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Inspection on 06/12/05 for Moor-haven (Nh) Limited

Also see our care home review for Moor-haven (Nh) Limited for more information

This inspection was carried out on 6th December 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

One relative who returned a comments card said "I like Moor-Haven because the home continually spends money on decorating, carpets etc so that the environment is always maintained to a high standard". Another resident said, "My Mother-in-law is very happy here and if there were any complaints she would tell me. She says she likes the staff and they are very helpful". One resident said he was very happy at the home and said staff and residents were a "friendly and sociable lot". Another resident said the manager was very approachable and although the resident was quite new to the home said she had started to make friends amongst some of the other residents. The majority of care staff have completed National Vocational Qualifications in care and the manager often works alongside the nurses and carers ensuring continuity of care and maintenance of high standards. The home is very clean, comfortable and homely.

What has improved since the last inspection?

Since the last inspection television points have been put in all bedrooms (some did not have a television point previously). The home has also arranged for the provision of `Sky Sports` as a number of residents enjoy watching sport on television. An ongoing programme of redecoration continues and a new bath has been purchased for the bathroom on the ground floor. A marked improvement was noted at this inspection in the standard of record keeping. Although there remains some work to be done the new IT system is much more user friendly and information about what care the residents need is generally more detailed.

What the care home could do better:

Although an improvement has been noted in documentation, staff still need to be more rigorous in ensuring that care plans are developed to address all residents` assessed needs. Recruitment procedures must be strengthened to make sure that all the necessary checks are made in respect of prospective employees to be certain they are suitable to work in a care home.

CARE HOMES FOR OLDER PEOPLE Moor-haven (Nh) Limited 193 Ripponden Road Oldham Lancashire OL1 4HR Lead Inspector Mrs Fiona Bryan Announced Inspection 6th December 2005 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.V263949.R01.S.doc Version 5.0 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.V263949.R01.S.doc Version 5.0 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.V263949.R01.S.doc Version 5.0 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). No more than 24 service users to be admitted for nursing care. Two registered nurses to be on duty between 8am and 1pm. One registered nurse to be on duty between 1pm and 8am. The manager to be supernumerary for 9 hours per week. No more than one named service user under the age of 55 years may be admitted into the home. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 15th August 2005 2. 3. 4. 5. 6. 7. Date of last inspection 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 DS0000025444.V263949.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the year. At the last inspection in August 2005 the home was performing satisfactorily in a number of areas so the purpose of this inspection was to review progress in the areas that were identified as needing improvement. This was mainly related to how care plans were developed and reviewed, the procedures for medicine storage and administration, staff recruitment and staff training. Five other key standards, which have to be assessed at least once year were not examined at the last inspection, and were therefore considered at this inspection. These standards included how the home promoted choices for residents, how the home dealt with complaints, residents’ personal finances and the qualifications of the manager and the care staff. This announced inspection was undertaken by one inspector who spent time talking to residents, visitors and staff. The needs of three residents were looked at in detail, with a particular focus being their experiences in the home from their admission to the present day. A selection of documents was examined including residents’ care files, medicine records, and personal finance records, staff personnel files and training records. Information was also obtained from a pre-inspection questionnaire, which the home completed prior to the inspection. Comments cards were distributed. Five residents had responded at the time of writing this report, of whom four were entirely happy with the services provided. One resident stated that they only sometimes felt well cared for. Five relatives responded who were all satisfied with the care their relatives were receiving. Prior to this inspection comments cards were sent to GP’s who visit residents in the home. One responded, who stated that the home was “excellent” and that the staff demonstrated a clear understanding of the care needs of residents. Standards which were not assessed at this inspection, were considered to be satisfactory at the last inspection. For further information about how the home met these standards please refer to the report of the inspection on 15th August 2005. What the service does well: Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 6 One relative who returned a comments card said “I like Moor-Haven because the home continually spends money on decorating, carpets etc so that the environment is always maintained to a high standard”. Another resident said, “My Mother-in-law is very happy here and if there were any complaints she would tell me. She says she likes the staff and they are very helpful”. One resident said he was very happy at the home and said staff and residents were a “friendly and sociable lot”. Another resident said the manager was very approachable and although the resident was quite new to the home said she had started to make friends amongst some of the other residents. The majority of care staff have completed National Vocational Qualifications in care and the manager often works alongside the nurses and carers ensuring continuity of care and maintenance of high standards. The home is very clean, comfortable and homely. 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 DS0000025444.V263949.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 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 the following standard(s): None of the standards in this section were assessed. EVIDENCE: Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9 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. Medicine procedures were generally satisfactory. EVIDENCE: The care files for three residents were examined. A marked improvement was noted in the standard of record keeping since the last inspection. Care plans and risk assessments are held electronically and the introduction of a new more user friendly IT system has made information more accessible. However, further work is still needed on some aspects of the documentation. Care plans did not always clearly state the intended outcomes for proposed interventions, for example one resident had a care plan regarding nutrition, which stated that the intended outcome was that the resident received adequate nutrition, but did not state how this would be assessed. The records Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 10 showed that this resident had lost 3kgs in weight in four weeks but no concerns had been raised about this. Although risk assessments had been undertaken care plans did not always state what interventions were in place to minimise identified risk, for example two residents were identified as being at risk of pressure sores but neither had a care plan to address this. Two of the three files contained no care plans for social care needs. The social care plan for another resident was vague stating that the resident was to join in with any social events arranged by the activities organiser. Although the personal and social histories of the residents were detailed this information had not been used to formulate a person centred plan for each resident. One resident who required wound care had been referred to the tissue viability nurse. Evidence was available that her instructions were being followed. It was not always clear what visits residents had received from other health care professionals, as the relevant part of the software package to record this using the home’s IT equipment had not been used. A selection of residents’ medication administration records was examined and satisfactory. Service users are identified prior to medication administration by the use of photographs attached to the medication administration records. Staff members with responsibility for medication administration can be identified by the means of a staff signature sheet. Ibuprofen and Tramadol had been removed from the original boxes and were stored in the medicine trolley in pre-packed strips. Medicines must be retained in their original packaging to reduce the risk of errors in administration. Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 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 the following standard(s): 14 Residents are assisted to exercise choice and control over their lives. EVIDENCE: Residents said that they were able to choose how to spend their day and were given options regarding activities going on in the home. One resident who had a bedroom upstairs had been given the choice to move to a room on the ground floor as she spent a lot of time in her room but liked to see staff in the near proximity. The resident made her own decision to move and was pleased with her new room. Another resident said staff allowed her to do what she could for herself and as a result she was getting stronger. Since the last inspection mobile handsets have been purchased to ensure that residents are able to make and receive phone calls in private. Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents and relatives are confident that their complaints will be addressed properly. Further training and stricter adherence to recruitment procedures are required to ensure that residents are protected from abuse. EVIDENCE: The home had only received one verbal complaint since the last inspection, which was resolved immediately. There was no written record of this. A record should be maintained of any complaints received as part of the home’s quality assurance procedures and for audit purposes. Residents said that if they had any complaints they would speak to the manager who they felt sure would deal with any issues appropriately. The majority of care staff had received some training in the prevention of abuse as part of their NVQ training. However, all staff including ancillary staff should receive this training and be aware of local adult protection procedures. 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 DS0000025444.V263949.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were assessed. EVIDENCE: Although the standards in this section were not formally assessed it was noted that a new bath had been purchased on the ground floor and further redecoration of the home had taken place. Television points had been inserted in all bedrooms (some did not previously have a television point) and the home has begun to subscribe to the Sky Sports channel as a number of residents enjoy watching sport on television. Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30 Residents are cared for by competent staff. Failure to follow recruitment policies and procedures puts residents at risk. Staff receive ongoing training but updates in some mandatory topics are required. EVIDENCE: Sixteen of the nineteen care staff employed at the home (84 ) have achieved NVQ level 2 or 3. This exceeds the target to meet this standard. Examination of three staff personnel files indicated that staff had been employed without obtaining the necessary documents and information. One employee only had one reference on file and the designation of the referee for the other employee was not stated. Another staff member had not provided a reference from her last employer. In all cases the employees’ employment histories could not be properly verified, as the dates of their previous positions were not provided. One staff member had been recruited without checks having been made to ensure they were not included on the POVA list. Since the last inspection records of staff training have been updated on the IT system. Examination of this indicated that various members of staff had attended training in dementia awareness, venepuncture, control of infection, falls awareness, nutritional awareness, basic and intermediate life support, wound care and flu immunisation. Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 15 The majority of staff had undertaken fire safety training but many had not had an update in moving and handling and all staff who handle food need up to date training in food hygiene. Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 The manager has the skills and knowledge to properly manage the home. Residents’ financial interests are safeguarded. Further staff training is needed to ensure that the health, safety and welfare of residents and staff are protected. EVIDENCE: The manager has obtained a diploma in management studies and has undertaken other training periodically to ensure that she has the skills and knowledge to fulfil her role. Secure facilities are provided for the safe keeping of money and valuables on behalf of the residents. Written records are in evidence of all transactions. An individual account record states how much money is in each resident’s Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 17 account. The majority of residents are assisted with their finances by their families. As stated previously staff require training updates in some mandatory health and safety topics. Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 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 OP7 Regulation 15 Requirement The registered person must ensure that care plans are developed to meet residents’ assessed personal health and social care needs and that expected outcomes are clear and measurable. (Timescale of 30/09/05 not met). The registered person must ensure that all staff receive training in the prevention of abuse and local adult protection policies. 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. (Timescale of 30/09/05) not met). The registered person must ensure that staff receive updated moving and handling training and that staff responsible for handling food receive food hygiene training. Timescale for action 28/02/06 2 OP18 13 30/04/06 3 OP29 19 28/02/06 4 OP30OP38 13, 18 30/04/06 Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP8 OP9 OP16 Good Practice Recommendations The registered person should ensure that visits from all health care professionals are recorded. The registered person should ensure that medicines are kept in their original packaging. The registered person should ensure that a record is kept of any complaints made to the home, together with a record of any investigation taken and the outcome. Moor-haven (Nh) Limited DS0000025444.V263949.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs 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 DS0000025444.V263949.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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