Inspection on 31/08/07 for Molescroft Care Home

This inspection was carried out on 31st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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Larchfield Manor

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Molescroft Care Home 30 Molescroft Road Beverley East Yorkshire HU17 7ED Lead Inspector George Skinn Key Unannounced Inspection 31st August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Molescroft Care Home Address 30 Molescroft Road Beverley East Yorkshire HU17 7ED 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) 01482 860367 01642 867357 Southern Cross Healthcare (Focus) Limited ****Post Vacant**** Care Home 44 Category(ies) of Dementia (44), Old age, not falling within any registration, with number other category (44) of places Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider 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 fall within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 44 2. Dementia - Code DE, maximum number of places 44 The maximum number of service users to be accommodated is 44. Date of last inspection 16th October 2006 Brief Description of the Service: Molescroft Court is situated close to the centre of the market town of Beverley. The home is registered for forty-four people over the age of sixty-five, some of whom may suffer from memory impairment. The home is made up of three separate buildings, the Main House, the Haven and the Annexe. Fifteen service users live in the Main House, sixteen in the Annexe and thirteen in the Haven. The annexe has three bungalow units to allow for more independent living. Each of the three areas has a conservatory for the use of the service users and these provide views of the well maintained and spacious grounds. The home is owned by Southern Cross Healthcare (Focus) Limited. Currently the scale of charges are • Local authority placements £334 plus a third party top up of £20 to £381 plus a third party top up of £25 per week • Privately funded service user pay £400 per week Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection undertaken over 8 hours. During the site visit service users and staff were interviewed and records were looked at. The building was looked at, and before the site visit questionnaires were sent to the home for service users, staff and relatives to complete. This information helped to form the judgement made in this report. What the service does well: What has improved since the last inspection? Since the last inspection the home have been taken over by new owners, this a large company who have homes al over the country. The new owners have changed a lot of things at the home and this has included employing a new manager. Those service users and staff commented that this had been a positive change as the new manager is approachable and gets things sorted out quickly. The new owners have introduced a lot of paperwork to make sure the home is run the same as all the other homes in the company and these have improved the way information is recorded about the service users, this helps staff to provide more personal care and helps to improve reviews. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 7 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 Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area. Prospective service users needs are assessed prior to moving into the home. Prospective service users receive information on which to base an informed decision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective service users are assessed prior to moving into the home; this includes those who are privately funded. Files looked at contained assessments being undertaken by both the home and local authority placements officers. The home has recently changed ownership and the company has amended the statement of purpose and the service users guide this is now in line with current legislation regarding smoking in public places. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area. All service user have a plan of care Service user health care needs are met Medication is handled safely Service users are treated with dignity This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the service users at the home have a comprehensive care plan in place. Those looked at contained evidence of needs assessments, risk assessments, regular updating of information and reviews. The quality of daily recording was variable and did not always reflect the needs of the service users following major changes. There was evidence within the care plans of regular visits being undertaken by GPs and district nursing services being accessed when required. Service users also have access to chiropody and optical services. Medication was seen to be handled safely; records were kept of receipt of medication and disposal. Medication was stored appropriately. There was no Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 10 evidence that staff who handled medication had received any training other than in house training. There was no evidence that the staff had received accredited medication training. The home has a policy for respecting service users dignity. Observation made during the site visit indicated that staff do respect service users dignity and up hold their rights. Staff were seen to be sensitive when undertaking personal tasks and spoke to the service users with respect and were courtesy. Those eservice users spoken with commented that the staff are very caring and meet their needs effectively. Comments included “the girls who work here are very nice” “they can’t do enough for you they are all very caring” “my key worker takes me shopping” Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area Service user social cultural and recreational interests are met Service user maintain contact with relative and friends Service user are helped to exercise choice in their daily lives Service user are provided with a well balanced nutritional diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users interests are recorded in their care plans, the staff then endeavour to provide this if they can. The home employs an entertainments organiser who works for 2 hour a day. He organised group activities, which includes playing bingo sport and playing board games. The staff make sure that those service users who cannot join in the group activities have one to one time where individual activities and interests can be undertaken. Relatives are welcome to visit the home and are supported in taking the service user out of the home by the staff. One relative spoken with during the Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 12 site visit commented positively about the home and confirmed that the staff were supportive. The service users right to exercise choice in their daily lives is respected at the home, they can choose when to get up when to go to bed, and have a choice of where and how they spend their day. All service users spoken to and completing the comment cards enjoyed the food provided. The cook has a basic food hygiene certificate and arrangements are being made for her to take the intermediate level. Food is nutritious and provides a balanced diet, with choices offered at all times. Breakfast includes cereals, toast, fruit, a cooked breakfast or bacon sandwiches. Lunch is a three course meal with choice of main course and there is a set menu for tea time with a choice of sandwiches as an alternative. Supper is usually cheese and biscuits or toast, but staff have access to the kitchen for alternative choices; drinks are provided throughout the day and on request. Special diets are catered for as required and currently vegetarian and diabetic options are provided. Menus are seasonal and there is an opportunity for service users to influence the content when they are discussed at monthly relative and service users meetings. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area Service users knew whom to complain to and were confident that these would taken seriously Service users are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive complaint procedure this is displayed around the home and included in the statement of purpose and service user guide. This sets time scales and records the outcome of the complaint and the satisfaction of the complainant. Those service user spoken with knew who to complain to and were confident that any concerns would be taken seriously; they said they would “see the boss” or “tell the staff”. The relative spoken with during the site visit had used the homes complaint procedure and was satisfied with the way her compliant was handled and with the outcome. Those staff spoken with during the site visit were aware of how to make a safeguarding adults referral and were confident in the management of the home. The staff were confident that any concerns or allegations would be taken seriously. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 14 A Safeguarding Adults investigation is currently being undertaken by the local authority the outcome of this is not known at the time of the site visit. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area. Service users live in safe well maintained clean environment This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and well maintained all areas both communal and private were clean and comfortable. Some redecoration has taken place since the last inspection and the new owners have implemented a rolling programme of refurbishment which will address those outstanding requirements set at previous inspections. Staff are provided with the equipment to assist the service users. Equipment is provided around the home for service users to lead an independent lifestyle. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area Service users needs are met by the mix and skills of the staff on duty Service users are in safe hands Service users are protected by the homes recruitment and selection procedures Staff receive appropriate training some mandatory training needs up dating. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence seen during the inspection indicated that there are enough staff on duty to meet the needs of the service users. Rotas indicated that staff were provided in number which were appropriate to needs of the service users. The acting manager stated that agency staff are used rarely. She was aware of the need to ensure that the staffing numbers are in line with the guidance provided by the department of health in the Residential Staffing Forum Guidelines. Records indicated that there remains some staff who need to have their mandatory training updated. The new owners are providing appropriate training for the staff and the staff spoke positively about the training provided. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 17 Staff files looked at contained references and Criminal Records Bureau (CRB) checks being completed prior to employment commencing. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area. Service users live in a home which managed well and run in their best interests. Service users financial interests are safeguarded. Lack of updated mandatory training for the staff puts the service users at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an acting manager in post currently, she has a long experience in the care industry and prior to being the manager was the deputy manager at the home; she is not registered with the CSCI. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 19 The home have been taken over recently by new owners and they have ensured that all the policies and procedures have been up dated and changed to be in line with other homes in the company. The company has implemented a new updated quality assurances system, which includes the opinions of all stakeholders in the home, and there is an emphasis on setting targets and managing achievements within the company. There is an expectation that the acting manager complies with company policy and there are regular checks made by the area manager on how she is performing. Reports are complied which comply with Regulation 26 of the Care Homes Regulations 2001. The home is not involved in service users’ financial matters, although small amounts of money are kept by the home on their behalf. Evidence indicated that some staff need to have their mandatory training updated. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 20 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 X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 21 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. 1 Standard OP9 Regulation 13, 18 & 19 Requirement The registered person must ensure that all staff who administer medication are trained to an accredited standard. The registered person must submit a plan of refurbishment of the building to meet pervious requirements. Timescale for action 01/03/08 2 OP19 16, 17 & 23 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP31 Good Practice Recommendations The registered person should submit an application to the CSCI for the registration of the acting manager. Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Molescroft Care Home DS0000069699.V350650.R01.S.doc Version 5.2 Page 23 - 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. 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