Inspection on 23/08/05 for Moor Cottage

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Moor Cottage 09/10/07

Moor Cottage 30/11/06

Moor Cottage 09/01/06

Moor Cottage 22/02/05

Moor Cottage 22/09/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE MOOR COTTAGE High Street Cookham Berks SL6 9SF Lead Inspector Susan Cledwyn-Davies Unannounced 23 August 2005, 10:25 am 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 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. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Moor Cottage Address High Street, Cookham, Berks, SL6 9SF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01628 526036 01628 524144 info@moorcottagecare.co.uk Mrs R Rezajooi Mrs R Rezajooi Care Home (CRH) 17 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5 March 2005 Brief Description of the Service: Moor Cottage is a large grand house situated close to the centre of the village of Cookham. Shops and local facilities are within walking distance. The home accomodates up to 17 older people. Rooms are varied in size, some being very large and having en-suite facilities. All of these rooms have been refurbished and redecorated. The home has been closed while the refurbishment took place. A manager has now been appointed and people are now being admitted to the home. The home has been open since 1985. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 10.30am and 2.45pm. Included in the visit was a partial tour of the home, conversation with residents, discussion with the manager and proprietor plus examination of the records. In discussion it was agreed that service users would be referred to as residents within this report. What the service does well: What has improved since the last inspection? 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. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Prospective residents are given information about the service. Each resident has a contract with terms and conditions. All prospective residents are assessed prior to admission and they and relatives have opportunity to visit the home prior to admission. Residents know that the home will meet their needs EVIDENCE: The statement of purpose was seen. This has been newly prepared and is being expanded. The service user guide was not seen. The home has recently reopened following redecoration and improvements. There was discussion about consideration be given to additional providers being registered to reflect the current management. The proprietor is appointing a Manager to be responsible for the day-to-day management of the home. Each resident has a statement of terms and conditions and contract. In discussion it was noted that no conditions when a resident may be asked to leave the home were included. This is to be added. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 8 During the visit a review involving relatives, the care manager and relatives took place. Residents were positive about the care and liked the staff. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Residents’ care needs are considered in a plan of care. Residents’ health needs are met and they are treated with respect. EVIDENCE: There are individual care plans for each resident. These show details including social history and care needs. The manager is ensuing that care plans are full and regularly reviewed. Health needs are met by the local GP surgery. Individual residents routines and wishes are respected. This was shown during the visit by staff and confirmed by residents. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Residents have a varied lifestyle. Relatives are able to visit as they wish. Residents have a wholesome appealing diet. EVIDENCE: There were individual activities seen, the newspaper, jigsaws and books. One resident was attending a local day centre. There was discussion about extending the activities to include shows and concerts plus more organised in house activities. Visitors were present for a meeting. The meal eaten during the visit was tasty and freshly prepared. The menus reflected a good variety. Residents were positive about the food and ate well. Residents’ choice for breakfast was known and followed. There was no choice offered prior to the meal. The manager advices that an alternative is given if the meal offered is disliked. There was discussion about the menu being expanded to provide choice for the main meal and for tea. Residents would then be asked for their choice prior to the meal. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents are able to complaint and are listened to. Residents are protected from abuse. EVIDENCE: There has been one complaint made to the CSCI. The proprietor fully investigated the complaint and found it unsubstantiated except for ensuring that residents could have a bath in the evening. This has now changed and baths are available in the evening. This was confirmed in writing. There is a full complaints procedure given to residents and relatives. The new guidelines for multi-agency protection of vulnerable adults are available in the home. The staff on duty had had protection of vulnerable adults training and understood the importance of this. There were no staff training records available to confirm that all staff had completed this training. See standard 30. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Residents live in a comfortable and well-maintained environment. The home is clean and hygienic. The exception is lack of corridor from the main house to the laundry and side wing including some residents’ rooms. EVIDENCE: A lot of work has been achieved in the house including decoration, new carpeting and radiator covers. Planning permission has been achieved for a new corridor to the laundry and bedrooms in the wing and will not be through the kitchen as at present. Quotes for the building work are being obtained and it is hoped to start the work as soon as possible. The bedrooms in this side wing are not being used unless there is a specific request and the constraints are understood e.g. that residents cannot walk through the kitchen but need to walk outside to reach the main house. The proprietor explains this to prospective residents. An occupational therapist has assessed the home. The report has been considered and recommendations followed if necessary. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Sufficient staff meets residents’ needs. Staff recruitment is considered; records were not complete. Staff confirmed that they had training but training records were not available. EVIDENCE: The staff rota is covered to provide a minimum of 2 staff on duty. There were three residents in the home during the visit; one was out for the day. There is one waking member of staff. Staff training records have not been collated centrally. One member of staff is using the free training and completing the mandatory basic training prior to NVQ 2. Central records are important to ensure that all staff have completed mandatory training e.g. health and safety, lifting and handling, food hygiene and first aid plus completing a minimum of three training days a year. The staff recruitment records seen included an application form, one reference and further letters. The proprietor makes CRB checks. No record was seen of identity checks and these are to be added as well as ensuring 2 references. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The home was well managed. Standard 38 was partially inspected, health and safety is understood as important. The fire precautions need further addition. EVIDENCE: A new manager has been appointed pending registration by CSCI. The registration application form has been sent to the home and a completed application is now required. The proprietor is not present in the home daily and has a manager to provide supervision therefore Regulation 26 visits and reports are needed. These are unannounced visits made monthly to ensure that the standard of care is satisfactory and a copy of this report is sent to CSCI. There was one communal door and one resident’s door held back with wedges and furniture. This was discussed and the importance of having emergency release holdbacks for all doors so that if the fire alarm is activated then the door will close. Doors should either remain closed or holdbacks be obtained. MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x x x 2 MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 16 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard 19 29 30 31 31 Regulation 23 19 18 8 26 Requirement That an alternative access corridor to the extension be built. That the staff recruitment includes all of the required areas. That there is a central training record. That the manager applies to CSCI to register. That monthly unannounced visits are made to the home by the proprietor and a report sent to CSCI. That no doors are held back unless with fire release holdbacks. Timescale for action 1.3.06 1.10.05 1.10.05 1.10.05 1.11.05 6. 7. 38 23 1.10.05 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 Good Practice Recommendations MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Berks RG7 4SA National Enquiry Line: 0845 015 0120 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 MOOR COTTAGE H52 H01 S11322 Moor Cottage V235558 230805 Stage 4.doc Version 1.40 Page 18 - 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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