Care Home: Millreed Lodge

Similar services:

• Abbey The
• Snydale Care Home
• Larchfield Manor
• Hawkhills
• Beeches The - North Yorkshire County Council
• Carentan House
• Ravensworth Lodge

What the care home does well The home is well managed and run in the best interests of the people who live there.Millreed LodgeDS0000057454.V376671.R01.S.docVersion 5.2The people who live at Millreed Lodge said they are happy and the home is warm and welcoming. We were told that the staff do what people want in the way people prefer. Visitors call regularly and are always made welcome. There is a relaxed, comfortable and friendly atmosphere in the home. The staff have a good relationship with people and everyone seemed to be very content. Everyone we spoke to said they are satisfied with the care and support they receive. All the relatives we spoke with also said they are very happy with the home and feel their relatives are well looked after. Before moving into Millreed Lodge, people`s needs are thoroughly assessed to make sure that the home is able to meet their needs. Everyone said that staff listen to them, and act on what they say and people said they like the meals and enjoy the activities. The staff understand the needs and preferences of all the people who live at the home. People`s health is looked after and the staff have the skills and experience they need to do this. There is good and friendly interaction between the people who live at the home and the staff. There seemed to be enough staff on duty to make sure they have time to spend with people in conversation as well as supporting people to take part in individual and group activities. The home`s recruitment procedures are thorough, making sure that staff are safe to work with the people who live at the home. All the staff said they enjoy working at the home and felt they were well supported by their manager. They said the training is good and helps them to do their job well. The complaints and adult protection systems work well and people said they know and understand what to do if they have a concern. The home is clean and well maintained and everyone we spoke to said the home is always kept fresh and clean. One person said `Millreed Lodge is always clean and fresh.` What has improved since the last inspection? When someone moves into the home a plan of care is developed within the first three days. This is then built upon and improved as staff get to know the person better. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 The medicines administration procedures have been improved, to make sure the records are always accurate and to confirm that people are receiving their medicines in the way their doctor has prescribed. The home has appointed an activities co-ordinator who is gradually expanding the range of activities available and getting the staff more involved. There is plenty of training available for staff and they said the training is good and keeps them up to date. The home keeps good records of staff training, which also shows when updates are needed. What the care home could do better: When staff are recruited who have worked for organisations whose policy is not to provide references, it is essential that additional references are obtained and careful notes kept of any verbal references people are willing to give. Key inspection report CARE HOMES FOR OLDER PEOPLE Millreed Lodge 373 Rochdale Road Walsden Todmorden Lancashire OL14 6RH Lead Inspector Liz Cuddington Key Unannounced Inspection 20th July 2009 10:40 DS0000057454.V376671.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millreed Lodge Address 373 Rochdale Road Walsden Todmorden Lancashire OL14 6RH 01706 814918 01706 817919 millreedlodgecare@btconnect.com 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) Millreed Lodge Care Ltd Mrs Elizabeth Shufflebottom Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (2), Terminally ill (2), of places Terminally ill over 65 years of age (2) Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To accommodate a maximum of two persons in category TI/TI(E) at any one time To accommodate a maximum of two persons aged under 65 years of age with a physical disability Two named persons over 60 years of age Date of last inspection 21st July 2008 Brief Description of the Service: Millreed Lodge is set in landscaped grounds alongside the Rochdale canal and Walsden Water, and is situated on the main Rochdale Road in Todmorden. Banks, a post office and shops are one mile away in the local town. The home provides care with nursing for up to thirty-three people The accommodation was created many years ago by the conversion of a textile mill. A conservatory and reception area has been added to the ground floor accommodation. All of the bedrooms have en suite toilets and washbasins. There is a passenger lift that serves all floors. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star – good service. This means the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The weekly fees at Millreed Lodge are between £365 for residential care without nursing and £486 for care with nursing. Hairdressing, chiropody, newspapers and personal items are not included in the fees. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Millreed Lodge. The visit to the home was carried out over one day by one inspector. The last key inspection was in July 2008. The methods used to gather information included conversations with the people living at the home, the staff and visiting healthcare professionals as well as looking at care plans and examining other records. We received the homes self-assessment questionnaire before the inspection visit. This gave us a lot of useful information about the home and helped us plan the visit. We would like to thank the people who live at the home and their relatives for their welcome and hospitality and for taking the time to talk and share their views during the visit. What the service does well: The home is well managed and run in the best interests of the people who live there. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 6 The people who live at Millreed Lodge said they are happy and the home is warm and welcoming. We were told that the staff do what people want in the way people prefer. Visitors call regularly and are always made welcome. There is a relaxed, comfortable and friendly atmosphere in the home. The staff have a good relationship with people and everyone seemed to be very content. Everyone we spoke to said they are satisfied with the care and support they receive. All the relatives we spoke with also said they are very happy with the home and feel their relatives are well looked after. Before moving into Millreed Lodge, peoples needs are thoroughly assessed to make sure that the home is able to meet their needs. Everyone said that staff listen to them, and act on what they say and people said they like the meals and enjoy the activities. The staff understand the needs and preferences of all the people who live at the home. Peoples health is looked after and the staff have the skills and experience they need to do this. There is good and friendly interaction between the people who live at the home and the staff. There seemed to be enough staff on duty to make sure they have time to spend with people in conversation as well as supporting people to take part in individual and group activities. The homes recruitment procedures are thorough, making sure that staff are safe to work with the people who live at the home. All the staff said they enjoy working at the home and felt they were well supported by their manager. They said the training is good and helps them to do their job well. The complaints and adult protection systems work well and people said they know and understand what to do if they have a concern. The home is clean and well maintained and everyone we spoke to said the home is always kept fresh and clean. One person said Millreed Lodge is always clean and fresh. What has improved since the last inspection? When someone moves into the home a plan of care is developed within the first three days. This is then built upon and improved as staff get to know the person better. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 7 The medicines administration procedures have been improved, to make sure the records are always accurate and to confirm that people are receiving their medicines in the way their doctor has prescribed. The home has appointed an activities co-ordinator who is gradually expanding the range of activities available and getting the staff more involved. There is plenty of training available for staff and they said the training is good and keeps them up to date. The home keeps good records of staff training, which also shows when updates are needed. 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 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. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 does not apply People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: People said that they were given enough information about the home before deciding to move in, and they had also received a contract. Where possible the home encourages people and their families to visit and talk to the people who already live at the home, their relatives and the staff. The home invites them to come and spend time there, share a meal and maybe take part in the days activities. This means that the home’s staff can get to Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 10 know the persons needs and the individual has the information he or she needs to make a decision. Before moving into Millreed Lodge, peoples needs are assessed, to make sure that the home has the necessary equipment and staff have the skills to care for people properly. This assessment, as well as Social Services needs assessments when available, forms the basis for the individual plan of care and support. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and healthcare needs are met and the care plans accurately reflect peoples care and support needs. People are protected by the medication administration systems. Staff treat people with respect, care and consideration at all times. EVIDENCE: From observation and discussions with staff and people living at the home, it was clear that the staff are aware of each persons needs and preferences. The staff make sure they provide the help people need in the way they prefer. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 12 When someone moves into the home a plan of care is developed within the first three days. This can then be built upon and improved as staff get to know the person better. Staff said they are always kept up to date with peoples changing needs. Three care and support plans were looked at, to make sure that peoples health and personal care needs are being met in the way the person prefers. The plans cover each area of the individuals care needs, emphasising any special needs the person may have. The manager said that the people who live at the home and their families are invited to go through the plan and agree any changes. We saw evidence to show that this is happening. Also, the staff review each part of the plans every month, to make sure the reflect peoples current care and support needs. These reviews confirmed our observations that the staff are fully aware of everyones needs and are offering the level of care and support each individual needs. The plans include risk assessments and management plans where someone is at risk of falling, becoming malnourished, injuring themselves or any other area the staff feel may put the individual at any risk. Health care visits and treatments are recorded in detail and everyone who commented said they always receive the healthcare they need. One healthcare professional confirmed that the home always seeks advice and acts upon it, to improve the health of the people who live there. The people we spoke with said they are satisfied with the care they receive and everyone who commented said they are looked after well. The medicines are kept safe and secure in locked cabinets and the medicine trolleys were locked when unattended. Most of the medicines are supplied by the pharmacy in a monitored dosage system, but some remain in the original packaging. We examined the Medicines Administration Record (MAR) charts, which must show clearly the quantities of medicines received and in stock for each person. The medicines supplied in the monitored dosage system appeared to be recorded accurately. We checked some of the medicines that were supplied in their original packaging, to make sure the numbers that had been signed as administered tallied with the amounts received and the quantities remaining. We looked at four different medications and found that they all appeared to be accurate. Staff had signed the MAR charts each time a dose of medicine was offered. The manager has introduced a procedure where the nurse administering medication counts all medicines that are supplied in their original Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 13 packaging after each dose is administered. This makes sure that the quantities in stock and the amounts administered tally with the quantity originally received from the pharmacist. During the visit, all the staff were seen to treat people with respect and maintain their dignity. The people who commented said that they receive the care they need and are supported to maintain their independence for as long as they are able. Everyone said the staff listen and act on what they say. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in a range of activities. People are offered a good choice of meals to make sure their dietary needs and preferences are met. EVIDENCE: The activities are organised by the activities co-ordinator with support from the care, nursing and administrative staff. The staff spend some time with people on one to one activities, as well as doing things people can enjoy together. One person was clearly enjoying a new game that had been purchased, which was designed to support people to keep up their cognitive and decision making skills. The activities co-ordinator said she is gradually widening the range of activities that are available. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 15 There is a four week activities plan which includes painting, model making and other crafts as well as quizzes, dominoes, trips to the pub and the shops. The home also celebrates special events and outside entertainers come in to do musical activities, which people said they enjoy. The activities co-ordinator is gradually developing life histories for everyone and people’s families are being asked to bring in photos and other items that will help bring back memories. These are being put together to make a memory book and memory box for each person. These will help staff get to know people even better and plan activities and have conversations that remind people of the things they have enjoyed during their lives. The care staff should be encouraged to spend more time with people, doing activities or just talking. At present the care staff spend most of their time on care and other tasks and although they do take some time to socialise with people, this needs to be a more central part of their responsibilities. The activities co-ordinator cannot improve the social life of the people who live at Millreed Lodge without the full participation of all the staff. At mealtimes there are always alternatives available if people do not want the choices on the menu. As well as a cooked meal at lunchtime, there is a choice of hot and cold dishes at teatime. People said that they enjoy the meals, the portions are generous and the food is always hot when it is served. People are offered hot and cold drinks and snacks throughout the day. Special diets are catered for and staff were seen to assist people who needed help in a calm and discreet manner, following the persons own pace. The people who live at Millreed Lodge said they can do what they want, when they want. This confirmed our observations that the staff support people to live their life in the way they choose. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. The staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people at the home are safe. EVIDENCE: Any complaints or concerns are recorded in a complaints file. The actions taken and the outcomes are recorded. Where they are needed, improvements are made as a result of complaints investigations. Staff said they know what to do if anyone has concerns. The people who live at the home and their relatives said they know what to do if they have a concern or complaint. Newly employed staff are made aware of the homes whistle blowing policies and procedures, to be used if they suspect abuse or see examples of poor practice. All the new staff take adult protection and whistle blowing training as part of their induction training. More than half of the staff have already Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 17 taken refresher training in adult protection and the rest will complete this by the end of the year. All the appropriate policies and procedures are in place to guide staff. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable and well-maintained environment. EVIDENCE: The home is clean and well maintained and everyone we spoke to said the home is always kept fresh and clean. The home is attractively decorated and the furniture is comfortable. The rooms are comfortably furnished and have a welcoming feel. There are sufficient, accessible toilets and bathrooms on all floors of the house. One of the bathrooms is in the process of being upgraded with a specialist bath and Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 19 another bathroom has already been upgraded. All of the bedrooms have an en suite toilet and wash basin. The gardens are attractive and well kept and are a very pleasant place for people to sit out in. There is a seating area at the back of the house, overlooking the river and there is ramped access to the front door from the car park. The front garden is accessible and attractive, with a sloping walkway leading to a shaded seating area looking onto the garden and the pond, which is filed with plants and ornamental fish. During the last year a new central heating and hot water system has been installed. When we visited workmen were in the roof space extending the sprinkler system, which is already installed throughout the rest of the house as part of the home’s fire safety measures. There is an ongoing major refurbishment programme. When we visited, eight bedrooms had been improved and en suite toilets and washbasins fitted. There is a programme of re-decoration throughout the house. The laundry is to be re-built and a new, quiet lounge created. This is a facility that people said they would value. Staff are employed to help look after the maintenance of the house and grounds as well as keeping the gardens tidy. Protective gloves, aprons and disinfecting hand rub are available for staff to use when necessary, to support the homes infection control measures. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet peoples needs. People are generally protected by the recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Suitable training is provided to make sure staff have the skills and knowledge they require to be able to meet peoples needs. EVIDENCE: The staff rotas, and peoples comments, confirmed our observations that there are enough staff on duty to meet peoples care, social and leisure needs. In addition to the manager, there is a nurse and five support staff on duty during the day and evening, and three waking staff at night, including a nurse. There are also plenty of housekeeping, catering and other staff on duty each day. These staffing levels seem to be sufficient to provide care and support for the people who currently live at Millreed Lodge. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 21 The staff confirmed that staffing levels are adjusted to meet peoples needs. People who live at the home said there are enough staff around and our observations confirmed this. One person said there are always staff around, making sure that everyone is all right. The homes recruitment procedures are thorough, making sure that staff are safe to work with the people who live at the home. All new staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. There is plenty of training available for staff and they said the training is good and keeps them up to date. The home keeps good records of staff training, which also shows when updates are needed. Staff have recently attended training courses on moving and handling, fire safety and other health and safety training as well as infection control. Training in the implications of the Mental Capacity Act and deprivation of liberty is planned for later this year. Other training courses that staff are to attend this year include communication skills, dementia care, care of the dying and person centred planning. All new staff complete induction training which meets the Skills for Care criteria. This gives them good basic training to help them do their job effectively, and provides a sound basis for taking a National Vocational Qualification (NVQ) course. Thirteen of the twenty-three care and support staff have achieved an NVQ in care at level 2 or 3, and eight are currently taking the level 2 or 3 award. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe and well managed, in the best interests of the people who live there. EVIDENCE: The manager has the necessary experience and qualifications to manage the home, in the best interests of the people who live there. The manager attends training to keep up her professional development. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 23 The records and the staff confirmed that all staff have one to one supervision meetings with their line manager. Supervision meetings support staff to plan their personal and professional development and give them the opportunity to discuss any areas of concern in a confidential setting. The staff said that they are well supported and they work well together as a team. Regular staff meetings are held and staff are encouraged to make their views known and contribute to the running of the home. Peoples personal information is stored securely when it is not being used. The homes policies and procedures are up to date, which makes sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. Following their most recent inspection, the Environmental Health Officer has awarded the homes kitchen a score of four stars out of a maximum of five, for hygiene and good kitchen practice. The requirements of the report have been dealt with. When we looked, the kitchen was clean and well organised. The home has a range of quality assurance systems in place, to help determine the quality of service the home offers. These include surveys for the people who live at the home, their relatives and visitors and regular meetings with the people who live at Millreed Lodge and their relatives. The information and comments are used to improve the quality of the service offered. We received the home’s annual self assessment form before the inspection. It contained information about the home and the service that is provided, but it could be more detailed in order to give us a fuller picture of the service and any improvements or difficulties they have had during the past year. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations When staff are recruited who have worked for organisations whose policy is not to provide references, additional references need to be obtained and careful notes kept of any verbal references people are willing to give. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 26 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 27 Millreed Lodge DS0000057454.V376671.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!