Inspection on 10/07/07 for Moor-haven (Nh) Limited

This inspection was carried out on 10th July 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 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-haven (Nh) Limited 25/06/08

Moor-haven (Nh) Limited 08/01/07

Moor-haven (Nh) Limited 06/12/05

Moor-haven (Nh) Limited 15/08/05

Moor-haven (Nh) Limited 07/01/05

Moor-haven (Nh) Limited 24/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Moor-haven (Nh) Limited 193 Ripponden Road Oldham Lancashire OL1 4HR Lead Inspector Michelle Haller Unannounced Inspection 10th July 2007 09.00 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-haven (Nh) Limited DS0000025444.V339729.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. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moor-haven (Nh) Limited Address 193 Ripponden Road Oldham Lancashire OL1 4HR 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) 0161 628 2064 0161 628 9801 Moor-Haven (NH) Limited Mrs Teresa Harwood Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (33), Physical disability of places over 65 years of age (33) Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 33 service users to include: *up to 33 service users in the category of OP (Old age not falling within any other category). *up to 33 service users in the category of PD (Physical disability). *up to 33 service users in the category of PD(E) (Physical disability over 65 years of age). Date of last inspection 8th January 2007 Brief Description of the Service: Moor-Haven is a 33 bedded care home providing nursing care for up to 24 service users and personal care only for a further nine service users. The home is owned by a private partnership and is under the control of a manager who is also a registered nurse. Accommodation is provided over two floors, accessible by passenger lift. Eleven bedrooms are single with en-suite facilities. A further 20 single rooms are provided with hand washbasins. One double en-suite room is available for service users wishing to share. There is a lounge/dining room on the ground floor, with two further lounges, one of which is provided for service users wishing to smoke. On the first floor there is one lounge area. The home is situated in the Watershedding district of Oldham, close to local shops and on a main bus route. Fees for accommodation and care at the home range from £333 to £602 per week. Additional charges are also made for hairdressing, newspapers and personal toiletries. A copy of the previous Commission for Social care Inspection (CSCI) report is on display in the reception area of the home and a copy is given to all prospective residents. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Tuesday 10th July 2007 over a period of approximately 10 hours. The manager did not know beforehand of the visit. Time was spent talking to residents and staff and observing the home’s routine and staff interaction with residents. This was to see what they thought of the service provided. Six residents were looked at in detail, through examination of assessment, care plans and other documents showing their experience of the home. A tour of the building was conducted and staff and other records concerned with the running of the home were examined. We also spoke to two relatives to see what they thought of the service provided to their relatives. The manager returned inforamtion to the Commission for Social Care Inspection (CSCI) called a ‘Annual Quality Audit Assessment’. This document tells us what the manager thinks the service does well, what has improved, and what they need to do better. This has also been used as a basis for the outcomes in this inspection. One CSCI service users survey was also returned and this information was also used to inform the findings of the inspection. What the service does well: The service at Moor-Haven provides comfortable and spacious accommodation and people benefit from having a homely, pleasant, adaptable and accessible place to live. Activities that are provided meets the needs of those who participate and the manager has forged strong links with the local community and this means that people living there remain part of the community. The overall view of people living in the home can be summed up by the person who said: ‘I’m very happy- I enjoy the activities, I can have visitors whenever and I feel well looked after.’ The meals provided are well prepared and fully meets the expectations and preferences of people at Moor-Haven. The meals are a highlight of the day and were well-prepared, enjoyed and talking point amongst the diners. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 6 Everyone ate and enjoyed the lunch and teatime meals provided for them during the site visit. The manager makes sure that there are enough staff on duty to look after all the residents and over 50 of care staff are trained to at least NVQ level 2, which means that staff have the skills and knowledge to deliver a high standard of care. The manager has ensured that where possible the routines at Moor-Haven are flexible so that people are able to make choices about their lifestyle. What has improved since the last inspection? What they could do better: The record keeping in the home needs to improve so that the manager can demonstrate that all care and support required by people is actually identified and provided. This will ensure people’s needs are being met consistantly. The manager needs to audit the practice of staff in relation to responsibilities that have been delegated; this will improve further the quality of care, as it will be in keeping with her expectations. The manager needs to ensure that staff are consistent in the records they keep when administering medication. This will safeguard against people suffering from the effects of misadministration of medication. The manager needs to introduce a forma quality assurance system that gives everyone involved in the home with the opportunity to comment on all aspects of the service so that areas of strengths and weaknesses from a users perspective can be identified, analysed and incorporated in future development plans. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 7 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-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 8 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-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 9 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): 3 (6 is not applicable at Moor Haven) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager makes sure that she receives information about the needs of people before they move into the home, so she is confident staff have the skills to meet those needs. EVIDENCE: Assessments are undertaken on people before they move into the home. A record is kept of the assessment. Three paper files were examined and each contained a copy of assessments that had been completed by the referring agency, in these cases the social workers involved with the placement. These forms are standard throughout the borough and assess the physical, emotional and social needs of people. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 10 The information is then transferred and updated on to files that are held electronically. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 11 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): 7,8,9 and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The information in care plans does not always reflect a persons current needs and so needs may not be managed appropriately, however, support is provided professionally and in the main privacy is respected. EVIDENCE: A significant number of electronically held care plans were examined. These are both assessments and care plans combined. The manager explained that as assessment and care-plan information is inported concerning a specific area if a particular score is reached the system automatically indicates that a specialist assessment, care plan, risk assessment or additional observation is required. It was noted that in respect of moving and handling and nutrition the sytem worked well. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 12 The system did not appear to work for all aspects of care as it had not triggered risk assessments for people with sensory impairment, mental health or behavioural management needs. However the inspection process highlighted these as areas of concern for certain individuals. Furthermore, as files and reports were not dated contemporaneously, it was not possible to conclude that care plans had been reviewed monthly or in line with changing needs, The manager stated that copies of the most recent reviews were held in peoples rooms, however, when cross-referenced, this was not consistently the case. The electronic system indicated that routine health care was provided and included podiatry, general practitioners, dietician, physiotherapist, speech and language therapist and specialist nursing input such as mental health team and the continence service. Records also confirmed that additional care relating to the treatment and prevention of pressure areas was effective. The medication round was observed and this was administered and stored safely. The Medication records sheets (MARS) were examined and a number of gaps were noted from previous days. This was discussed with the manager. Observation of staff throughout the day indicated that in the main staff were respectful, although moving and handling within Moor Haven could be improved if staff always gave people time to prepare before commencing any procedure. It was acknowledged in care plans that some people did not want to use foot rests on their wheelchairs, however it was noted that these were not always used even when they were in place Discussions with people living at Moor Haven indicated that health care in the home was effective and promoted well-being and independence. People related their experiences and detailed the improvement in their general health since moving into the home. For example people were encouraged and supported in regaining their appetite, and others who had been admitted in a confused state and requiring assistance in all areas were now strong enough to regain some mobility and independence. During the inspection it was observed that people were supported in remaining fully clothed, including tights or stockings, socks and shoes or slippers. Hair was neat and clothes were well laundered and ironed. People looked smart and tidy, their finger mails were clean and neatly trimmed and staff had made sure that people were given their glasses and fitted with hearing aids as prescribed. Comments included: ‘Yes I get the help I need- the doctor comes if I’m feeling off colour.’ And ‘yes the care is very good- they don’t force things.’ Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 13 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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at Moor Haven are able to make choices about their lifestyle, and are able to participate in a variety of activities. EVIDENCE: Care plans and files contained very little information concerning the social history, hobbies, past interests or future wishes of people living in the home. People stated that they enjoyed the activities that were organised every other day by the activities co-ordinator. Pictures, items on display and the report of people in the home confirmed that activities included: arts and crafts, individual and group projects, dominoes, armchair exercise, quiz sessions, bingo, entertainers, reminiscence and visits from a ‘pet a dog’ service. MoorHaven is seen as part of the local community and the pursuits of the residence often feature in the local newspapers. Moor-Haven also holds fetes and other fundraising events that are open to families, friends and the local community. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 14 Relatives commented that if people initially didn’t want to leave their room’s staff would spend time talking in private. ‘The co-ordinator went and visited him and talked about his interests and what was going on.’’ The home also hosts an act of worship each week and this well attended. Visitors were observed entering the home throughout the day and people stated that there were no restrictions –‘My visitors come whenever.’ And ‘you can come whenever you want.’ Care plans identified some preferences and people were able to make choices about the time they ate and whether to go to the dining room for lunch or tea. The menu indicated that meals in the home were traditional, varied and wholesome. Dishes included Lancashire hotpot; plate meat pie, roast meats, chicken and other casseroles, Finney haddock and other fish meals, salads, hot muffin, soups and flans. Snacks included crisps, cakes, biscuits and a choice of fruit. On the day of inspection the mid-day and early evening meals were observed. For lunch chicken casserole and vegetables was served followed by meringue, strawberries and cream. People were observed enjoying this meal and those requiring support were treated with courtesy and respect. The teatime meal was a choice of soup and sandwiches or tripe and tomatoes. People were also enjoyed this meal and again commented to each other about how good the food was. Comments included: ‘Lunch was very nice.’ ‘The food is very good’ and- ‘I’ll bet it’s not every where that you’ll see tripe been served!?’ and ‘Excellent meals!’ Hot and cold drinks were also offered to people throughout the day. A food intake chart was in place and this was in sufficient detail to assist with monitoring the diet taken by people with poor appetites. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 15 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Moor-Haven are able to express their concerns and are protected by a robust adult protection protocol. EVIDENCE: The manager reported that the home had not received any formal complaints and no concerns or comments had been recorded since the previous inspection. Discussion with people using the service indicated that they were aware of the written complaints procedure and felt confident in discussing concerns with the manager. However, those interviewed did differentiate between serious complaints and concerns. Outcomes could be improved for people in relation to complaints if the manager could demonstrate that all concerns, even those thought of as unofficial or minor, were given consideration and dealt with seriously. The manager stated that the homes adult protection policy had been revised. Staff who were interviewed were clear about the actions they would take if they suspected or witnessed abuse. The training record also confirmed that the majority if staff had attended protection of vulnerable adult training since the previous inspection in January 2007. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 16 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures that environment at Moor Haven provides a well maintained environment that is pleasant use, comfortable and accessible for the people who live in or visit the home. EVIDENCE: A tour of the building was completed at different times of the day. The rooms are pleasantly decorated, bedrooms had been personalised with items brought from home or purchased by the occupant. Many rooms had televisions and these had been provided on request. The lounge areas were warm and cosy, the carpets clean and all furniture was clean and free from stains. The home was, in the main fresh smelling. Wheelchairs are stored in the main corridors however accident records did not indicate that this caused any problems and people were observed mobilising Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 17 around the home independently using walking frames, walking sticks and hand rails as required. Bathrooms were warm and assisted baths and shower room in place. The seats of toilets had been raised and rails put in place to assist people in maintaining their independence in this area. Each bath and toilet area also had a list of the moving and handling needs required for each person so that this information was readily available to staff. Most people who commented stated that the home was clean and people were pleased with their bedrooms and reported. ’The home is clean and free from smells.’ And ‘they keep my room clean.’ Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 18 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): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager can demonstrate that staff at Moor Haven are trained and provided in sufficient numbers to meet the needs of people living there. EVIDENCE: On the day of this inspection there were 33 people living in the home and their needs were been met by a team of staff that comprised of the manager, two trained nurses, two care assistants, a cook and a kitchen assistant, one laundry worker and two cleaners. People who were asked felt that there were sufficient staff on duty- comments included: ‘I only have to ring my buzzer and they come pretty quickly.’ Observation of interactions in the home indicated that there sufficient staff as they were unhurried and the atmosphere was calm. The duty roster confirmed that this was the usual staff compliment for busy periods. Qualified staff who were interviewed also felt that staffing levels were adequate and stated: ‘generally there is enough staff- quite a few have worked here a while and we work well together.’ Training has improved since the previous inspection and electronic records indicated recent courses included moving and handling, dementia care, Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 19 dysphagia, assertiveness, basic life support, adult mental health, protection of vulnerable adults, fire safety, safer food better business, health and safety awareness. Care staff are supported in attaining National Vocational Qualification (NVQ) level 3 in care award and Registered nurses have also provided with opportunities to maintain and develop their skills through opportunities to attend specialist courses including, the principles of cauterisation, venupuncture and additional training concerning tissue viability for the specialist tissue viability link nurse. The proportion of staff who have received this training will increase as it is to be provided on a rolling program. The manager stated that more training had been provided but as the administrator was not working she could not access all the information. It must be noted that at the previous inspection the administrator had stated that more training had been provided but this had not been recorded. Staff made positive comments about the training opportunities: ‘Training is very good.’ The recruitment process for the recently recruited staff was examined. Files contained confirmation that POVA first and CRB checks had been completed. There were also two references in place. The manager stated that new staff had commenced on an induction programme that was in keeping with the Skills for Care common induction guidelines. Pictures identifying the staff are on display in the home. When asked people did not have any negative comments about the staff in Moor-Haven. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. A qualified person who has a vision of the strengths of the home and also has ideas for improvements, manages Moor-Haven. EVIDENCE: It was observed that the manager at Moor-Haven leads by example and spends time working with staff and getting to know people and their families, the manager has attained a recognised management award. Residents meetings are organised and minutes of these meeting confirmed that people feel able to air their views at this forum. The manager stated that she had taken action in response to some of the comments recorded. Unfortunately the manager was not able to demonstrate that people had been Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 21 made aware of the actions she had taken and so demonstrated to people that their comments had been acknowledged and issues dealt with. People reported that they would she was approachable and would listen to suggestions. The manager stated that people are safeguarded from financial misconduct as, money is held by the person or their representative. The home sends an invoice for money that is spent on the person’s behalf and receipts are maintained for auditing purposes. The accident records were examined and cross-referenced with information in care files. On occasion these did not reflect each other. It is important that the manager makes it clear to staff that any incident that is of or potential to the detriment of those in the home should be highlighted. This is to assist with monitoring and ensure that if a pattern of incidence develops this can be recognised and dealt with quickly. Moor-Haven has been awarded the Investor in People Award the manager stated that this was due for reassessment later in 2007. The inspection process highlighted aspects of administration that require additional supervision. For example the manager believed that the review of care plans were up-to-date but this could not be evidenced, she also assessed, as detailed in the returned AQAA, that an in-depth social history had been completed fro each person although when cross-referenced again this was not the case. The manager could not identify how the home could improve aspects of personal care, the environment or management and administration methods. These could be one of the areas explored with people, their families, and health and social care professionals, as a part of a formal quality assurance monitoring system. The manager reported in the AQAA the dates on which the appliances, lifts and utility services in the home where last maintained and inspected by an appropriately registered person. These dates were within the expected time spans. Fire safety equipment was checked and this had been serviced within the last 12 months. It was noted throughout the day that additional instruction is required in respect to moving and handling issues in the home, however the training record indicated that staff had received updated training in this topic. The cook has successfully completed the Safer Food better business course as part of the local environment health agency inspection process and control of substances hazardous to health training has commenced. Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 22 Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 16 Requirement The registered person must ensure that an accurate record is maintained of the medication administered in the home. This will safeguard against people being over or under medicated. The registered person must ensure that risk assessments are reviewed and evaluated thoroughly and updated to reflect changing needs and current objectives for health and personal care. This is so staff are clear about the actions they need to take to meet current needs and also to confirm that people are, regularly, given the opportunity to discuss what they would like to happen. (previous timescale 31/03/07 not met) Timescale for action 01/11/07 2. OP8 13 01/11/07 Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 25 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 OP16 Good Practice Recommendations The registered person should ensure that the complaints policy is revised and displayed within the home for the information of residents and their representatives. The registered person should ensure that she has a system of audit to make sure that what she expects staff to do, is done. The registered person should ensure that residents care plans are further developed to set out in detail the action that needs to be taken by staff to ensure all aspects of the health, personal and social care needs of the residents are met. These should be kept up to date, accurate and reviewed so that people’s changing needs are met. 2 OP33 3 OP7 Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Moor-haven (Nh) Limited DS0000025444.V339729.R01.S.doc Version 5.2 Page 27 - 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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