Inspection on 30/11/06 for Moor Cottage

This inspection was carried out on 30th November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Moor Cottage 09/10/07

Moor Cottage 09/01/06

Moor Cottage 23/08/05

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 Berkshire SL6 9SF Lead Inspector Tracy McGuire Brown Unannounced Inspection 30th November 2006 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 Moor Cottage DS0000011322.V318609.R02.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. Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moor Cottage Address High Street Cookham Berkshire SL6 9SF 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) 01628 526036 01628 530621 info@moorcottagecare.co.uk www.moorcottagecare.co.uk Mrs Rana Rezajooi Mrs Orcilla Magdelena Aletta van Eck Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 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 has been open since 1985. The home accommodates 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 was closed while the refurbishment took place. This is a small home with individual care given to each resident. Fees range between £450 and £700 per week. Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected over a period of 4 days between 6th and 14th November with a visit to the establishment taking place on 13th November between 10.30 and 5.00 pm. The inspector spoke to residents and staff. Resident files and care plans were seen. Information from inspection records, documents and surveys were used. The inspector also spoke to health professionals and a relative. The inspector toured the building and observed practice throughout the visit. What the service does well: What has improved since the last inspection? What they could do better: The home needs to improve risk assessments and ensure that the furnishings and adaptations are suitable for all the current service users. The additional corridor to the wing has not been started and as these bedrooms are only accessible via the garden or through the kitchen it is not advisable to use these until the building work is completed. All required recruitment checks need to be in place on staff files. Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 6 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. Moor Cottage DS0000011322.V318609.R02.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 Moor Cottage DS0000011322.V318609.R02.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): Quality in this outcome area is good. Service users needs are assessed to determine if they can be met prior to admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user records were examined; staff and service users were spoken to. Record seen indicate that pre admission information is sought and a form completed, in addition to the current files additional files contained information and care management assessments which were used prior to admission. Service users and a relative confirmed that they were involved in the admission process. Moor Cottage DS0000011322.V318609.R02.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): Quality in this outcome area is good. Service users needs are assessed to determine if they can be met prior to admission to the home This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records of 3 service users were case tracked. On each service user file there is a care plan, a needs summary and a fuller and more detailed care plan. These are written for each individual detailing care needs and outcomes. The care plans are evaluated on a monthly basis. The Inspector was informed that theses evaluation are shared with the families and service users on a monthly basis, this good practice is currently not documented. Service users have healthcare recorded on their files n the communication section and on the GP visit recording. The Inspector noted handling assessments and weight charts are completed for service users. District nurse visits are recorded and the district nurse keeps files in service users rooms of specific and current treatment. The Inspector had some discussion with the RI and a staff member about the organisation of health care records. Service users spoken to were all very happy with their healthcare and felt that the Gp visited when requested of other healthcare appointments are made. On the Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 10 day of the visit to the home the district nurse was visiting one service user and another was attending a routine appointment at hospital. Evidence was seen of input from the psychiatric nurse also. The home has detailed medication policies in place and a handbook available for staff. Staff undertake in house training prior to being authorised to administer medication, certificates of in house training are retained on staff files and were seen on the visit to the home. The home operated the Nomad system and the Pharmacist visits the home to assess the medication cupboard and offer advice. A member of staff was observed administering the lunchtime medication and explained the procedure and signed the record sheets. The Inspector spoke to 5 service users during the course of the visit and service users were positive about being treated with respect and their privacy respected in the home. Staff were observed knocking on service users doors. Service users have access to a phone and some service users choose to have their own telephone. Moor Cottage DS0000011322.V318609.R02.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): Quality in this outcome area is good. . Service users are offered a variety of activities and have contact with the local community, friends and family. Service users have choice and the meals are health, nutritious and well balanced This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records of 3 service users were case tracked, service users and staff were spoken to and a relative. Service user records seen indicate that the staff discuss activity options and record individuals likes and dislikes. Staff have set up rummage boxes, which are popular with service users. On the day of the visit one service users was out at a local day centre another was knitting in the lounge, one lady was listening to talking books and another gentleman was buy listening to a favourite radio programme. Most activities take place after lunch and activities are varied and include flower arranging, planting bulbs, doing puzzles, piano and singing. Staff informed the Inspector that they take staff out round the Moor and into the village, service users also make good use of the extensive garden and there are photos of many events and birthdays being enjoyed in the garden. Some service users choose to opt out of activities; this is recorded on the communication section of the file and staff still offer and encourage service users to join in. Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 12 On the day of the visit to the home, a visitor to the home was complimentary and service users and staff make visitors very welcome. The service users records sampled demonstrated that service users have frequent visitors and go and visit family and friends. Records of visits are made in daily diaries. The local community also visit the home and religious services are offered in the home if service users choose. Service users informed the Inspector that they do not wish to handle their finances so chosen relatives manage this. Service users are supported and encouraged to bring their own possessions into the home and were positive about having their personal possessions around them. The Inspector spent some time with the cook who has been at the home since July 2006. The cook works with the owner of the home to develop varied, nutritional and health menus, service users likes and dislikes are recorded and currently the home caters for the dietary needs of a diabetic. The menu is varied and samples were supplied. Choices are always available. Lunchtime was observed and the meal was freshly cooked and nicely presented. Service users spoken to were happy with the meal and positive about the food provided in the home. The cook also makes homemade cakes and shortbread; individual birthday cakes are home baked for birthdays. The cook was observed coming out and charting to the service users. Food temperatures are taken and recorded alongside fridge and freezer temperatures. Training is offered and the cook is due to attend a food hygiene course at Windsor and Maidenhead on 21st November. Staff were observed assisting service users at lunchtime, explaining the menu and working in a positive and sensitive manner. The day’s menu is detailed on a board on display in the home. Mealtime preferences are detailed in service users individual care plans. Moor Cottage DS0000011322.V318609.R02.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): Quality in this outcome area is good. Service users complaints are listened to and acted upon. Staff are aware of safeguarding adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a detailed complaints policy in place and in addition service users have a representative who they can contact if they have any concerns or worries. Most service users knew who to complain to, some have memory problems but felt they could talk to staff on duty. The complaints log was seen and contained 3 complaints made by service users in the last 12 months. Action taken to address and fully resolve all these complaints was noted. The home has policies in place in respect of safeguarding adults and the staff handbook provides further detail and explanation. Staff records sampled demonstrates that Training in the protection of vulnerable adults has been undertaken by some staff in the home. Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. The home is well maintained and comfortable. Specialist equipment is available but this need to be reviewed to ensure all service users needs are met. The home was clean and tidy throughout. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was undertaken the side wing is still not accessible other than through the kitchen; the Inspector was informed, as at the previous inspection that there are plans to address this and building work will be undertaken in the future. The Inspector was assured by the proprietor that the wing is currently not used due to the access issue. There is a stair gate located at on the second floor, there was no risk assessment in place in respect of this and this issues and fire risk was discussed with the Proprietor. The issue of the external doors being kept locked and potential fire risk was raised; this was not addressed in the homes detailed fire risk assessment. A copy of the OT assessment completed in March 2005, in light of this report the home needs to Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 15 consider some of the recommendations contained due to the fact the needs of some service users are different from when the report was compiled for example one service user has specific sensory needs, it would be beneficial to look at furnishings such as beds and chairs when the OT assessment is undertaken. It will be requirement of this report that the home addresses the issues of service users safety in respect of the stair gate, locked doors and the OT assessment. The home is nicely decorated and furnished throughout, new carpet has been fitted to the ground and first floor but is worn in places on the second floor. There is a communal lounge, separate dining room and bedrooms located on the ground, first and second floors. There are bathroom facilities on each floor and there are adaptations in the bathrooms. The home has a large garden which is well utilised by service users, on the day of the visit one service users requested to spend some time in the garden. The home has separate laundry facilities and was clean and tidy throughout. Moor Cottage DS0000011322.V318609.R02.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): Quality in this outcome area is adequate. Service users needs are met by sufficient experienced and qualified staff. Staff training is available and ongoing. Recruitment processes are in place but need to be more robust to meet regulations This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff records were examined and the inspector spent time talking to staff and service users. A copy of the rota was supplied and this demonstrated there are always a minimum of 2 staff on duty at all times. There is one waking night staff on duty. Since the previous inspection staff records have been improved the Inspector examined a sample of staff records, which included information about qualifications, training and recruitment. Records sampled demonstrated that staff hve varied experience and qualifications. Recruitment records have been improved and include photos of all staff, copies of at least 2 references, and training obtained or applied for. CRB’s had been obtained but some staff still did not have copies of CRB checks specific to Moor Cottage. The proprietor assured the Inspector that these had all been applied. It will be a requirement of this report that these are all obtained. Training records are included on staff files and evidence was seen that staff have undertaken a range of training opportunities in the last 12 months, including fire, food hygiene, first aid, medication, POVA and Issues of ageing. The staff reported that training opportunities are available. Evidence was also Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 17 seen that some staff have had “skills 2 care” assessments and training profiles developed. Moor Cottage DS0000011322.V318609.R02.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): Quality in this outcome area is adequate. The home has a registered Manager in place. The home is run taking the views of service users into account and their financial interest are safeguarded. Health and safety in the home needs to be reviewed and developed further to meet regulations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was on annual leave on the day of the assessment visit. The manager has successfully completed the registration process with the CSCI. Staff and service users spoken to were positive about the manager and felt that they could approach the manager about any issues. Since the previous inspection the home has developed a monthly audit form to comply with regulation 26 and these visits are recorded and available for inspection. Samples of these records show that a selection of service users, Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 19 relatives and staff are involved and their opinions detailed from this an action plan is developed and reviewed monthly. The Inspector was informed that the home currently had no dealings with service users monies and service users spoken to confirm that chosen relatives or representatives currently hold their money. Service users spoken to were all happy with this arrangement. Health and safety issues were discussed, the Inspector discussed with the staff the need to develop more individual service user and staff risk assessments. A fire risk assessment is in place but does not take into account locked doors, the stair gate and any specific mobility or sensory issues of service users in the home. The fire checks were all up to date, details of the lift service were supplied and this was I date, the electrical wiring check in date but Portable Appliance test documents were dated 21/3/05 and hence not up to date. Health and safety records need to be maintained and available and it will be a requirement of this report that identified health and safety issues are attended to. Moor Cottage DS0000011322.V318609.R02.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 3 X X 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 2 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23 Requirement It is required that an alternative access corridor to the extension be built. (Outstanding from previous inspection) It is required that an up to date Occupational Therapy assessment in respect of aids adaptations beds and chairs is undertaken taking into consideration the needs of all current service users. Consult with relevant authority and review the fire risk assessment in respect of locked doors and stair gate in place Ensure all relevant checks are in place prior to beginning employment in the home. Ensure all relevant health and safety checks are up to date and maintained and risk assessments are developed. Timescale for action 01/03/07 2. OP22 23 01/03/07 3. OP22 23 (4) 01/03/07 4. OP29 19 01/03/07 5 OP38 13 01/03/07 Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 22 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 OP38 Good Practice Recommendations Consider the provision of suitable washing and drying facilities for visiting professional when providing treatment in individual service users rooms Moor Cottage DS0000011322.V318609.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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