Inspection on 09/01/06 for Moor Cottage

This inspection was carried out on 9th January 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 30/11/06

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 Susan Cledwyn-Davies Unannounced Inspection 9th January 2006 9:55 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.V270606.R01.S.doc Version 5.1 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.V270606.R01.S.doc Version 5.1 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 521030 www.moorcottagecare.co.uk Mrs Rena 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.V270606.R01.S.doc Version 5.1 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. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9.55am and 3.30pm. Included in the visit was a tour of the home, conversation with 5 of the residents and one relative, discussion with staff, the manager and the provider’s representative and examination of records. In discussion it was agreed that service users would be referred to as residents within this report. There were 7 residents in the home. 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 DS0000011322.V270606.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 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 the following standard(s): 2 and 3. Standard 6 is not applicable. Each resident has written contract and service user guide. All residents are assessed prior to admission into the home. EVIDENCE: There is now an information pack to be given to potential residents including the terms and conditions and service users guide. New brochures have been prepared for the home. Pre-admission assessments take place for all potential residents. The assessments are used initially to plan the care. Care plans are detailed and prepared within a month of new residents moving in. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 8 and 9 Residents’ health care needs are met. Medication is responsibly kept and administered. Medication training for care staff is given but not recorded. EVIDENCE: Residents’ health care needs are met initially by the local GP surgery. The doctor visits as necessary. The Doctor sees all new residents following admission. A record is kept of visits and any actions necessary. Community nurses visit to give support as necessary e.g. dressings. Medication is safely stored. A monitored dosage system is used. Records of medication brought in and of any disposed of are kept. Administration records are kept well and records for controlled drug storage also kept. No controlled drugs are kept at present. The manager or trained care staff administers medicines. All staff are trained and assessed prior to administering. There is no detailed record of each individuals training demonstrating competence. The manager will be starting this. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 12 and 14 Residents are encouraged to take part in activities. Residents are encouraged to have choice and control over their lives. EVIDENCE: There is an activities schedule arranged. The schedule includes activities provided by staff plus occasional entertainers brought in. Activities include coffee mornings, piano playing, games and activities. Activities are largely recorded on residents’ records and staff will ensure that this record is complete. One resident attends a local club. Residents are encouraged to make choices for themselves during the day. Residents confirmed this. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 16 and 18 There is a positive approach to complaints and residents are confident that they will be listened to. Residents are protected from abuse. EVIDENCE: The complaints record has been started. There is a complaints procedure. Residents spoke of being able to talk to staff, including the manager and were confident that their concerns would be listened to. There is a good awareness of individual rights. Most staff have completed POVA training, the provider is looking for training for the remaining 2 members of staff. The local authority guidelines detailing how POVA investigations will be managed are kept in the staff procedures file. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 19, 24 and 26 Residents live in a comfortable and safe environment. The exception is the need for an alternative corridor around the kitchen for residents and staff to access the extension. Residents’ rooms are varied and comfortable. The home is clean, pleasant and hygienic. EVIDENCE: The decoration and furnishings are satisfactory, being comfortable and varied. Residents are able to bring in their own furniture and personal items as long as there is sufficient room. Each room is individually arranged and furnished. Residents spoke of being comfortable and relaxed in the home. There is a good standard of cleanliness and the home is fresh smelling. The laundry room is the other side of the kitchen to the main home. The manager confirmed that staff walk round outside the home with dirty laundry and not through the kitchen. The provider’s representative confirmed that planning permission for the extension has been obtained and that the builders quote was due. It was hoped to complete the building work shortly. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Residents’ needs are met by satisfactory numbers of staff. NVQ Training is promoted. The recruitment practice is responsible; some additional information is being obtained. EVIDENCE: The staff rota and staff confirmed that there is a minimum of 2 staff on duty. There are domestic staff on duty as well. There are 7 residents in the home and residents and staff confirmed that sufficient staff are on duty. NVQ training is encouraged. There are 8 staff with at least NVQ 2 and a further member of staff taking NVQ 2. There are 13 carers employed in the home therefore over 50 have NVQ 2. The recruitment files have been prepared. These files need current photographs. Many of the staff have been re-employed in the home from before the closure. Up to date employment histories were not present. The provider’s representative has already given application forms to all staff that have not completed one. This form will then be added to the recruitment file to update them. The training records are being put onto a computer database to more easily monitor training. A central training record was not available during the inspection. Training records for each individual are in the staff file. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The manager is now registered with CSCI. Views of residents are important and sought. Residents’ finances are safeguarded. Health and safety of residents is generally safeguarded, the exceptions are the need for a full fire risk assessment and to use food thermometer. EVIDENCE: The manager is now registered with CSCI. She has NVQ 4 in care and has completed in depth management courses previously. The content of these courses is being checked to see if they comply with NVQ 4 in management. Residents and relatives views are sought. Prior to Xmas all were invited to a social and the manager and provider were present to talk to people. Residents are consulted individually. There was discussion about the use of questionnaires to find residents, relatives and outside professionals’ views. This is being developed. The provider visits the home frequently but there is Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 14 no regulation 26 report kept. The providers’ representative will be starting to keep these records. The manager does not hold any residents finances. Any items purchased on residents’ behalf are added to the monthly account. Health and safety checks are made. Within the kitchen checks are made of the fridge and freezer temperatures. There are no checks of cooked food temperature, to ensure that the food is cooked properly e.g. roasts and frozen food. There is a food thermometer and this will be used in the future. Fire system checks are made and fire drills take place. There is no fire risk assessment prepared and this needs to be. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 16 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 2. 3 4 Standard OP9 OP19 OP33 OP38 Regulation 18 23 26 23 Requirement It is required that a detailed record is kept of medication training. It is required that an alternative access corridor to the extension be built. It is required that records are kept of visits, at least monthly, to the home. It is required that a fire risk assessment be prepared. Timescale for action 01/03/06 01/03/06 01/03/06 01/02/06 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 2 3 Refer to Standard OP29 OP30 OP38 Good Practice Recommendations That the individual staff files are completed. That there is a central training record. That the cooked food temperature is taken and recorded. Moor Cottage DS0000011322.V270606.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Berkshire Office 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 DS0000011322.V270606.R01.S.doc Version 5.1 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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