Care Home: Milton House

What the care home does well People are generally happy with the service offered at Milton House. Positive comments were received such as, "I am quite happy here," and, "The staff do their best to help us" were made. When people are considering moving into Milton House staff from the organisation will assess their needs and try to help them in finding a suitable placement. Milton House provides people with a well maintained and homely environment. People said that they liked the food provided at Milton House and were offered choices about what they ate. People are able to welcome their visitors at any time, and there are regular opportunities for families to enjoy time together at events put on by the home. Staff have a kind and caring approach to residents. The home has a friendly atmosphere and staff and residents get on well together. What has improved since the last inspection? A new permanent manager has been appointed this year. They are enthusiastic, and are committed to continuing to make improvements at Milton House. Since the previous inspection redecoration and refurbishment has continued. This means that people are living in a home where the environment is continually improving. A new dining area has been created that provides more space and a pleasant place for people to enjoy their meals. Opportunities for activities are improving. More activity equipment and games are available. A minibus is now also available for the home use so that in the future people may benifit from occasional trips out. Staffing has been an issue at the home with a fairly high staff turnover, and use of agency staff. Things now seem to have settled down. People are benefiting from having more permanent staff to care for them. When staff start work at the home they are now given better initial support and training. This will help to ensure that they understand their role and develop good practice in their work from the start of their employment. People can now feel more confident that management and staff understand the importance of managing any concerns properly through referral to the local safeguarding team. Staff training has been ongoing to ensure that staff have a good level of core skills and care for people in a safe way. Improvements have been made to some aspects of documentation such as the preadmission assessment format. This is to keep up to date with changes in Legislation. What the care home could do better: Care planning at the home has improved, but people still cannot be sure that all of their individual needs will be identified, assessed, planned for and carried out in practice. Care planning needs to be developed so that it provides a robust and person centered approach to meeting people`s individual needs. So that people can feel confident that their medicines are managed safely and effectively, systems and procedures relating to this aspect of care need to be reviewed. Staffing numbers at the home need to be sufficient to ensure that staff employed do not work excessive hours. This is poor practice and could potentially place residents at risk if they are being cared for by staff who may be tired. Key inspection report Care homes for older people Name: Address: Milton House 58 Avenue Road Westcliff On Sea Essex SS0 7PJ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Vicky Dutton     Date: 1 8 1 1 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Older People Page 2 of 31 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. 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 Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Milton House 58 Avenue Road Westcliff On Sea Essex SS0 7PJ 01702437222 01702436536 info@strathmorecare.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Davie Vive-Kananda care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 28 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Milton House is owned and managed as part of the Strathmore Care group of homes. Care and accommodation is provided for up to twenty eight older people. The home is not registered to provide care for people who have dementia. The home has twenty six single rooms and one shared bedroom. Most bedrooms have an en suite facility. There are two spacious lounge areas and a dining room. There is a car parking area to the front of the building and an enclosed secure courtyard garden, overlooked by a lounge and dining area. Care Homes for Older People Page 4 of 31 Over 65 28 0 1 6 1 2 2 0 0 8 Brief description of the care home Milton House is situated close to central Southend and has good access to local bus and train routes. Milton House has both a Statement of Purpose and Service Users Guide available to provide people with information about the home. Fees at the home range between £395.78 to £439.88 per week. Fees charged vary according to individual needs and funding arrangements. There are additional charges for chiropody, hairdressing, and other personal requirements. Care Homes for Older People Page 5 of 31 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: one star adequate 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: This was an unannounced key site visit. At this visit we (CQC), considered how well the home meets the needs of the people living there, how staff and management work to provide good outcomes for people, and how people are helped to have a lifestyle that is acceptable to them. We spent eight hours at Milton House. We looked around the premises to see if it was pleasant and safe for people. We viewed some care records, staff records, medication records and other documentation to see how well these aspects of care and running the home are managed. Time was spent talking to, observing and interacting with people living at the home, and talking to management and staff. We also spoke to three visitors during the site visit. The homes Annual Quality Assurance Assessment (AQAA) was sent in to us. The AQAA is a self assessment that providers are required by Law to complete. It was received by Care Homes for Older People Page 6 of 31 the due date. The AQAA was briefly completed, but outlined how management feel they are performing against the National Minimum Standards, and how they can evidence this. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives, involved professionals and staff. The manager confirmed that a good number of these had been returned to us. However we had only received two responses, both from people living at the home, at the time of writing this report. Any surveys received subsequently will continue to inform our opinion of the service. The views expressed at the site visit and in survey responses have been incorporated into this report where appropriate. We were assisted at the site visit by the manager, the admissions co-ordinator for the Company and other members of the staff team. Feedback on findings was provided throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the staff team, residents, relatives and visiting professionals for their help throughout the inspection process. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? A new permanent manager has been appointed this year. They are enthusiastic, and are committed to continuing to make improvements at Milton House. Since the previous inspection redecoration and refurbishment has continued. This means that people are living in a home where the environment is continually improving. A new dining area has been created that provides more space and a pleasant place for people to enjoy their meals. Opportunities for activities are improving. More activity equipment and games are available. A minibus is now also available for the home use so that in the future people may benifit from occasional trips out. Staffing has been an issue at the home with a fairly high staff turnover, and use of agency staff. Things now seem to have settled down. People are benefiting from having more permanent staff to care for them. When staff start work at the home they are now given better initial support and training. This will help to ensure that they understand their role and develop good practice in their work from the start of their employment. People can now feel more confident that management and staff understand the importance of managing any concerns properly through referral to the local safeguarding team. Staff training has been ongoing to ensure that staff have a good level of core skills and care for people in a safe way. Improvements have been made to some aspects of documentation such as the preadmission assessment format. This is to keep up to date with changes in Legislation. Care Homes for Older People Page 8 of 31 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. Care Homes for Older People Page 9 of 31 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 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can feel confident that staff will work with them to ensure that the home is suitable to meet their needs. Evidence: The home had a Statement of Purpose and Service Users Guide in place. When people are considering using the home they are not routinely given a copy of the Service Users Guide. This should happen so that people are provided with useful information that they could study at their leisure to assist their decision making. The admissions co-ordinator said that verbal information is given and people encouraged to visit the home. The manager added that a generic Company brochure is given. It was stated that if people visited the home the Service Users Guide would be gone through with people. When people move into the home we saw that a Residents Handbook and copy of the Service Users Guide were available in their rooms. On surveys people said that they had received enough information to help them to make a decision about moving in to the home. Two visitors spoken with both said that they had visited the Care Homes for Older People Page 11 of 31 Evidence: home and had been happy with the information given. One person said, This was the best home by far and the staff were informative and helpful. To ensure that Peoples needs can be met by staff, an assessment of their needs should be undertaken before they move in. We looked at the files of three people who had been more recently admitted to Milton House. Pre-admission assessments are undertaken by an admissions co-ordinator for the Company. They then advise the person about the most suitable home in the group to meet their needs and encourage them to visit. The manager is not involved in the assessment process. We did however see that it is now recorded that admissions are discussed with the manager, information shared and an agreement reached to accept the placement. It is not clear however if the manager would be able to refuse a placement if they felt that the person was not suitable for the home. For example two recent admissions to the home have been short term placements for people who are very much younger than the other residents at the home. It has been difficult for the home to fully meet their needs. We saw that good pre-admission assessments of the persons needs had been undertaken. Sometimes the assessment and the admission occurs on the same day so the home may not have time to fully prepare and brief staff on the person needs before they arrive. Pre-admission assessments are undertaken using a set format that covers peoples physical and social needs. The format has been revised to include information about a persons mental capacity. The assessments viewed were well completed and highlighted actions that need to be undertaken by the home such as refer to district nurse and register with a local doctor. Care Homes for Older People Page 12 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Milton House will receive care that seeks to recognise and meet their their individual needs and preferences. Evidence: During the day people living at the home and relatives told us that they were happy with the care they received at Milton House. People were generally well groomed and appropriately dressed. On two surveys people living at the home said that they always or usually received the care and support that they needed. People using the service said, I am very happy with everything, and, They treat you very well and I am quite happy. Relatives said, The residents are clean and cared for, and They always let you know if anything happens. Our (CQCs) observations of care on the day of the site visit showed that people were offered appropriate care and support. Staff were quick to respond if someone needed assistance. Staff spoken with seemed to have a good understanding of individual residents needs and abilities. We saw that everyone at Milton House had a care file in place containing various assessments, care plans and daily documentation. We looked at a four care files to Care Homes for Older People Page 13 of 31 Evidence: see how well care is planned for and arranged. We wanted to see if people have a say in their care, how the home ensure that staff are made aware of peoples needs, and how staff are helped to meet peoples needs in an individual way. A new manager is in post at Milton House. They are working on care plans to try and make them more usable and easier to read. They are also trying to incorporate all records about each individual resident in one place. This is good practice. Whilst people are happy with the care they are receiving at Milton House, this is not particularly well supported by robust care planning. Some shortfalls found in care records were concerning. At the moment people are not proactivly involved in planning for their care. The manager did however say that plans are discussed with families. They hope to develop this area by strengthening the key worker system in the home, and encouraging staff to work more directly with residents in relation to care planning. We saw that for newer residents some information from the preadmission assessment had been incorporated into care planning. Other important information, such as specific medical conditions, had not. For example one person was identified as having osteoporosis. This was not mentioned in the falls risk assessment, as this was a generic rather than person centred format. It was also not mentioned in mobility care plan. This means that staff may not be fully aware of peoples needs, or react appropriately to any given situation. Care plans are divided up into ten different aspects of care for example personal care and skin care, and mobility, exercise and physical activity. These sections are then sub divided further to prompt staff to identify all aspects of needs. Care plans varied in quality. Some aspects were good such as describing where people liked to eat and what their preferences were. Most provided a good level of basic information. However care plans tended to be descriptive rather than provide staff with information enabling them to meet peoples needs in an individual and person centred way. For example, for one resident the care plan said, X is slightly deaf but does not wear a hearing aid. No information followed for example if they had a good side, face the person and so on. There was a lack of detail on many care plans for example X will require assistance with bathing and washing and X will require assistance from carers to wash and groom their hair. This information will not help staff to understand peoples needs or unique preferences and deliver care in an individual way. A residents/relatives meeting in October recognised that there were still issues to be addressed. The minutes said Personal care of residents is average at present and needs to improve to ensure it is more person centred. Sometimes information on care records could be confusing and give staff mixed messages. For example one person had a risk assessment in place relating to the use of a specific incontinence aid, but the care plan said that they wore pads. For the same person their care plan said that the person, has a wash every day, has a bath every week. No baths were recorded. The manager said that they did not have Care Homes for Older People Page 14 of 31 Evidence: baths anymore. Care plans did not always give a feel for the whole person. For example one person spoken with became quite distressed and weepy. The manager said that they did this and had a history of depression. There was no mention of this in their care plan to help staff to understand and support them effectively. Daily care such as bathing is recorded on separate sheets. It was not clear whether staff do not maintain these records well, or, if people do not have many opportunities for bathing, and are only offered strip washes. For example one person was recorded as having only four baths and four showers since they moved in during August this year. For another person, admitted at the beginning of October, only one bath and three bed changes had been recorded. One person had stated that they wished to have a shower every day but had only had one. Records showed however that staff had offered further opportunities. When we spoke to the person they told us that they would really like to have a daily shower, but that the water was too cool for them. The home are required to maintain hot water temperatures at a very safe and low level that protects people from scalding. It may be that this is not hot enough for this particular resident. The manager undertook to check the temperatures and see if anything could be done about this in order to meet the persons needs. Daily notes were well maintained, and we saw that care plans are kept under review. The above findings on care plans were disappointing as care planning has been an ongoing issue at the home. The new manager is committed to improving the situation. Discussions took place with the manager and a senior member of staff in the organisation about how this could be achieved. On surveys people said that they always or usually received the medical care that they needed. Training records showed us that some staff have undertaken training relating to peoples healthcare needs, and conditions relating to old age such as Parkinsons disease. This will assist them in supporting residents. Records showed that people access appropriate health care to meet their needs such as district nursing, chiropody and general practitioners. We saw a thank you letter from a relative praising the home for the support given to a resident in attending hospital appointments. We were however concerned that records of medical issues or interventions may not be well maintained. For one person an entry of a doctors visit in August stated that a referral to a specialist was to be made. The manger confirmed that this had taken place, but there had been no specialist visits recorded on the sheet provided for this purpose. The same person had seen a doctor on the day before the site visit. This had not been recorded on the appropriate sheet provided. No short term care plan had been put in place to recognise their illness or highlight potential care issues relating to this, and the use of antibiotics. Peoples nutritional needs are assessed, but again when these flagged up any potential risk factors, these were not Care Homes for Older People Page 15 of 31 Evidence: always carried forward into the persons care plan. We saw that people are regularly weighed to highlight any potential concerns. Nutrition records are maintained to monitor peoples diet. One relative was particularly pleased that people always had drinks available and were encouraged to drink plenty to prevent dehydration. As part of this inspection we looked at medication systems and records and found that they were generally well maintained. However, for people to feel fully confident that this aspect of their care is properly managed there are a number of issues that need to be addressed. Since the previous inspection two issues have been alerted to us about the management of medication. The home had been open with us and informed of two incidents where medication was not managed properly. They took action to retrain staff. When we looked at records we saw that there was a lack of consistency in how things are managed in relation to medicines. For example, sometimes there were protocols in place for medicines prescribed to be taken on an as required (PRN) basis, sometimes there were not. Sometimes handwritten entries on the medication administration record (MAR) sheets were countersigned to confirm quantities and instructions, and at other times this had not happened. Boxed and bottled medication had not always been dated on commencement to provide a good audit trail. Sometimes it appeared that medication had not been booked in with quantities received recorded. This was because there was no carry forward system in place for medicines that had been delivered on previous months. This does not provide a good audit trail. There were issues relating to controlled drugs. Although the stock and records balanced, the two people using these both had three boxes in place with two of these being used. Ordering mechanisms in place had continued to order stock when none had perhaps been required. Boxes were not being used in rotation. The situation had not been picked up on, in spite of the controlled drugs being audited and signed for between each shift. For one person using warfarin white out fluid had been used on their MAR sheet. This is poor practice as legal records must not be altered in this way. Staff spoken with confirmed that they had completed training via a distance learning course. Appropriate policies and procedures were available in the homes office. Observations through the day showed that staff approached residents in a calm and kind manner. Staff treated residents with respect. Doors were kept shut when personal care was being carried out so that peoples privacy was maintained. Some staff have undertaken training in dignity and respect. This will help them to understand good practice. Care Homes for Older People Page 16 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a lifestyle that meets some of their needs and preferences through access to basic activities, being able to welcome visitors and enjoying good food. Evidence: On two residents surveys completed one person said that there were always activities arranged that they can take part in. The other person said that there sometimes were. Pre-admission assessments identify peoples past/current interests. These are identified to a degree on the Routines of Daily Living. Likes and Dislikes, Social Activities/Hobbies care plan. But things identified may not fully reflect peoples wishes. For example one person told us that they would really like to go out for walks as they missed their garden and getting fresh air. There was no mention of this in their care plan, and activities recorded consisted of watching television, bingo, visits from family and chatting. An activities co-ordinator works at the home on two afternoons each week. During the site visit they were on duty and provided entertainment and activity for people. They also spent time with people who were less able to participate in group activities. When the activity co-ordinator is not on duty care staff are expected to provide activities for people. During the morning we saw one member of staff send one to one time with a resident playing dominoes. A weekly timetable is in place but the manager agreed that this is not fully adhered to. We saw that there is a good Care Homes for Older People Page 17 of 31 Evidence: range of activities equipment and materials available. Larger events such as a recent indoor garden party with belly dancers and Halloween party take place on a regular basis. These events are enjoyed by residents. The manager is aware that activities continually need to be developed. The AQAA said under what we could do better To ensure that activities occur regularly and all service users are invited and encouraged to join in. Minutes of a recent residents meeting indicated that people were still not entirely happy with the level of activity provided. Staff meeting minutes stressed the importance of promoting this aspect of care. The manager showed us plans for helping to achieve this such as improved activities records that seek feedback on how the resident had responded and so on. The home has access to a Company minibus and they hope to get more use out of this in the future. Regular church services are held in the home to help people to fulfil their spiritual needs. People can also go out to attend church if they wish. However staff perhaps need more education about different cultural needs and religions. For one person with a deep, but non Christian based, faith it was recorded in their care plan that they did not have time to pursue their religious services and would be willing to attend the in house worship. People living at Milton House are able to have visitors at any time. A visitor spoken with during the site visit said that they were always made welcome by staff and could visit at any time. Staff were respectful of peoples wishes and they were able to go where they wished in the home. Information on advocacy services was available so that people know where they can go for independent support and advice. A tour of the premises showed that people are able to bring in their own possessions in order to make their rooms homely. Since the previous inspection the home has changed the accommodation usage so that a large and pleasant dining room is now available for people to use. People are encouraged to go to the dining room to eat, but fully supported if they prefer to eat in their rooms or elsewhere. During the day when drinks were offered, people were always offered a choice and asked if they had finished or if they wanted another cup. The home operates a four weekly rotating menu. These provide choice and are adapted to meet individual needs and preferences as required. The AQAA told us that the food is home cooked and that they try to use local produce. At lunchtime we saw that people had been offered choices other that what was on the menu to accommodate their individual needs. People are able to choose on the day what they will have for lunch. People spoken with seemed happy with the food provided. They said, I have no complaints about the food, The food is good, and, There is always Care Homes for Older People Page 18 of 31 Evidence: plenty to eat. On surveys one person said that they always enjoyed the food, and the other that they usually did. The lunchtime meal looked well presented and people who needed assistance were helped in a sensitive manner. Staff do however need to be vigilant to ensure that people are always in a suitable position, and are able to eat easily and safely. During the site visit we saw three people who were not in a good position to see their food or eat properly. When this was pointed out to management they immediately remedied the situation. However these people had already been served with their meal so this is perhaps an area for staff to be made more aware of. Care Homes for Older People Page 19 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected through procedures and practice in the home. Evidence: We saw that there was a complaints process in place that was on display for people to refer to. People spoken with and the two surveys returned indicated that people understood how to raise concerns. The AQAA told us that ten complaints had been made since the previous inspection. When we looked at records we saw that complaints made had been properly recorded, investigated and responded to. Monthly audits are undertaken to identify any patterns or causes for concern. One person had raised concerns with us (CQC) about the home and copied us in to their correspondence with management. The complainant, social services and management have worked together to resolve the issues raised. The homes training matrix, staff files and discussion with staff showed that training in safeguarding people had taken place. The manager confirmed that training was ongoing and that they were shortly to attend a safeguarding for managers course. Local guidelines relating to safeguarding practice were available, as well as the homes own policies and procedures that provided good information. Safeguarding flowcharts, information about actions to be taken and contact details of the safeguarding team were on display in the staff room. The manager confirmed that staff have also recently been given a booklet about safeguarding. Apart form one occasion where a Care Homes for Older People Page 20 of 31 Evidence: safeguarding referral should have been made and was not, the home are now proactive in making referrals to the safeguarding team. Six safeguarding referrals have been made by or about the service since the previous inspection. This shows that the home are now able to better identify poor practice and work openly with the safeguarding team. Although the level of complaints and safeguarding alerts made about the service have been high, things do now seem to be settling down. New management is having a positive impact on improving the service and establishing good practice expectations in the staff team. Care Homes for Older People Page 21 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable and improving home. Evidence: As part of this inspection we undertook a partial tour of the premises. Since the previous inspection the ongoing refurbishment of the home has continued to improve the environment for people and maintain the home to a good standard. New windows have been fitted in some areas, a communal area has been decorated, and new equipment such as beds and laundry equipment have been purchased. People seemed happy with the accommodation provided. One person said I have a very nice room that I have been able to make as I want. Another said, I like my room. There is outdoor space for people to enjoy in a central courtyard garden with places to sit. People spoken with said that they thought the home was kept clean and pleasant. One person said, The home is always clean. On the day of the site visit the home appeared generally clean. Odour control was good. Training records showed that staff had received training in infection control. The laundry area was suitable to meet the needs of the home. The member of staff in the laundry had received appropriate training and was knowledgeable about correct procedures. Care Homes for Older People Page 22 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are looked after by staff who are caring, safely recruited and adequately trained Evidence: During the day we saw that residents and staff had a good rapport with one another. People told us that they liked the staff and got on well with them. People said, There is not a bad one among them, They are all good staff, and, Lovely staff always with a smile. I could not wish for anything better. We received positive comments about staff working at Milton House from relatives who also felt that the staff team were good, supportive and Always friendly and helpful. The AQAA indicated that staff turnover at Milton House has been high and that seven staff had left within the last year. The manager and deputy explained that some of these had left for specific reasons. Staffing now seems more stable. No agency staff are currently used at the home. This will help to provide people with consistent care from people that they are familiar with. On the day of inspection 22 people were being accommodated at Milton House. Rotas showed us that staffing levels are maintained at four or five staff between 08.00 and 14.20. The manager is sometimes supernumerary to this and is sometimes included in as part of the shift numbers. Three staff are available between 14.00 and 20.20, with the manager also being available until 17.00. At night three staff are provided. Ancillary staff are provided for domestic and catering duties. The manager felt that current staffing levels were sufficient to meet peoples needs. During Care Homes for Older People Page 23 of 31 Evidence: the site visit there were generally staff around in the communal areas, or quickly available and assist people. On two occasions when we used a call bell to get assistance for a resident staff responded promptly. On surveys two people felt that there were always or usually staff available when they needed them. A concern at the last inspection was the excessive hours being worked by staff. The manager thought that this was now much better and that staff no longer worked addittional hours in other homes. In general we could see that things were better. However, when we looked at rotas we saw that some staff are still working in excess of sixty hours each week, and that one member of night staff had worked six nights without a break totalling 74 hours. This is not good practice, as staff may not perform as well if they are tired. So that people receive care from a well trained workforce it is recommended that at least 50 of a homes care staff achieve a National Vocational Qualification (NVQ) in care at level two or above. The rota identified that currently 16 care or trainee/senior care staff are employed at the home. Information provided on the AQAA and confirmed at the site visit indicated that of these seven have an NVQ at level two or above, and a further three staff are working towards this. The home have therefore nearly reached the 50 basic target. Staff are recruited centrally by the organisation. Management, staff or people living at the home have no input into the recruitment process. This means that potentially the staff recruited may not meet the needs of the home or fit in with the existing staff team. The manager felt that this was an area that they would like to be more involved with. We looked at the files of two members of staff who had most recently started work at Milton House to ensure that recruitment procedures protect people living in the home. Files viewed were satisfactory and showed that proper checks such as POVA first, references taken up, proof of identification sought and health declaration had been undertaken before people started work. Both members of staff had commenced work following a POVA first check, but before a Criminal Records Bureau check was in place. This is not best practice. Staff files of new members of staff looked at showed that a good induction process was in place. A detailed initial induction had been undertaken. This was being followed up by a Skills for Care Common Induction Standards workbook being completed. We also saw that staff were supported in the initial stages of their employment through supervision and observation of their practice. The Company has a designated training co-ordinator to identify training needs and arrange training for staff. Staff spoken with during the day identified that they had Care Homes for Older People Page 24 of 31 Evidence: undertaken a good level of basic training. Training information viewed showed that some staff had also undertaken training in areas such as epilepsy, continence care, pressure area care, diabetes and falls prevention to enhance their knowledge and skills. It would be beneficial for these skills to be more widely disseminated among the staff team. A training plan has been in place for 2009 which identifies training that has taken place and is still scheduled to the end of the year. Although Milton House is not registered to provide dementia care this is an important area for all staff to be trained in and aware of. It would help them to identify if people are starting to experience difficulties, and properly support those who may already have symptoms of dementia. A number of staff have still to complete training in this area. Care Homes for Older People Page 25 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe and well managed home where their views are listened to. Evidence: A new manager started at the home in June this year. The manger has appropriate experience and has completed their NVQ level four in health and social care. They hope to start their Leadership and Management award in the new year, and will be applying for registration with us (CQC.) People liked the new manager and felt that they were doing well. One person said, The new manager is very good, you can talk to them easily. This inspection has highlighted areas that need improvement, particularly relating to effective care planning and medication management. Overall however the manager demonstrated a good awareness of where the home needs to improve and how they are going to achieve this. Milton House had a friendly open atmosphere and people seemed comfortable and at ease with staff. People have opportunities to express their views at monthly residents/relatives meetings. These were recorded, and showed that peoples views Care Homes for Older People Page 26 of 31 Evidence: are listened to and acted on. For example at the last meeting menus were discussed. It was agreed that a discussion group would start to look at peoples likes and dislikes to incorporate these into the menu. A suggestions box is available for people to use. The manager also said that they were going to revive the use of listening forms for those who prefer not to participate in meetings to ensure that their views are heard. We saw that staff meetings also take place where practice and other issues are discussed. The provider employs an external agency to undertake quality reviews of their services. At Milton House the manager said that the quality review had taken place a few weeks previous to this inspection and that they were awaiting the report. Monthly visits to review the service by the registered person or nominated individual are required by Regulation. We saw that these are being undertaken by a Consultant to the organisation. The visits include talking to people about their experience of the service. The AQAA was completed by the manager. It was briefly completed and some areas could have given us more information. It did however give us a reasonable idea about how the home was functioning, and recognised areas where the home needs to continue with improvements. The AQAA did not detail the dates of last review of the homes policies and procedures. This is because they are not dated. The organisation should address this in order that they can evidence that staff are working to up to date guidelines and procedures. People can feel confident that if they or their families ask the home to help them look after their personal monies, this will be done in a way that safeguards their interests. When we sampled two peoples monies they balanced. Good records were maintained and receipts were in place for all transactions. The AQAA completed identified that systems and services are monitored and maintained. A partial tour of the premises showed that the home seemed well organised, and no particular health and safety issues were identified. A fire risk assessment was seen to be in place. Fire records were well maintained. Systems are tested weekly, and regular fire drills are carried out to ensure that staff know what to do in an emergency. The last environmental health officers visit at the end of September this year year found standards of food hygiene to be satisfactory. A three star Good rating was awarded. Good accident records are maintained and these are audited to identify any concerns or issues. A training matrix and discussion with staff showed that training in core areas such as moving and handling, fire awareness, health and safety and basic first aid is kept up Care Homes for Older People Page 27 of 31 Evidence: to date. Care Homes for Older People Page 28 of 31 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 29 of 31 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 7 15 Care plans must be developed that are consistent, and address peoples holistic needs. So that peoples needs and preferences are recognised and addressed. 01/02/2010 2 9 13 Medication practices at the home must be reviewed to ensure safety and consistency. People must feel confident that this aspect of their care needs are competently and consistently managed. 01/01/2010 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 1 People considering moving into the home should be given a copy of the Service Users Guide so that they have written information to assist their decision making. Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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