Inspection on 25/06/08 for Moor-haven (Nh) Limited

This inspection was carried out on 25th June 2008.

CSCI found this care home to be providing an Adequate service.

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 10/07/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Moor-haven (Nh) Limited 193 Ripponden Road Oldham Lancashire OL1 4HR Lead Inspector Michelle Haller Unannounced Inspection 10:00 25th and 30th June 2008 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.V365558.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.V365558.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 moorhavench@btconnect.com Moor-Haven (NH) Limited 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.V365558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 33 service users. Date of last inspection 20th November 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. 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. 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 £360 to £510 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. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection that included an unannounced visit to the service. This means the manager did not know in advance that we were coming to do an inspection. During the visits we looked around the building, talked to residents, relatives and staff including the deputy manager and registered provider. We observed the interactions between people living at Moor Haven and examined care plans, files and other records concerned with the care and support provided to people in the home. We also looked at all the information that we have received or asked for since the last inspection. This included: The annual quality assurance assessment (AQAA) that was sent to us by the manager. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how Moor Haven has managed any complaints and any adult protection issues that may have arisen. What the manager has told us about things that have happened in the home through ‘notifications.’ We also received 16 Commission for Social Care Inspection (CSCI) surveys that were returned to us by people using the service and from other people with an interest in the service such as staff and relatives. Since the last inspection there has been one investigation carried out in the home relating to safeguarding vulnerable adults. This was fully investigated by the local authority social services, and the registered providers responded appropriately to the outcome. There has been one complaint received by CSCI and this was investigated fully and a response sent to us which we were satisfied with. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the record keeping in the home has been improved so that the “acting” manager can demonstrate that all care and support required by people is identified and provided. Since the last inspection the way care-plans and daily records are completed have been revised so that the “acting” manager can guarantee that they are tamper proof. It is also now possible to identify who has written the reports and who has taken responsibility for each area of care. Since the last inspection some areas of the home including the dining room and lounge areas have been refurbished and decorated. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Moor-haven (Nh) Limited DS0000025444.V365558.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.V365558.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 (standard 6 is not applicable) 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 benefit from having their needs fully assessed before moving in so that the manager is confident that their needs can be met. EVIDENCE: The files of the most recent admissions were examined and each held a copy of a pre admission assessment completed a qualified member of staff. These assessments held detailed information about peoples care needs, including medication, moving and handling needs, there was also information about communication and emotional needs. This information was expanded on and developed into care plans. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 10 People who were spoken to also said that staff from Moor Haven visited people in their home’s or in hospital before being accepted into the home. One person said ‘Yes, she was visited by the head nurse.’ Moor-haven (Nh) Limited DS0000025444.V365558.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 good. This judgement has been made using available evidence including a visit to this service. People at Moor-Haven benefit from effective health care and personal care, and this is provided with dignity and respect. EVIDENCE: After discussion with the acting manager five care files and other information about these people were examined. The manager is in the process of transferring care plans and daily records from being held electronically to being hand written. The care plans looked at are assessment and care plans combined. This meant that when care plans are reviewed a reassessment of needs also took place. In the main the information in the care plans did reflect information in the assessments. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 12 Additional risk assessments had been completed and the information made clear in the care plan. These included moving and handling, pressure area risk, falls, using bed rails, oral hygiene and nutritional status. These care plans are hand written, dated and signed. The manager is now able to confirm that care needs are reviewed monthly or when necessary. Daily records were examined. The contents are now written more respectfully and personalised. The information written also showed that staff dealt with difficult situations calmly and in a manner that maintained peoples dignity. There continues to be some gaps in respect of the instructions in the care plan compared to the record of what people actually do. For example a number of people were assessed as having a medium to high risk of developing pressure areas, however, the actions staff were to take was not always clear, and neither was there always evidence that appropriate action had been taken. This could include confirmation that pressure areas had been assessed, or signed confirmation that pressure area care had been applied. Daily records did not always show that appropriate action had been taken in respect of the observations that staff had made. These matters were discussed with the registered provider and the acting manager. Computer records that were printed out confirmed that people received routine and specialist health care include ding, podiatry, general practitioners, dietician, physiotherapist, speech and language therapist and specialist nursing input such as mental health team and the continence service. 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. This was discussed with the manager. Observation of staff throughout the day confirmed that they treated people with dignity and respect. People were approached gently and they were given a choice about complying with procedures such as having a clothes protector put on. On this inspection moving and handling appeared safe and in keeping with peoples care plan, the training calendar and discussion with the manager confirmed, however, that this is still an outstanding training need for staff. Staff was also discreet when offering to support people with personal care and hygiene. People living at Moor Haven mostly felt that health care in the home was effective and the majority of those that returned CSCI surveys felt that their health needs were always met. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 13 People who were spoken to also say that their health needs were always met. They said ‘yes they are quick to get help.’ Personal care in at Moor Haven is to a good standard. People who were seen were well groomed and clean. The ladies and gentlemen were fully dressed wearing tights or stockings, socks and shoes or slippers. Hair was neat and clothes were well laundered and ironed. People looked smart and tidy, their fingernails were clean and neatly trimmed and staff had made sure that people were given their glasses and fitted with hearing aids as prescribed. Comments from relatives included: ‘The staff treat the residents with respect, patience and kindness’ and ‘The manager is on the ball- she gets help quickly and keeps me informed.’ Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 14 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 offered interesting and varied meals, there are, however, insufficient activities. EVIDENCE: The majority of care plans and care files examined contained very little information concerning the social history, hobbies, past interests or future wishes of people living at Moor Haven, this is an observation that has been made on previous inspections. There was no indication from the training calendar or discussion with service users or their family that activities could be individualised or person centred. The need to remedy this was discussed with the acting manager and the registered provider on this occasion. On this inspection there was very little evidence that people had been offered a varied program of activities either in the home or the local community. The manager stated that the activities organiser kept her own records. This needs Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 15 to be made available at all times so that she can look at it daily and determine what additional work in this area is needed. An activities calendar is on display, however, on the day of inspection no activities took place because the activities organiser was not available. This matter was discussed with the manager as, ideally, all staff should be capable of providing activities even if this is planned and organised by staff with a special interest or skills. Although people who returned surveys were not negative about the activities they did not comment on the things they had done. Pictures on display in the home did confirm that people had celebrated St George’s day 2008. Pictures also confirmed another highlight for this year, which was a visit to the home from the Bishop of Manchester. This was also reported in the local newspaper. According to the information displayed for people to see activities included; a one-hour quiz session, armchair exercises, games and crafts, holistic therapies and reminiscence bingo. Holy Communion, the library service and a visiting entertainer are also offered once a month. Unfortunately, as previously stated, there was little evidence to confirm that what was written had taken place. It was clear, however, that the activities co-coordinator did spend time with residents because; a significant number of the CSCI surveys that were returned had been completed with her assistance. People living in the home who were spoken to either said that they preferred to spend time in their rooms or that they would join in with what was offered. Relatives commented that people did not have many outings although there were things going on that they could do. ‘Yes –does quizzes and bingo- but likes watching- everything is offered though.’ Visitors were observed entering Moor Haven throughout the day and people stated that there were no restrictions –‘…keeps good contact with the family and we can visit any time.’ And ‘I can have visitors anytime.’ Discussion with the staff and relatives confirmed that the routines in Moor Haven were flexible and that people were able to make choices about what they did and when. People were able to take their meals in their room if they wanted although the manager stated that people were also encouraged to socialise. Observation throughout the day confirmed that people living at Moor Haven did develop friendships and were able to sit with people who had similar abilities and interest. Discussion with the manager about people who choose to remain in their rooms indicated that this should be monitored closely. This will make sure that people who do so are not isolating themselves because of the way they may be Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 16 treated by other residents. And, if this is the case, steps to promote an individuals right to access all communal areas must be taken. At this inspection the chef was interviewed. He said that the change in ownership of Moor Haven had a positive outcome in respect of diet and food. He said that there was now a better choice of snacks for people on a diabetic diet. The only problem was purchasing some of the specialist items such as tripe. He felt, however that this problem could be overcome. The lunchtime meal on the day of inspection was sliced potatoes and butter, baked in the oven, stewed steak, cauliflower and green beans. The dessert was pears and ice cream. The teatime meal included cheese and potato cake. The lunchtime meal was sampled and this also included a portion of cheese and potato cake. The meal was appetising to look at and the meat was easy to eat. The menu is rotated every three weeks and the manager also explained that it changes from season to season. The summer menu included dishes that were traditional, varied and wholesome. Meals included poached fish, liver and bacon, cheese and onion flan and toad in the hole. Evening meals included soup with a selection of sandwiches or cooked foods such as cauliflower cheese, filled jacket potatoes, quiche or muffins filled with hot meat. The menu showed that for lunch people were offered a light dessert such as ice-cream or fruit, and at teatime they could have a more substantial dessert such as sponges, milk puddings and crumbles. Snacks included crisps, cakes, yoghurts, biscuits and a choice of fruit. On the day of inspection the mid-day meal was observed. People were observed enjoying this meal and those requiring support were treated with courtesy and respect. People were provided with adapted plates and cutlery to help them to maintain their independence and dignity. Staff supported people to eat by sitting with them and taking time. People also said that if they didn’t like what was on the menu an alternative such as omelette would be offered. The residents who returned CSCI surveys were ambivalent about the meals in that half ‘always’ or ‘usually’ enjoyed the meals and half felt that they ‘sometimes’ enjoyed the meals. However none made further comments about this and people who were spoken to had only good things to say about the food. Comments about the food included: ‘The food fine- she’s doing well and eats everything.’ ‘The food is great’ and ‘Yes I do like the food though I don’t feel much like eating.’ Hot and cold drinks were offered to people throughout the day and jugs of cold drinks were available and refilled. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 17 A food intake chart was in place and this was completed in sufficient detail to assist with monitoring the diet taken by people with poor appetites. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 18 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 not given enough support to express their concerns and senior staff do not fully understand the local adult protection protocol. EVIDENCE: The training calendar records show that the majority of staff have now completed Protection of vulnerable adult training with the Oldham Metropolitan Borough Council (OMBC) training partnership. One member of staff was interviewed and was able to describe actions that could be considered abuse and what they would do if they witnessed behaviours that a could be considered as abuse. However the incident records showed that when an incident had occurred the correct steps had not been taken. Although a complaints procedure is in place and on display, people we spoke to said they did not know how to make an official complaint and the necessity for staff to fully understand the OMBC adult protection protocol was highlighted to the registered person. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 19 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: Moor Haven was looked around 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. There were no bad odours. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 20 Since the coming under new ownership a refurbishment program has commenced and some areas of the home including a lounge and bathroom areas have been re-decorated. Wheelchairs continue to be stored in the main corridors and accident records did not indicate that this caused any problems. People were observed mobilising around the home independently using walking frames and walking sticks. Everyone who returned the CSCI survey felt that Moor Haven was always clean and fresh. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 21 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. Staff at Moor Haven are provided in sufficient numbers to meet the needs of people living there. EVIDENCE: On the day of inspection the manager reported that there were 31 people living at Moor Haven The staff for the early shift was 2 qualified nurses including the manager, 5 carers, 1 laundry worker, 1 cleaner, 1 housekeeper the chef and a kitchen assistant. People who returned surveys mostly felt that there was usually staff available when needed, and staff felt that there was usually enough of them to do the jobs required. Observation throughout the indicated that staff were deployed in numbers that met needs. People were not hurried and call bells were answered quickly. At lunch time 2 carers were seen sitting with people and other went to people’s rooms with trays. In the afternoon it was noted that staff did take the time to sit and talk to residents. The training record was discussed with the manager and the registered provider, as this did not seem to provide an accurate picture of the training provided to staff since. However the records made available confirmed that staff had received Protection of vulnerable adults and fire safety training. Care staff are also supported in attaining National Vocational Qualification (NVQ) Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 22 level 2 and 3 in care award. The manager provided information that, in addition to trained nurses and domestic staff, 20 care staff were also employed and of these 11 have attained NVQ level 2 in care. This proportion is in keeping with the expected figure of 50 . On the day of inspection staff came into Moor Haven to receive specialist training in Palliative Care. Staff who returned CSCI surveys all assessed that the training received fully prepared them for their jobs and kept them up dated with new ways of working. The recruitment process for the recently recruited staff was examined. Files contained confirmation that POVA first had been done, and the majority had confirmation that CRB checks had been completed. There were also two references in place for each person. The manager stated that new staff had commenced on an induction programme that was in keeping with the Skills for Care common induction guidelines. The member of staff who was interviewed confirmed this. although it was not included on the training record. Pictures identifying the staff are on display in the home. Comments made about the staff included: ‘Staff are careful and take time up to now.’ And ‘Yes you can have a joke with them.’ Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 23 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): 31,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider is making sure, in the absence of a Registered Manager, that Moor Haven continues to be managed in a way that will promote the general well being and safety of people involved with the home. EVIDENCE: There have been major changes in the management of Moor Haven the longstanding registered manager has moved on and the home has changed ownership. The current acting manager is a qualified nurse, and has worked at Moor Haven for about 6 years. No firm plans have been made about her applying to the CSCI to become the registered manager for the home. The registered individual is experienced in running care homes and takes an active Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 24 interest in the day progress of the home. The company also provides an operations manager who the acting, manager can refer to for advice and guidance. Currently the new owner is collecting baseline information about training needs, replacement of equipment, refurbishment and local resources that may be beneficial to people living at Moor Haven. 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 made aware of the actions she had taken and so demonstrated to people that their comments had been acknowledged and issues dealt with. The administrator 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. Moor-Haven has been awarded the Investor in People Award the manager stated that this were successful in maintaining this reward when they were reassessed in 2007. 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. The chef continues to manage the kitchen through the Safer Food better business protocol and Control of Substances Hazardous to Health (Coshh) has been completed. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 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 3 X 3 X X 3 Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 26 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. (outstanding from 20/11/07) A manager must be appointed who is registered with the Commission For Social Care Inspection. Timescale for action 01/10/08 2. OP31 8 30/09/08 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 made known to residents and their representatives. Complaints received should be acknowledged and investigated fully and fairly. This will ensure the people are protected through an ethos of DS0000025444.V365558.R01.S.doc Version 5.2 Page 27 Moor-haven (Nh) Limited 2. 3. OP33 OP7 4. OP12 5. OP18 openness and transparency and will help to identify areas for improvement. The registered person should introduce a quality assurance system so that people can participate in planning what happens at Moor Haven. 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 aspects of social care needs of the residents are met. The registered person should be able to show that all people living in Moor Haven are offered a variety of activities so that they can remain motivated and interested in life and what is happening about them. The registered person needs to make sure that staff respond in line with guidance when they identify behaviours that could be related to safeguarding adults in line with the home’s safeguarding policy and that of Oldham Social Services. Moor-haven (Nh) Limited DS0000025444.V365558.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Central Registration 9th Floor Oakland House Talbot Road, Old Trafford Manchester M16 0PQ 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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