be acknowledged and investigated. The home had robust procedures in place to safe guard service users from abuse and harm. EVIDENCE: There had been no complaints since the last inspection, and a policy and procedure was in place. The home policy did not fully met with the required legislation however the service users guide contained the necessary information needed. Staff were aware of the homes policy and service user had a picture version, which they could use to express any concerns. The home should ensure that information in the homes policy is consistent and under-pins the home procedure for making complaints. On the day of the visit the home had just updated the homes policy and procedure for protection of vulnerable adults. The policy was comprehensive and detailed and reflected the “No Secrets in Lancashire” document. Although the documentation provided a procedure for reporting and recording it was advised that this information be transferred from the lengthy document and a protocol devised. This would provide clear instructions for staff at difficult times. Staff are provided with training and were able to confirm the correct procedure they would follow. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The home was clean comfortable and homely and provided an environment that was suitable for its stated purpose. Risk assessments were needed to ensure the continued safety of the service users. EVIDENCE: The home was clean and tidy and service users rooms had been personalised with their belongings. The home was accessible and suitable for the people living there. The environmental health officer had visited the home and no requirements had been made. The fire safety officer had visited the home and reviewed the homes risk assessments. A follow up visit had been made by the fire safety, and the amendments to the risk assessment were approved. Maintenance works are carried out at the home and on the day of the visit external repairs were taking place. Risk assessments are in place for none guarded radiators. The inspector noted that not all windows in the home have restrictors fitted. The manager must ensure that a risk assessment is in place and action taken to minimise any identified risk. All risk assessment should be reviewed on a regular basis. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 15 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): 34 and 35 There is a recruitment policy and procedure in place however the home current practice with regards to staff records does not ensure the safety of service users. EVIDENCE: The home had a recruitment and selection procedure in place. One new staff members file was examined, the file contained all the appropriate documentation and checks required by law. However the inspector noted that the home did not have a staff file or information relating to one staff member working in the home on the day of the visit. The registered manager informed the inspector that a number of staff employed by the company cover casual work at a number of the homes. The inspector discussed with the manager the need to retain documentation in relation to staff working in the care home and that having no information relating to staff does not ensure the safety of service users. All staff are provided with mandatory training and additional training was available to support the service users needs. The home had two staff working towards an NVQ in Care qualification. The manager is aware of the need to ensure that 50 of the staff team is qualified to NVQ Level 2 by 2005. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 16 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): 42 There are safe working practices in the home, which ensure the safety and wellbeing of the service users living there. EVIDENCE: The staff in the home are provided with mandatory training, which includes moving and handling, fire safety and food hygiene. Procedures are in place for reporting and recording incidents and accidents and theses were examined by the inspection and seen to be appropriately recorded. All equipment in the home is serviced on a regular basis and water temperatures have recently been adjusted to ensure the right temperature for service users safety. The home had policy and procedure in place for health and safety and this area along with the fire procedures for the home is covered at induction with all new staff. The home has recently reviewed and updated the homes fire risk assessment in accordance with the advise from the fire safety officer. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
The Old Mill House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000005924.V260037.R01.S.doc Version 5.0 Page 18 yes 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 2 Standard YA2 YA2 Regulation 14(1)(a) 14(1)(b) Timescale for action The registered person must 31/12/05 ensure that each service user has a full assessment of needs. The registered person must 31/12/05 ensure that a copy of the service users assessment undertaken prior to admission is obtained. The registered person must 31/12/05 ensure that all the service users needs are written on the care plan and the actions staff need to follow to met those needs. The registered person must 30/11/05 ensure that a risk assessment is undertaken of all none restricted windows in the home and take appropriate action to minimise any identified risk. The registered person must keep 30/11/05 a record of all staff employed at the Care Home which includes all the checks required by law. Requirement 3 YA6 15(1) 4 YA24 13(a)(c) 5 YA34 17(2) Schedule 4 The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 19 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 3 4 Refer to Standard YA20 YA23 YA24 YA35YA32 Good Practice Recommendations The registered person should record the number of drugs leaving the home and returning to the home following service users home visits. The registered person is advised to develop a protocol, which provides clear instructions for staff to follow for reporting and recording any allegations of abuse. The registered person should ensure that all environmental risk assessments for the home are reviewed. The registered person should ensure that 50 of care staffing the home achieve an N.V.Q level 2 by 2005. The Old Mill House DS0000005924.V260037.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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