Care Home: Milford House

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What the care home does well Accommodation at Milford House is to a very high standard and a wide range of equipment and facilities are provided to meet the needs of people with a disability, in what remains a homely environment. One of the members of staff commented that one of the strengths of the home was to "provide equipment needed for individual`s care". The providers regularly review quality of care provided to residents and there was much evidence that they are keen to find out about residents` experience of care provision and to use this to improve quality of care provision. One relative commented that the home was "well run". The home uses a person-centred approach to care, with detailed assessments of need and care plans to direct staff on how peoples` needs are to be met. All assessments and care plan were individualised in tone and reflected what residents told us and staff reported. Residents relatives are supported so that they can continue to visit the resident and remain important in the residents` life. People commented favourably of the home. One person reported "family, friends and relatives of the service user are lucky to have their loved ones living in Milford House", another "I could not recommend this home more highly", another "Milford House is one of the best care homes in the area" and another "I wouldn`t want to go anywhere else". People commented on the quality of care provision. One person reported that they "always leave Milford House confident in their excellent care", another "I have never worried about their quality of care" and another "fundamentally it`s sound". People commented on the staff. One person reported "the staff are wonderful, caring and very considerate", another "I know them all by name", another "everybody laughs here" and another "staff don`t moan, they`re very open". Staff also commented on how they felt about working in the home. One person reported "we all receive excellent support from the manager and I feel the atmosphere is good", another "I think that Milford House provides an excellent standard of care whilst encouraging a close knit team with good support from the manager" and another "very happy with my job; fully supported and well informed". What has improved since the last inspection? Two requirements and nine good practice recommendations were made at the last inspection. All had been addressed by this inspection. Information to residents has improved with the revision of the home`s statement of purpose and service users` guide. Documentation relating to resident care has been much developed. Documentation is now always completed using clear, measurable wording. Staff now consistently complete documentation in accordance with company policy. Where residents need thickening agent in their fluids to enable them to swallow safely, the consistency of the fluid is always documented. Care plans for complex medical conditions such as diabetes have been much improved. Responsibility for drawing up of care plans has been delegated, to facilitate improved audit systems for care plans. Infection control practice has improved. Clinical waste is now placed in bins which are not operated by hand. All deteriorated bed rail protectors have been replaced, so that they can be wiped down when needed.Systems for ensuring resident safety has been improved. Where residents need bed rails, there was evidence that a risk assessment is always performed and if a risk is identified, action is taken to reduce the risk. Air cushions have been provided to support people who are at high risk of pressure ulceration when indicated. Where air mattresses are used, the resident`s weight is always considered when using equipment. What the care home could do better: This inspection showed that the home are providing an excellent service. As Milford House is large at 80 beds, the fact that it only one requirement has been identified, gives evidence to the quality of service provision. Seven good practice recommendations were also advised. Practice in relation to preventions of risk of spread of infection could be improved if brushes for cleaning sanitary items were always clean and stored dry. Glove dispensers should be provided in en-suite bathrooms and all other areas where personal care may be carried out to provide ease of access foe all people who need them. Some areas of documentation could be improved. This relates to records of changes of position where a resident spends some of their time outside their room and documentation where care assistants support residents in activities or exercising choice. To support residents, the home should further review equipment and systems to ensure that all residents` own clothing is easily identifiable and can be returned to them after laundering. The systems for regular quality audits would be improved by a system for written monthly audit of complaints. People would benefit from improvements in practice relating to bed rails .The home should review why none of the people in profiling beds have had their bed lowered to the floor and crash mats used. Also assessments for the use of bed rails should state what other alternatives to bed rails have been considered. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Milford House Milford Mill Road Milford Salisbury Wiltshire SP1 1NJ     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 1 0 0 7 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Milford House Milford Mill Road Milford Salisbury Wiltshire SP1 1NJ 01722322737 01722410339 milford@barchester.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Barchester Healthcare Homes Ltd care home 80 Number of places (if applicable): Under 65 Over 65 80 0 7 old age, not falling within any other category physical disability terminally ill Additional conditions: 0 4 7 No more than 4 service users with a physical disablement in the age range 18-64 years may be acommodated at any one time. No more than a total of 7 service users with a terminal illness may be acommodated at any one time. The Maximum number of service users who may be accommodated in the home at any one time is 80. The staffing levels set out in the Notice of Decision dated 4 July 2005 must be met at all times. Date of last inspection Brief description of the care home Milford House Nursing home is registered to provide nursing care for 80 older people. Much of the home is purpose built, providing a comfortable standard of accommodation. Services are provided over two floors and in a linked wing, called the Care Homes for Older People Page 4 of 35 Brief description of the care home Cathedral Wing, which is also over two floors. Part of the main building also has a second floor for support services such as the laundry and staff rooms. The home provides large garden areas, which are accessible to wheelchair users. Milford House is situated on the outskirts of the city of Salisbury, with pleasant views of the surrounding countryside. There is parking on site. The home is owned by Barchester Health Care Services Limited, a national provider. The Registered Manager is Mrs C Fountain and she leads a team of nursing and care staff. A full team of ancillary, support and administrative staff are also employed. Prospective residents are issued with a service users guide at the time of admission. Fees charged range from 750 pounds to 1250 pounds a week. Charges are also made for hairdressing, chiropody, newspapers and sundries such as toiletries. Care Homes for Older People Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: As part of the inspection, 60 questionnaires were sent out and 48 were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. As part of this inspection, the homes file was reviewed and information provided since the homes last inspection considered. We also received an Annual Quality Assurance Assessment (AQAA) from the home. This was their own assessment of how they are performing. It also gave us information about what has happened since the last inspection. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home. This enabled us to decide what to focus on during the inspection. As the Milford House is a larger registration the site visits were performed over two Care Homes for Older People Page 6 of 35 days. The first site visit took place on Thursday 2nd July 2009 between 9:10am and 4:45pm. The second site visit took place on Friday 10th July 2009 between 8:50am and 12:25pm. Both visits were unannounced. While one inspector performed both site visits, this person is referred to as we, as the report is made on behalf of the Care Quality Commission (CQC). The deputy manager was on duty for the first site visit and the registered manager, Mrs Cathy Fountain was on duty for the second site visit, she was available for feedback at the end of the site visits. During the site visits, we met with fourteen residents and six relatives. We also observed care for ten residents who had difficulty in communicating. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for eight residents, one of whom had been newly admitted and looked at specific areas for an additional two residents. As well as meeting with residents, we met with the deputy manager, the training manager, four registered nurses, five carers, a domestic, the activities coordinator, the chef, a catering assistant, two laundry people, an administrator and the maintenance man. We observed lunchtime meals in all three dining rooms and two activities sessions. We reviewed systems for storage of medicines and observed two medicines administration rounds. A range of records were reviewed, including staff training records, staff employment records, accident records and complaints records. What the care home does well: What has improved since the last inspection? Two requirements and nine good practice recommendations were made at the last inspection. All had been addressed by this inspection. Information to residents has improved with the revision of the homes statement of purpose and service users guide. Documentation relating to resident care has been much developed. Documentation is now always completed using clear, measurable wording. Staff now consistently complete documentation in accordance with company policy. Where residents need thickening agent in their fluids to enable them to swallow safely, the consistency of the fluid is always documented. Care plans for complex medical conditions such as diabetes have been much improved. Responsibility for drawing up of care plans has been delegated, to facilitate improved audit systems for care plans. Infection control practice has improved. Clinical waste is now placed in bins which are not operated by hand. All deteriorated bed rail protectors have been replaced, so that they can be wiped down when needed. Care Homes for Older People Page 8 of 35 Systems for ensuring resident safety has been improved. Where residents need bed rails, there was evidence that a risk assessment is always performed and if a risk is identified, action is taken to reduce the risk. Air cushions have been provided to support people who are at high risk of pressure ulceration when indicated. Where air mattresses are used, the residents weight is always considered when using equipment. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 35 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be encouraged to visit the home before admission, so that they can find out if it can meet their needs. They will benefit from a full assessment of their needs prior to admission. Evidence: In their AQAA, the home comment that people are encouraged to visit us at any time both with or without appointments. They report that before admission is agreed all prospective residents are assessed by the General Manager, deputy matron or senior sister to ensure that we are able to meet his/her needs and also to introduce ourselves if we havent had the opportunity to do so and answer any concerns he/she may have. They also report that the transition to our home is generally well organised with minimal stress to the resident and family as we work hard to support them through this difficult time. We ensure that all relevant staff are aware of admission and can fully prepare with necessary equipment etc. Care Homes for Older People Page 11 of 35 Evidence: We reviewed comments that people had made about the admission process. Thirty two of the thirty four people who commented on this section of the questionnaire reported that they had had enough information about the home prior to admission, to enable them to decide if Milford House was the right place for them. One person reported that my [relatives] visited this home and were invited to look round and make our opinion. We thought it fulfilled our requests in every way, another we made several visits to the home before [the person] moved in and another the home were very helpful and answered our questions. During the inspection, we met with people and discussed their admission to the home. One person reported that their spouse had found out about the home and another that they had come to visit the home with a family member. Another person reported that the home had had a very good recommendation. One person reported that they had spent a short time in another home in the area and that it was not a patch on this one. We met with two people who had recently been admitted and a person who had been admitted for respite care. Two of the people said that they had been unwell and so could not remember the assessment process. The person admitted for respite care reported that the home had improved each time that they had been admitted. People reported on how the home had helped them to settle in. One person reported on the supports given to them in bringing items of their own into the home and that they were still doing this, to help them to settle. One person was admitted on the day of the inspection, we observed that the home promptly noted that they had not had all their medication sent with them from their previous provider and took immediate action to ensure that their drugs were sent on for them, so that the persons medical needs could be met. We looked at records relating to people admitted to the home. Two people had very clear admission assessments, which included social care needs as well as the persons nursing and general care needs. Both assessments reflected in full what the person said and what we observed. When we discussed one of these peoples needs with the registered nurse in charge of the unit, what they reported fully reflected what was documented in the persons records. This included reports in the persons records that they were gradually becoming stronger and more independent, with the supports given to them by the home. One relative described to us about how a manager from the home had completed a full assessment on their relative before admission and had explained to them how they were planning to meet the persons specific needs. Care staff told us that they were always informed of when new people were to be Care Homes for Older People Page 12 of 35 Evidence: admitted, so that they could prepare the persons room and ensure that they had the equipment that they would need. The activities coordinator reported that there was a brief head of department meeting every morning and that they would be informed of people who were to be admitted at that time. They would then try to meet the new resident soon after admission, including the persons relatives and supporters. The chef reported that they were always informed of peoples dietary needs prior to admission, including specific likes and dislikes, as well as any medical dietary requirements. They would then seek to find out more about the person soon after admission. Care Homes for Older People Page 13 of 35 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in Milford House can be ensured that their individual medical, nursing and care needs will be met and that where their needs change that staff will be able to respond to such needs. Evidence: In their AQAA, the home commented on their careful and detailed assessment of a residents needs. They reported that standards of care are monitored continuously both on a daily basis by our trained staff and via internal audits. They reported on their close working relationships with external health care providers, including the local hospice. They reported on their systems to ensure safe practice in the administration of medicines, which is supported by regular audits from the provider. Of the 32 people who responded to this section of the questionnaire, all people reported that they always or usually received the care and support that they needed. One person reported yes they are looking after [my relative] very well, and I am very pleased how my [relative] looks now, another that their relative is well cared for Care Homes for Older People Page 14 of 35 Evidence: and another the care and support given to our relative is consistently of a very high standard. During the inspection we met with a range of residents who had differing needs, discussed their needs with staff and reviewed their records. We met with one person who was totally reliant on staff for all activities of daily living who appeared to have very limited communication abilities. We observed that throughout the day, they were nicely turned out, with a clean mouth, eyes and fingernails. We discussed with a care assistant about how they communicated with the resident. The care assistant reported that they relied on apparently little things such as eye movements and tension in the persons fingers, elbows and knees. They reported that the key area was to get to know this resident and to support more junior staff who may not know them, in understanding how to communicate with the person. The care assistant was aware of signs to show that the person was in pain and in pain and said that they would report such observations to the registered nurse. We reviewed this persons records and found them to be very person-centred, fully reflecting what the care assistant reported and also detailing areas such as how the person could be moved safely, how risks of pressure ulceration were to be prevented and details of management of their artificial feeding system. Practice in relation to the assessment and meeting of peoples needs as described for the person above was replicated throughout the home. All people had comprehensive assessments of risk, including manual handling, risk of falls, nutritional risk and risk of pressure ulceration. Where a person had a risk or a need, a full person centred care plan was drawn up. Assessments and care plans were highly individualised. When we discussed care plans with staff, they were fully aware of how individual peoples needs were to be met. For example, one care assistant was able to tell us why frequent changes of position were important for a certain frail person, to prevent them from developing pressure ulceration. Where people were not able to support themselves with activities of daily living such as giving themselves food or fluids or changes of position. Monitoring charts were in place and these were observed to be fully completed at the time care was given when the person was in their room. Where people went to the sitting rooms to attend activities or just be out of their room, their turn charts did not go with them. This meant that for a few people, such charts were not always up-dated at the time care was given. People reported to us on how staff met their needs. One person reported to us that they had asked not to be disturbed at night. This was documented in their records and they reported to us that they were pleased that staff always followed their request. We observed that one person showed signs of becoming uncomfortable whilst in the sitting room, this was promptly noticed buy the activities person, who ensured that the Care Homes for Older People Page 15 of 35 Evidence: person was seated more appropriately. Care plans were regularly reviewed and up-dated when a persons needs changed. For example one person had become more independent since their admission. This was fully reflected in their care plan. Another resident had a progressive illness, which meant that their needs were changing as they became more dependant. Relevant secretions of their care plans were up-dated when this happened. We asked care and nursing staff about how they found out about such changed needs. They reported that they had a full report when they came on duty and that they found care plans informative of notifying them of changes in a persons needs. One care assistant reported to us about a resident who was loosing weight and the actions being taken to support the person in reducing weight loss. Another persons records showed that care staff had promptly reported on a changed skin condition to the registered nurses and about what actions had been decided upon to meet the persons changed needs. We observed that all staff, including support staff such as the maintenance man, always knocked on the door and awaited a reply prior to entering. All of the residents were nicely presented, in an individual manner. This included people who spent much of their time in bed and residents who were confused and who not be fully aware of their appearance. One relative commented on how the home treat people with great dignity. We noted that where people had additional care needs relating to dementia, people had care plans relating to such needs, including their communication needs. Such care plans were written in a non-judgemental style. We observed that despite many residents having complex needs in relation to continence, that there were no odours anywhere in the home. We observed that staff were supportive to residents with confusion, for example one resident became lost in the corridors on several occasions and staff supported them in finding their way again. One relative commented particularly on how impressed they were that one resident who repeatedly asked the same question was supported by staff, who always answered them and explained matters to them, even though the person may have asked the same question of them during the space of a few minutes. Where people had more complex needs such as catheter care, would care or diabetic management, there were clear records to show that these needs were being met in accordance with guidelines. Where a person had a urinary catheter, the clinical reason for the catheter was always documented. There are clear systems for the management of wounds and one of the registered nurse has a qualification in tissue viability and leads in the area. Care plans relating to diabetes were clear, with detailed instructions on actions for staff to take if the persons blood sugar levels were too high or low. Registered nurses spoken with had a detailed understanding of more complex needs of residents. Care Homes for Older People Page 16 of 35 Evidence: We noted that the home had good liaison with external health care providers. Records showed that people were promptly referred to their GPs as and when needed. Of the 33 people who responded to this section of the questionnaire, 32 reported that they always or usually received the medical support that they needed. One person reported staff are very good at providing medical support, and in calling in the doctor when required, another my [relative] has suffered poor health for many years and is now better physically than [the person] has ever been and another excellent Sister [name of registered nurse] liaises well with my [relatives] GP and passes back any change in medication to us efficiently. Records also provided evidence of close liaison with other professionals such as the speech and language therapist, physiotherapist and dietitian. We observed two medicines administration rounds and noted that the registered nurses performed them in an organised and consistent manner in accordance with the providers and Nursing and Midwifery Councils guidelines. We observed that one registered nurse ensured that a sleepy resident was fully awake before asking them to take their medication and changed the drink they were giving the person to take their medications with, at the persons request. For another resident who was unable to open their mouth wide, the registered nurse gave the resident their tablet on a teaspoon. Both nurses did not complete the medication administration record until they were satisifed that the person had taken their medication. The home has safe and secure systems for storage of medicines. This is reviewed by the prvider and we observed that improved storage systems had been provided for medication since the previous inspection, which gave registered nurses more space for storage and management of medicines. All records were fully completed, including Controlled Drugs. Where a resident was prescribed medication on an as required basis, there were care plans to direct staff on this, to ensure that registered nurses acted in a consistent manner to meet the residents individual needs. Residents had care plans drawn up in relation to drugs which could affect their daily lives such as mood-altering drugs or aperients. These were regularly reviewed, to assist in ensuring that such drugs remained effective for the individual resident. One person was prescribed oxygen, which the registered nurse reported that they did not actually need at present but that the person became nervous if they did not have it available. This was fully reflected in their care plan. Care Homes for Older People Page 17 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported in continuing to live the life that they chose in their daily lives, including at meals times. Evidence: In their AQAA, the home report on their full and varied programme of activities. They also report that many new activities have been introduced following monthly meetings with residents. Of the 25 people who responded to this section of the questionnaire, 17 reported that there were always or usually activities provided by the home which they could take part in. One person reported that they liked to attend knitting clubs, stroke club, quiz session and art another there are frequent activities arranged and a caring dedicated activities coordinator and another the activities are very good for all the older people. One person who did not leave their room much reported on how they appreciated the bird table outside their room, saying that they had such fun watching the birds and the squirrels. Some of the people who responded less positively reported that it was because they did not wish to join in. For example my [relative] does not want to participate in any activities although offered them. In their AQAA, the home reported that our staff ensure residents are introduced to Care Homes for Older People Page 18 of 35 Evidence: each other to enable them to form friendships. During the inspection, we observed several activities sessions. These were lead and supported by the activities person who clearly knew the residents well and had a good rapport with them. She reported on the feedback from residents and how she planned to change activities, following comments. For example the first day of the inspection took place on a very hot day and she reported that several of the residents had asked for a paddling pool and she was already planning how to meet this request. She reported on how popular promoting fitness with care class was. She reported that as well as organising large and small group activities, she also performed 1:1 visits to people who were unable or unwilling to leave their rooms. All residents have a life history performed. Staff reported that this is an important area in planning care and that they relied particularly on residents relatives to support them in this. The life histories we reviewed were clear and individual in tone. One person we met with was a Roman Catholic and their care plan documented how important their faith was to them and how they were to be supported in this. Another person reported to us on how important visits from their relatives dogs were. This was fully documented in their records. All residents had care plans to document how their individual social care needs were to be met and a record of activities participated in was maintained, including benefit to the resident. During the inspection we observed that social supports were not only performed by the activities person. For example, we observed one carer supporting a resident in reading the newspaper and explaining aspects of the news which were of interest to them. Another care assistant reported to us on the changed supports for a married couple in the home, which they knew about. These matters had not been documented and it is advisable that they are, as such interventions are a significant area in meeting individual peoples social care needs. The home reported in their AQAA that they had recently introduced a relatives communication book and that this had proved popular. We observed that some relatives had taken the opportunity to use these books to communicate apparently small but significant matters for their relative, such as specific preferences about the persons morning routine. During the inspection we met with several relatives. All of them reported that they felt able to come and go as they wished. Residents reported that they appreciated this. We observed a visitor bringing in their dog for the relative to see and also taking the dog to other residents, which was clearly enjoyed. Another relative reported on how they regularly took their relative out of the home for lunch and that they appreciated this. One person described Milford House as very friendly and that they were always made welcome. We noted as good practice on the first site visit that by 10:00am most residents were not yet up, as they preferred to get up more slowly, later in the morning. We asked Care Homes for Older People Page 19 of 35 Evidence: residents if they could chose how they spent their day. Residents reported on how they appreciated being able to bring items of their own into the home. We observed that where residents had a preferred name that staff consistently used it, following directions in care plans. One resident commented on the lots of choice. A care assistant reported that the most important area in ensuring that a resident was able to exercise choice was to give them time. We observed that before lunch carers came up to some of the more dependant residents, asking them if they wanted to go to the dining room for lunch, if they were ready for lunch and how they could help them. Of the 26 people who commented on the meals in the home in questionnaires, 25 people reported that they always or usually liked the meals. One person commented I have eaten the meals and can say I always like them, another the food is not only VERY good but well presented and hot. The kitchen should be congratulated and another a good protein content in the meals and beautifully served. People also commented to us on the meals during the inspection. One person reported the food is absolutely marvellous - dont know how they do it catering for so many different meals and another the food is good nicely cooked, nicely served. However three people did comment that they found the meat tough and one person that the quality of cooking could be variable. Residents are given a choice at every meal. One relative commented on how they appreciated when [my relative] asks for particular foods/recipes these are usually given to [the person]. In their AQAA the home described their enthusiastic catering team. We met with the chef who described their four week menu, which they had drawn up with support from residents, their relatives, staff and the provider. The catering manager reported that they go out and meet with residents regularly to receive their comments on meals provided. They showed a detailed individual knowledge of different residents in the home, their needs and preferences. The catering manager reported on how they tried to give frail people as near normal a meal as possible. For example, that three residents had opted for a finger-food diet, so that they could continue to be as independent as possible. During the inspection, we met with a catering assistant who knew the needs of the residents in the area they were working in. They also reported that they were promptly informed by staff of changes in residents conditions. Milford House has three dining rooms, one in each area of the home. The dining rooms are attractive and there is enough space to accommodate people in large wheelchairs. All meals were well organised, with clear systems in place to ensure that residents had the meal that they wanted. Meals were individually plated up so that people had the portion size that they preferred. People eating in the dining room were served tableby-table, with desserts served after the main meal, so that they remained hot or cold, depending on the type of dessert requested. Staff worked hard to make meals a social Care Homes for Older People Page 20 of 35 Evidence: occasion, encouraging conversation. A choice of drinks was offered with the meal, including wine and beer. We particularly noted that this choice of alcoholic drinks continued to be offered to people who showed signs of confusion, to support them in a normal social occasion. We also observed that when a resident lost concentration when eating a meal, that this was promptly observed by staff and the resident was gently re-awoken and reminded that their food might be becoming cold. Where residents were not able to support themselves independently in eating, relevant aids were provided. Where people were not able to feed themselves, a care assistant sat with them, supporting them and engaging them in conversation, as well as ensuring that they were swallowing their meal safely. Two care assistants we spoke with reported on the importance of mealtimes to residents, even the most dependant residents and encouraging them in remaining independent for as long as possible. Care Homes for Older People Page 21 of 35 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will have their concerns taken seriously and they will be safeguarded from harm. Evidence: In their AQAA, the home commented on the importance to them of free and open communication, so that they could ensure that residents could live the life that they choose. We observed that the complaints procedure is available in the entrance areas of the home, as well as the service users guide. Thirty one of the 33 people who responded to this section of the questionnaire reported that they knew how to make a complaint. One person commented problems are dealt with by family and staff have always been helpful. The activities coordinator is always very helpful, another any complaint is handled locally and quickly and another yes, if I have any complaint I contact Cathy [the manager] and it has always been handled in a very satisfactory way. All of the 14 staff who responded to this section of the questionnaire reported that they knew what to do if a person had concerns about the home. One of the staff members reported on meetings which were held to discuss any concern. We asked people during the inspection how they raised any concerns. One male resident commented that they appreciated having male staff available as he felt he Care Homes for Older People Page 22 of 35 Evidence: could talk to them more easily if he were not happy. Another resident commented that the home was run round us, you tell if you are not happy and they do respond, another person commented you can talk to the staff, you can talk to everybody and another you can talk to staff, say youre not happy, they like you to do that sort of thing. A visitor we spoke with commented on how they appreciated the communications book provided in their relatives room, so that they could highlight small matters before they became an issue. No complaints have been made to us about this service since their last inspection. We reviewed the homes complaints register. The register was kept in an orderly manner, which facilitated audit. Records showed that all matters reported were investigated and prompt responses made to complainants. Where investigations were necessary, these were completed in detail and in an impartial manner. Persons involved in complaints were informed of outcomes. In their AQAA, the home reported on the training for staff on the Mental Capacity Act, to ensure that residents were able to exercise choice, including risk assessments where indicated. All residents records we looked at had clear care plans to describe a residents communication needs. Where a resident was unable to use a call bell, a risk assessment was completed about this, together with a plan of how the persons safety was to be maintained. A review of staff training records showed that staff had been regularly trained in safeguarding vulnerable adults. All of the care staff we spoke with were able to inform us of relevant actions needed to be taken to safeguard vulnerable adults when they were given a range of scenarios, which could indicate that the person might be at risk. The manager and her deputy have experience of working withing local procedures. The home has made referrals in support of vulnerable adults via safeguarding procedures and has cooperated in full with multi-agency groups if referrals have been made in relation to their service. No issues raised during such processes have been up-held. Care Homes for Older People Page 23 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by a well maintained environment, which meets their needs and where the principals of infection control are maintained. Evidence: In their AQAA, the home reported on the extensive work done to the fabric of the building to ensure the safety and wellbeing of our residents during the past year. During the inspection, we toured all of the home and observed that all areas and equipment were well maintained and clean. One relative commented on the attractive decor. One resident commented on the promptness of the maintenance service. They reported that they had had a leak in their en-suite overnight which had meant there was water all over the floor. This had been promptly addressed and when we visited them mid-morning, the leak had been repaired and the en-suite was dried out. All of the 33 people who commented in this section in questionnaires reported that the home was always or usually fresh and clean. Comments included it makes and excellent impression on visitors and there has only been one occasion when I was not satisfied but this was soon rectified, I think it was due to a new member of staff. We observed cleaners performing their role and they were observed to clean under and behind items, as well as the top. A domestic reported that they had sufficient supplies of cleaning chemicals and equipment and that they worked well. We inspected items such as the undersides of raised toilet seats and bath hoists and Care Homes for Older People Page 24 of 35 Evidence: observed that they were all clean. Milford house is a large nursing home and accommodation is provided over two floors, with a two-floor wing to one side known as Cathedral Wing. Rooms generally exceed standards for room size and nearly all are en-suite. There are a range of communal areas in the home and large gardens, which are wheel-chair accessible. The home has different types of assisted bathrooms, to suit people with different disability needs. People expressed their appreciation of the home environment. One resident reported about the home I call it the hotel. A relative commented on how lovely the gardens were. One person reported on how they appreciated having an assisted bathroom close to their room, so that they could reach it using their frame, rather than having to use a wheelchair to get there. The home has a wide range of equipment provided to meet the needs of people with differing disability. Many of the beds were profiling. There were a range of different hoists to aid manual handling. Where people were assessed as being at risk of pressure ulceration, relevant aids were provided to reduce risk. Aids to support people in retaining independence were also provided. One person reported on how they appreciated having been given a walking frame, describing it as my friend. Another person described their en-suite as the most important part. The home follows full systems to prevent spread of infection. We observed in all double rooms that peoples toiletries and wash bowls were named and stored separately. All food in kitchenette fridges were labelled and dated and no items were stored over their due date. Where residents needed hoists to aid their manual handling, there were systems in place to ensure that hoist slings were not used communally and were regularly laundered. We observed that staff used disposable gloves and aprons when providing care, disposing of them correctly and promptly after use. Glove dispensers were available in some areas such as sluice rooms and bathrooms but not in en-suites, as is recommended, to ensure staff have ready access to such equipment. We observed in some sluice rooms that the brush for cleaning sanitary items was left wet and was not always clean. Such brushes need to be cleaned after use and stored dry, to prevent risk of cross infection. We visited the laundry and found that it was clean, including the areas behind the machines, and well organised. The laundress reported that staff consistently followed the providers policy on management of infected and potentially infected laundry. They also reported that all laundry was separated at source. We did observe that there were some un-named clothes in the laundry. We discussed this with the laundress, who reported that the naming of clothes could be an issue, particularly for people admitted for respite care. We discussed with both the manager and the laundress a range of Care Homes for Older People Page 25 of 35 Evidence: ideas as to how this area could be addressed for people who did not have relatives who were able to support them in marking clothes and they both agreed to progress this matter. Care Homes for Older People Page 26 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs will be met by a stable team of staff, who have been safely recruited and are fully trained in their role. Evidence: In their AQAA, the home reported on their stable workforce, some of whom have been employed in the home for several years. They report that they have adequate numbers of staff on duty with a skill mix to meet residents needs. People commented on staffing in questionnaires. Of the 27 people who responded to this part of the questionnaire, all people reported that there were always or usually staff available when they needed them. Comments varied from staff are not always available at the time requested particularly in the morning when help is needed to get dressed, through sometimes slow on answering a room call to a relative who reported that staff were always available especially if my [spouse] is in any discomfort. Of the staff who commented, one person felt that the home worked on minimum numbers, another that staffing levels did not present an issue apart from if people went off sick and another that there were enough care staff but that the home might benefit from more activities hours. We talked to residents and staff about staffing levels and responses to call bells when we visited the home. One person reported I ring my bell and yes they DO come, Care Homes for Older People Page 27 of 35 Evidence: another person Ive got a call bell but the response varies and another when I ring my bell, they are surprisingly quick. We observed that one of the residents regularly called oy to staff when they were passing, that staff uniformly responded to this call, even if the person called several times in a few minutes. We discussed staffing levels with staff on duty and whilst some staff felt that the home was short of staff others did not. Staff reported that if they needed assistance with a resident, that staff came to help them promptly. The activities person reported that if they rang for assistance with a resident, staff always came. They reported that it they needed to use the emergency bell that staff were consistently prompt in coming to address any emergency situation. We observed a lunchtime meal and saw that there were plenty of staff available to support residents. We discussed staffing levels with a range of visitors, none of whom felt that there was a lack of staff in the home. We reviewed systems for recruitment of staff and observed that employment procedure complied in full with the providers policies and our Regulations. All staff had a proof of identity, two satisfactory references, a health status questionnaire and police checks on file. There was evidence that all staff were interviewed using a assessment tool. Where the home had received satisfactory protection of vulnerable adults check but had not yet had a criminal records check, there was evidence that staff worked fully supervised and were aware of their responsibilities for doing so. The home employs a training manager. This person is responsibility for ensuring that induction and training takes place. Of the 14 people who responded to this section of the questionnaire, 12 reported that their induction covered everything that they needed to know very well and two that it mostly did this. Induction records were clear and fully complied with guidelines. We spoke with staff about their induction and they reported that they had felt supported by the home. One resident reported that there had been a new carer put on their floor and that they had only been here a week but they felt that they had already got to know them. We looked at training records. The home supports all staff, including domestic and catering staff, as well as care staff in gaining relevant National Vocational Qualifications. The home employs two National Vocational Qualifications Assessors to support this process. Where new staff need supports in English language skills, the home has good links with a local training college to facilitate this. The home has a clear training matrix, so that the training manager can see at a glance who is due to undertake which training. Where residents are to be admitted with complex medical needs, the home ensures that staff are trained in such roles. For example, the training manager reported on recent up-dates on artificial feeding systems. Where, for example, a resident has a stoma, there were records that key staff had been trained and a cascading process put in place so all staff were aware of the roles they needed Care Homes for Older People Page 28 of 35 Evidence: to perform. The home also supports registered nurses in extending and developing their clinical skills. Staff reported on the supports for training. One person reported on frequent training for ALL staff and another that one of the strengths of the service was to provide training for all staff. Staff we spoke with were knowledgeable about how to meet residents needs, including care of a person with a stroke, breathing difficulties or dementia. Care Homes for Older People Page 29 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents at Milford House will be protected by its safe management systems and where the principals of health and safety are generally up-held. Evidence: In their AQAA, the home report we are fortunate to have a strong team of senior staff and managers all of whom have been with us for many years. They all work closely and well together having the same ethos and pride in their home. The manager, Mrs Cathy Fountain is an experienced manager and registered nurse. She has been in post for several years and is supported by a deputy, a training manager and senior sisters who are responsible for each of the floors and the Cathedral Wing. The home is supported by the provider, Barchester Healthcare. A regional manager visits the home once a month and compiles a written report of their findings. We noted as good practice that these reports do not simply report on good points, they also report on areas where action needs to be taken and progress in action plans for addressing improvements. For example, one area related to accessibility of the gardens for Care Homes for Older People Page 30 of 35 Evidence: wheelchairs. It was clear that peoples comments in relation to this had been heard and that action plans had been put in place for them to be addressed. The provider has standard systems for reviewing quality of care. These include seeking the views of users of the service both via questionnaires and regular meetings. The home also performs monthly audits of areas such as accidents, incidence of pressure ulceration and infection. Audits consider any trends and how risk is to be reduced and quality of service provision improved. Where risk is identified, this is automatically considered at the monthly health and safety meeting. As people have reported to the home on response times to the call bell, this is also regularly audited. The homes audit showed no issues in relation to response times when call bells are used. Mrs Fountain reported that they considered complaints as part of quality audit but this was not in writing and that therefore any trends in complaints were not considered. Residents moneys are effectively managed, with a full audit trail for sundry charges, such as hairdressing, chiropody and newspapers. Reviews of training records showed that staff were regularly trained in mandatory areas relating to health and safety. While we were visiting the home, we observed staff safely performing manual handling and up-holding the principals of infection control. The provider has standard systems to ensure that all equipment and services are fully maintained. The fire log book was fully up-to-date. We observed that where residents needed safety rails, that they were used correctly in accordance with guidelines from the Health and Safety Executive. When we looked at risk assessments for their use, we observed that records showed a tick under the section directing the person making the assessment to indicate that all other areas had been considered. Such assessments would be improved if the assessment states what other alternatives for the resident had been considered. We also observed that whilst the home uses profiling beds, that none were lowered to the floor and crash mats used, to prevent the use of bed rails and advise that the home should consider this option more actively. Nearly all of the parts of the home where old-style radiators were provided had been provided with protection. However we did identify a few radiators which had not been provided with protection. This had also been identified by the managers and there was an action plan in place to ensure that they would be protected. Care Homes for Older People Page 31 of 35 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 26 13 Brushes for cleaning 30/09/2009 sanitary items must be clean and stored dry. If sanitary items are cleaned with brushes which are not clean and dry, there is a risk to cross infection. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 8 Where a person who is unable to change their position independently spends much of the days out of their room, there should be systems to ensure that records of their changes in position can be completed in a contemporaneous manner. Where care assistants support residents in activities or exercising choice, this should always be documented. The home should further review equipment and systems to ensure that all residents own clothing can be returned to them after laundering. Glove dispensers should be provided in en-suite bathrooms and all other areas where personal care may be carried out. 2 3 12 26 4 26 Care Homes for Older People Page 33 of 35 5 6 7 33 38 38 A system for written monthly audit of complaints should be put in place. Assessments for the use of bed rails should state what alternatives to bed rails have been considered. The home should review why none of the people in profiling beds have had their bed lowered to the floor and crash mats used, to prevent the risks associates with the use of safety rails. Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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