Inspection on 15/08/05 for Moor-haven (Nh) Limited

This inspection was carried out on 15th 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 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 10/07/07

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

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

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 Lancs OL1 4HR Lead Inspector Fiona Bryan Unannounced 15 August 2005: 09:00 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-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Moor-Haven (NH) Limited Address 193 Ripponden Road, Oldham OL1 4HR 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) 0161 629 2064 Moor-Haven (NH) Limited Mrs T Harwood Care Home with Nursing 33 Category(ies) of PD Physical Disability - 33 registration, with number PD (E) Physical Disability - over 65 - 33 of places OP Old Age - 33 Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service user to be admitted to the home under the age of 55 years. 2. Two registered nurses to be on duty 8am-1pm. One registered nurse to be on duty 1pm-8am. 3. The manager to be supernumerary for 9 hours per week. 4. No more than 24 service users to be admitted for nursing care. Date of last inspection 7th January 2005 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. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector, who spent a total of 9.5 hours at the home. Time was spent talking to residents, visitors and staff. Three residents were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of staff and residents’ records were examined including records of care, medicine records, staff duty rotas and employment and training records. Comments cards were left at the home for residents and relatives but none had been returned at the time of writing this report. A pharmacy inspection was also held at the home on 4th July 2005. A number of requirements were made and checks were made at this inspection to assess if improvements had been made. What the service does well: Moor-Haven is a medium sized home with a very happy, sociable and relaxed atmosphere. The manager often works as part of the staff team and knows the residents very well. Residents and relatives felt she was approachable and accessible. Residents said they felt safe and secure in the home and staff were observed to interact well with residents, showing care and kindness. Comments from residents included “Staff are lovely, (their) attitude is very good”, “Staff are willing to do anything for you”, “ are very patient”, “Staff are very, very helpful” and “treat you well”. Residents said that they were happy with the activities and social events organised by the home. Efforts are made to suit all residents including those who join in with group activities and those who prefer their own company. Many positive comments were received about the food provided at the home, all the residents spoken to saying they enjoyed the food and were offered a choice. Residents and relatives opinions are taken into account and residents are treated as individuals. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 6 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-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Residents are assessed before they move into the home. Residents and their representatives are confident that their needs are being met. EVIDENCE: The care files for three residents were looked at in detail. An assessment was undertaken of each resident prior to their admission to the home. A resident who was quite new to the home said she felt staff had got to know her quickly and knew what she needed help with. Residents and relatives were confident that the home could meet their needs and staff were knowledgeable about their preferred routines and health care and personal care needs. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 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, 9 and 10 The residents’ care plans do not always set out all of their health, personal and social care needs, leading to the potential risk that health care needs may not be met. Failure to follow policies and procedures in respect of medicines puts the residents at risk. Residents are treated with respect and dignity. EVIDENCE: Since the last inspection a new computer software system has been introduced at the home – staff reported that it was easier to use and improvements have been made in the information that is available about each resident. Relatives said they were kept informed about changes in the residents’ conditions or care needs and several relatives had attended social services’ reviews of residents’ care. However, there was no clear method of recording resident or representative involvement and agreement with the care planned, within the electronic system. More consideration must be given to how and where information about each resident is recorded as some information such as residents’ weights, wound care records and details of visits to the residents Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 10 by other health care professionals are kept on paper. This causes confusion when reading the residents’ care files on the computer system, as it appears that a lot of information is not available. The reader should be able to retrieve all information about each resident using one system so a view can be formed of the holistic care needed. Although the activities organiser has started to record some of the residents’ personal histories this has not been undertaken with all residents and there was little detail regarding residents’ mental health or social care needs. Some care plans and risk assessments were undated and there was evidence that they had not always been updated to reflect residents’ changing needs. Wound care records lacked detail regarding the grade of wounds and the improvement or deterioration of the wound. The care plan for one resident referred to them requiring a pressure mattress – details of the type of mattress used and the pump setting if applicable should be included to ensure that staff have the information to monitor the effectiveness of the equipment. Photographs should be taken of wounds (with the consent of the resident) to assist staff in assessing progress. All the residents were well presented, appearing clean and comfortable. Relatives confirmed that when they visited the residents their personal hygiene had been attended to. The medicine records for three residents were looked at in detail. Over a threeday period it was found that on 20 occasions a signature for medication administration or a reason for non-administration had not been completed. The temperature of the medicines refrigerator was not monitored and recorded daily. The dosage instructions for medicines were complete and the maximum single and daily dosage was included for “when required” medication. It was reported that risk assessments had been undertaken for the residents who were selfadministering items of medication and this was recorded in their care files. A list of staff members authorised to administer medicines, with a record of their signature and approved initials was available. Procedures have been put in place to record all medication received or disposed of by the home. Records had been maintained satisfactorily for controlled medicines, with the exception of one missing signature, which the manager was informed about. Residents were very complimentary about the staff, saying that they were treated well, with kindness and respect. Staff attitudes, observed during the inspection, were positive, friendly and professional. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. The home is able to meet residents’ social, cultural, religious and recreational needs. Residents are able to maintain contact with their friends and families. Meals provided by the home are wholesome, appetising and suit most residents’ tastes. EVIDENCE: Residents and relatives were satisfied with the activities and social events provided for them, and stated that they were able to participate in leisure pursuits as they wished. Examples of some activities arranged by the home are quizzes, bingo and exercises. Outside entertainers are invited in to the home. On the day of the inspection the activities organiser had organised a quiz afternoon – about nine residents joined in and were really enjoying themselves, calling out the answers and laughing and chatting in between questions. Some questions led to further conversation and reminiscence amongst the residents. In addition to group events, the activities organiser also spends a lot of time talking to residents on a one-to-one basis. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 12 Residents had recently been to Alexandra Park and some enjoy sitting in the garden or go out with relatives. The home has arranged for an aromatherapist and a Reikki healer to visit, which some residents have found very beneficial. The minister from St Barnabus also visits the home. Residents reported that the routine of the home was flexible and that they were able to receive visitors at any reasonable time. On the day of the inspection lunch was mince, new potatoes, peas and carrots. The meal looked and smelled very appetising. Meals are held in two sittings so that staff can assist residents who need help in a pleasant and relaxed atmosphere. Residents were complimentary about the food provided, saying “(the food is) brilliant – really, really good”. One resident said that a particular cereal that they liked had been bought in especially. A cooked breakfast is available every day and residents said there was a choice at each meal. Mid morning and mid afternoon drinks and snacks are provided and residents are served a drink and biscuits or cake at suppertime. Residents who spent most of the day in their own rooms had jugs of juice or water and staff were observed helping some residents to have drinks whilst they were joining in the quiz during the afternoon. Examination of the menu indicated that it rotates over a three-week period. Many of the dishes are based on local dishes, which are popular with the residents, such as Duck a muffin and rag pudding. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Further training and stricter adherence to recruitment procedures are required to ensure that residents are protected from abuse. EVIDENCE: The home has policies in place regarding the prevention of abuse and whistle blowing. Some staff have received training in prevention of abuse as part of their NVQ training. However some staff have not received training in this topic and no staff interviewed had undertaken training in dealing with challenging behaviour. All staff stated that they would report any suspicion of abuse to the nurse in charge or to the manager. As discussed elsewhere in this report shortfalls in recruitment procedures lead to a possibility that unsuitable staff may be employed to work at the home. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is well maintained and safe for residents to use. The home is clean and pleasant to live in. EVIDENCE: Residents said they liked their rooms and had been encouraged to personalise them. All areas of the home seen on the day of the inspection were clean and tidy with appropriate, homely furnishings. Residents and visitors said they were satisfied with the standards of cleanliness in the home and no malodours were detected with the exception of one resident’s room, which was presenting a particular management problem. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 15 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 Staffing levels meet the needs of the residents. Failure to follow recruitment policies and procedures puts residents at risk. The home was unable to produce evidence of staff training. EVIDENCE: Staff, residents and relatives all said there were enough staff on duty. Examination of the staff duty rotas indicated that staffing levels were satisfactory. It was reported that agency staff were very rarely required to cover shifts. Two staff members had been recruited without criminal record disclosure certificates being applied for and without checks having been made to ensure they are not included on the POVA list. An immediate requirement was made to ensure that the relevant checks are made and evidence of this must be forwarded to the CSCI. Examination of two staff personnel files indicated that only one written reference had been obtained for one staff member, although it was reported that a verbal reference had been obtained. Staff reported that they had received training in palliative care, dementia care, health and safety and food hygiene. However, there were no records available to support this. In addition there were no records of other mandatory training having taken place such as moving and handling updates. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 16 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) 32, 33, 37 and 38 The management and ethos of the home ensure that it is run in the best interests of the residents. Improvements are required in record keeping and documentation. Further staff training is needed to ensure that the health, safety and welfare of residents and staff are protected. EVIDENCE: Relatives confirmed that there have been residents/relatives meetings. One relative hadn’t been able to attend and was sent minutes of the meeting through the post. Aspects of the home such as the menus and activities are discussed with the residents. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 17 The manager works with the nurses and carers on a very regular basis, delivering care. Residents and relatives stated that the manager was very approachable and they said they felt able to discuss any matters with her at any time. The less than satisfactory standard of record keeping in the home, in respect of both the residents care files and the staff training records does not reflect the high standard of actual care practices within the home. Environmental checks of the home in respect of health and safety, such as inspection of the fire exits, fire alarms, emergency lighting etc are undertaken regularly and recorded. Staff stated that they had not taken part in fire drills recently. As stated previously, it could not be evidenced from the training records that staff had received mandatory health and safety training. Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 18 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 x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x 3 3 x x x 2 2 Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 19 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 7 Regulation 15 Requirement The registered person must ensure that a care plan is written for each service user, which sets out in detail the action that needs to be taken to ensure that all aspects of the health, personal and social care needs of the service user are met. (Timescale of 28/2/05 not met) The registered person must ensure that care plans are reviewed at least once a month and updated to reflect changing needs. (Timescale of 15/2/05 not met) The registered person must ensure that the incidence of pressure sores, their treatment and outcome are recorded in the service user’s individual plan of care. (Timescale of 15/2/05 not met) The registered person must ensure that information and advice from other healthcare professionals is transferred on to the plan of care for a service user. (Timescale of 15/2/05 not met) The registered person must ensure that medication Timescale for action 30/9/05 2. 7 15 30/9/05 3. 8 17 schedule 3 30/9/05 4. 8 13 30/9/05 5. 9 13, 17 schedule 15/9/05 Page 20 Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 3 6. 9 13 7. 9 13 8. 18, 30 18 9. 29 19 10. 29 19 11. 30, 37, 38 17, 18 Schedule 4 12. 38 23 administration records are signed contemperaneously and accurately. (Timescale of 6/7/05 not met) The registered person must ensure that all medication is administered to residents as prescribed. (Timescale of 13/7/05 not met) The registered person must ensure that the temperature of the medicines refrigerator is recorded daily on a maximum/minimum thermometer and that staff members understand the action to take if the temperature recorded is outside the normal range. (Timescale of 3/8/05 not met) The registered person must ensure that staff receive training in prevention of abuse and dealing with challenging behaviour. The registered person must ensure that the two members of staff identified at the inspection apply for a CRB disclosure certificate and must ensure that a check is made against the POVA list. The registered person must ensure that all information and documents stated in Schedule 2 of the Care Homes Regulations 2001 are obtained in respect of employees at the home. The registered person must ensure that staff receive training in health and safety topics and other topics specific to the residents being cared for, and must ensure that a record is kept of all training delivered. The registered person must ensure that staff participate in fire drills and a record is kept of 15/9/05 15/9/05 31/3/06 Immediate 30/9/05 30/11/05 31/10/05 Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 21 each drill and which staff members attended. 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 7 Good Practice Recommendations The registered person should ensure that if residents lack capacity for involvement in the development of their care plan, this is documented and their representative should sign agreement of the care plan on their behalf if possible. The registered person should ensure that photographs are taken of residents wounds, in order to assist in assessing the effectiveness of treatment. 2. 8 Moor-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton-under-Lyne OL7 0QD 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-Haven (NH) Limited F54-F04 s25444 Moor-Haven v227896 150805 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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