Inspection on 24/08/06 for Moor House (Woking)

This inspection was carried out on 24th August 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Moor House (Woking) 06/12/05

Moor House (Woking) 24/06/05

Moor House (Woking) 22/11/04

Moor House (Woking) 23/06/04

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

CARE HOMES FOR OLDER PEOPLE Moor House (Woking) Moor House 13/14 Horsell Moor Woking Surrey GU12 4NH Lead Inspector Damian Griffiths Unannounced Inspection 10:00 24 August 2006 th 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 House (Woking) DS0000013725.V302594.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 House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moor House (Woking) Address Moor House 13/14 Horsell Moor Woking Surrey GU12 4NH 01483 740108 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) ladiestconnect.com Welmede Housing Association Ltd Mrs Sujata Seegum Care Home 9 Category(ies) of Learning disability over 65 years of age (9), registration, with number Physical disability over 65 years of age (1), of places Sensory Impairment over 65 years of age (6) Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 6th December 2005 Date of last inspection Brief Description of the Service: Moor House is a large detached property situated in a residential area close to the town centre of Woking. The accommodation is situated on two levels. The first floor is accessible by lift. There are nine single bedrooms one of which has an en-suite bathroom. The home has a number of communal areas for residents to enjoy including a conservatory. The home is registered for nine service users aged 65 and above with learning and physical disabilities. Currently all service users are female. The home is set in a nicely laid out garden that is well maintained by staff and the residents. The grounds are used frequently and readily accessible to the residents. There is car parking at the front of the premises. Costs: Required: Not included in the pre-inspection questionnaire. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Lead Regulation Inspector Damian Griffiths was assisted throughout the inspection by the Manager, Mrs Sujata Seegum representing the establishment. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new ‘Inspection record’ is compiled from details of the previous inspection and details supplied by the home in the form of a pre-inspection questionnaire that hopefully provides updated information. Notifications of significant events known as regulation 37 notifications sent to CSCI by the home are also considered, as are comments, concerns and complaints received. CSCI surveys were sent to the home before the inspection to be completion by service users, relatives and social and health care practitioners. The service users at the home live with a range of complex needs that included: physical, sensory and learning disabilities, some service users were more able than others to communicate their care needs and opinions, therefore, staff had helped some to complete the CSCI surveys. It was not always appropriate or possible for service users to consult with the inspector during the inspection therefore observations of the care being delivered, at the time, form the basis of this report. The inspector sampled three residents care assessments and care plans to confirm whether standards were met. Other areas relating to the residents care needs included a tour of the premises, inspection of staff rota’s, staff skill mix and recruitment practices. The inspectors would like to extend thanks to the residents staff and management at Moor House for their assistance and hospitality. What the service does well: The home provided up-to-date information that could be found in the residents guide and the home’s statement of purpose. The way the files had been set out provided quick and easy guide up-to-date information for the residents and their representatives and each resident had received a good initial assessment of their care needs. Care plans were up-to-date and well recorded and staff were praised for their care and respect of the residents by the residents’ representatives and health care practitioners. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 6 Residents felt safe and well cared for and enjoyed the activities made available at the home. Some enjoyed being able to participate with routine housework tasks such as; sweeping and helping with folding the laundry while others appreciated reading the newspaper in the conservatory. All the residents appreciated the £750.00 per year annuity they each received from Welmede and made available for holidays and leisure pursuits. Overall the home was comfortable and clean with no unpleasant cooking or other bad smells. The rear garden showed evidence of being well used and enjoyed by the residents and staff. What has improved since the last inspection? What they could do better: ‘Medical Administration Charts’ (MAR) had not been correctly maintained and reviewed. The deputy manager’s post is currently vacant. The home must employ suitably qualified competent and experienced persons to work at the home in such numbers as appropriate to ensure the health and welfare of the residents. The service must ensure that 50 of staff acquired level 2 of the National Vocation Qualifications (NVQ). In regard to residents financial matters the service manager must ensure, so far as practicable, that persons working at the home do not act as agent of the resident. Make suitable arrangements for the prevention of the spread of infection by ensuring that all foodstuffs kept at the home are appropriately labelled and stored. The service manager must ensure that suitable facilities and accommodation, other than sleeping accommodation, in particular the space currently used as the homes office meets health and safety workspace requirements. The premises were in need of repair internally: all woodwork including doors and skirting boards needed to be re-painted. Carpets throughout the home Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 7 and the canvas on the marquee in the rear garden needed to be replaced or cleaned. Recommendations included: That an alternative bedside or bed be considered that does not require any further improvisation. That the pharmacist use the pharmacy business stamp to confirm drug returns. That all staff personnel files are reviewed to establish whether they meet the required recruitment standards. That the garden gate be secured at all time to ensure security is maintained at a reasonable level. That Welmede consider renew the homes kitchen units and work surfaces and provide new folders for care plans and ‘ILP’ folders. 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 House (Woking) DS0000013725.V302594.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 House (Woking) DS0000013725.V302594.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided up-to-date information that could be found in the residents guide and the home’s statement of purpose. Resident received comprehensive assessments of their needs. The home does not provide Intermediate Care support. EVIDENCE: A sample of three residents files were checked and each resident had a copy of the homes residents guide and the home’s statement of purpose neatly contained in its own folder and located bin their room. The residents guide and the home’s statement of purpose had been updated and included staff qualifications and also: A ‘summary’ of the last inspection report, a licence agreement setting out the terms and conditions of residency and a separate sheet containing a breakdown of the costs and totals of their fee’s. The way the files had been set out provided a quick and easy guide providing up-todate information for the residents and their representatives. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 10 Assessments sampled comprehensively accounted for all aspects of care relative to the residents at the home. These included areas such as: Roles within the home, family, relationships and friendships, privacy and personal space: power of personality, ability to make needs known to staff and most importantly, likes and dislikes. This enabled staff to have a full understanding of the needs of the residents and a detailed account of how staff could help accompanied each section. Residents and their representatives did not comment about the lack of information in the CSCI survey. Moor House (Woking) DS0000013725.V302594.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9.and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from detailed care plans containing health care information that was up-to-date and informative. Medication was correctly administered to the residents however in one instance the medication records were incorrect. EVIDENCE: A sample of three residents care plan folders known as ‘Independent Life Plans’ (ILP) contained; Daily Diary Sheets, Risk assessments including outcomes that identified manual handling details such as the correct way to help a resident with a sensory impairment by holding her hand and elbow when supporting her to walk. Another risk assessment identified the need for the addition of ‘bedsides’ to protect and prevent a resident from falling out and included details of how to prevent her from slipping through or becoming trapped in the bedside bars. It is recommended that further risk assessment be considered in this case and that consideration be given for alternative bed/cot sides that do not require any further modification such as the quilt cover currently in use. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 12 Details of health and hygiene needs were included and these contained full details relevant to each resident. The ‘ILP’ folders were worn from constant use, it was recommended that that these be renewed. The CSCI Survey of residents and their representatives confirmed that they were well cared for and staff treated them well. Charts were in evidence recording changes of resident’s medication; foot care, dental care, hearing, sight and weight charts, all were in evidence. Assessment and review for speech therapy was in evidence Regulation 37 notifications received by CSCI indicated that two residents had not received their prescribed medication therefore theses residents records were checked. Directions for staff advising how to administer medication was clearly given, such as: give tables on a spoon because the resident cannot take them herself and why the resident required the medication, i.e., agitation and clear instructions for staff to watch and ensure that the residents had taken their medication had been included. Records of the date medication was given to a resident to combat an infection did not match the details recorded in the ‘Medical Administration Charts’ (MAR) and showed a discrepancy of nine days. Checks found that the MAR charts were from last year the correct charts were found and replaced. Drug returns were all in order, book lists checked against drugs returned. It was recommended that the home request the pharmacist to use the business stamp to confirm all drug returns. Some residents were observed queuing outside the small office to wait for staff to administer their medication. This practice was reminiscent of institutionalised care however the manager explained that these residents were encouraged to take some control of their medication in this way. Resident’s privacy was respected, staff were observed knocking on residents bedroom doors before entry and addressing each resident by their chosen or recognised name. Residents were dressed well in their own clothes and residents were able to spend time doing the things they enjoyed. One resident commented that she really enjoyed relaxing and spending quality time in the conservatory. The CSCI Survey of residents and their representatives confirmed that they were well cared for: ‘Staff cannot be faulted’. Please see the requirements and recommendations section of this report. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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. Residents were able to access the local community facilities and the home supported access to religious and social activities. The residents received regular choice of food and could request alternative meals from the menu provided. EVIDENCE: The home attempts to ensure that all the residents have some access to the local community and to the leisure activities of their individual choice. One example of this was in evidence in relation to a resident with significant care needs that meant she experienced a high degree of isolation despite the best efforts of staff at the home. She used to enjoy regular swimming trips but had not been able to enjoy this pursuit for a number of months due to the onset of incontinence. There was also the problem of adequately trained helper or swimming support to accompany her into the pool. The home had responded to this by finding and purchase a special swimming costume that protects against incontinence and a ‘swim support’ volunteer had been located. A list of events was available for the year and included: Tea dances, bbq’s discos and seasonal celebrations. Residents commented on being able to visit the local community centre and church, residents were mainly Church of Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 14 England. The spiritual needs of the residents was considered and was a part of the residents care need assessment. Residents commented on enjoying watching TV, listening music, playing bingo, at the community centre, cooking, aromatherapy and smelling the lavender in the garden and day trips. Resident were enjoying an impromptu sing-along organised by staff who were able to provide guitar accompaniment. Family and friends were able to visit and relatives completing the CSCI survey confirmed this. The local Mencap representative was involved with making arrangements to meet the special holiday needs of some of the residents. Staff were observed asking residents what they would like to eat for lunch and residents confirmed that the staff would ask them about their choice of clothes for the day, shopping they would like and activity of choice, however,there was little evidence of any home based activities evidence on the day of the inspection as most service seemed content to be left to their own designs. Staff take turns to cook for the residentsand there was a good variety of food stored in fridge-freezer and pantry, containing fresh fruit and vegatables. Unfortunaltey foodstaffs had not been labelled properly and did not contian the date they were opened and some were beyond their ‘sell-by’ dates. Menues were also discussed at the last residents meeting. Residents who needed help had received an assessment of their needs and staff were obsrerved helping them accordingly. A risk assessments had been completed for staff and resident by ensure that the maximum care was given to reduce the possibilty of choking because she tended to eat too quikely. This resident received one to one staff support which was given in a respectful and practical manner. A resident commented that she felt ‘allright here,I like helping out in the kitchen, sweep and help fold the laundry’. Residents were able to help out if they so chose, with clearing dishes and place settings. Specialist diets were avaiable such as soft foods and the approprite instruction was contained in aq special menu folder,in an alternative colour and with photo’s of the residents. The CSCI survey confirmed that residents liked the activities and meals provided at the home. Comments revcieved from relatives , over the past ‘nine years we have never had reason to complaint’. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some residents knew who to make a complaint if they were not happy and the home was aware that it needed to ensure that all staff including agency workers should be aware of the current ‘safeguarding of vulnerable residents’ procedures’ and be kept regularly updated. EVIDENCE: Complaints policy and procedures on file could be found in the office and the complaints folder was inspected. There had been no complaints recorded since tha last inspection. The home had placed the Welmede complaints policy and practice within each service users guide contained in residents folders and stored in their room. There were no complaints recorded or reported during the inspection by staff or residents. Residents commenting in the CSCI survey knew whom they could speak too; this was confirmed during the inspection by some of the residents. The Surrey Multi agency procedures were in place and staff had received training in safeguarding vulnerable adults from abuse. The staff on duty were aware of ‘whistle-blowing’ procedures in the event of concerns of abusive practice within the home and organisation. There had been no recorded instances requiring the implementation of procedures since the last inspection. Agency staff or floating staff from other homes within the Welmede organisation must also be confident and familiar with the safeguarding procedures. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 16 It was recommended that the garden gate be secured at all time to ensure security is maintained at a reasonable level. The CSCI survey concluded that residents felt safe at the home and there had been no cause for complaint from any of the resident’s representatives. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home was suitable for its stated purpose. It was accessible, safe, with a pleasant and homely atmosphere, but due to every day wear and tear maintainence was required. EVIDENCE: There was room to park at the front of the home containing small but well kept borders. A tour of the premises and grounds was conducted and the home was welcoming, bright, airy and clean with a distinct lived in feeling. There was evidence of normal every day were and tear to woodwork, doors and skirting boards especially in the dining area Hallways stairways and upper floors required sanding and painting and carpets were in need of either cleaning or replacing. The kitchen adjoining the dining area was clean and tidy however new kitchen units should be considered due to the worn condition of worktops, poor fitting cupboards and doors. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 18 The laundry area was in good order as were the communal toilets and bathrooms. Please see the requirements and recommendations section of this report. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff on duty had a good mix of skills available to ensure the care of residents however staff had no attained the basic NVQ training requirements and it was recommended to review training for home based activities. The overall quality of the staff recruitment process was adequate but in need of some minor improvements. EVIDENCE: The duty rota for the day was inspected and the files of the staff present were sampled to establish whether they had received adequate training to meet the needs of the service users and to ensure that staffing levels were adequate. Staff ratios were three staff (and Manager) for day care and afternoon with the night shift consisting of one sleeping and one staff member on ‘waking nights’. A vacancy existed for the deputy manager post currently being covered by a basic grade agency carer. A full compliment of adequately trained staff must be implemented to ensure that the health and welfare of the residents is maintained. Training received by the staff on duty included: Food hygiene, coshh, basic life support, first aid and fire safety and staff employed on the night duty had received a good standard of training including: Safe manual handling, fire procedures refresher, medication, protection of vulnerable adult and diabetes care. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 20 New staff received an adequate induction however the pre-inspection questionnaire completed by the home confirmed that only 27 of staff had attained level 2 of the National Vocational Qualification. A sample of three staff files were also checked for evidence of robust recruitment procedures. One staff file revealed references that contained only four lines of information and another reference had not stated the length of time the referee had known the staff member. However, the staff member questioned was very knowledgeable about the resident she had been assigned to as a key worker and had received good training. Please see the requirements and recommendations section of this report. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff and management worked well together to the benefit of the residents at Moor House. The home has yet to conduct a quality assurance exercise however they were well prepared to achieve this in due course. The residents’ money was safely handled and recorded however current appointee arrangements were in need of change. EVIDENCE: The manager was committed to continual professional development for herself and her staff. The door of the office was always open to staff, residents and their representatives. Residents representatives commenting in the CSCI Survey stated: The manager; is ‘an amazing person and certainly an asset to Moor House’ Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 22 A quality assurance exercise was ready to be implemented but due to the recent CSCI Surveys distributed it had been postponed. Evidence of letters and questioner’s were in place. Residents had been able to engage in a regular monthly resident meeting. Minutes recorded such topics as: purchases from the last shopping trip, feedback from the attendance of the residents representative to the ‘South East Area Welmede Meeting’ every month, a day trip to the seaside at Haying Island and more fish, sausages and pies to be included on the menu. Each service user has their own record book to record the exact amount of money and the transactions and checked three times each day or whenever there was a staff handover. Cashboxes were kept in a locked mental cabinet. One resident had a trust that was managed by a solicitors firm. An Annuity of approx’ £750.00 pa was paid to each resident as a contribution towards a holiday or leisure pursuit; this was listed on bank statements available for inspection. Each resident sampled had an account with the local bank and an account book with details of current balance available. The manager was the appointee to some of the residents but was unable to show authorisation. It is stated in the Care Homes Regulations (2001) that due to restriction of acting for residents’ staff cannot be an agent; therefore, alternative arrangements must be made. Health and Safety in order apart from kitchen repairs, Public Liability insurance was displayed and current. Electrical checks had been completed and water temperatures, fire extinguishers, COSHH and accident records had regularly checked. The office was very cramped and it was difficult for more than one person to work comfortably. The situation was exacerbated due to due cabinets, storage and the computer. Other areas of concern mentioned in this report were: For all foodstuff containers, jars etc be labels with the opening times and regularly checked against the ‘use-by’ date and it was recommended that the garden gate be kept closed at all times. Please see the requirements and recommendations section of this report. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X 2 2 Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation 23(2)(d) Requirement The service must ensure that the carpets and canvas on the marquee situated in the rear garden be replaced or cleaned. The service must ensure that the premises are kept in a suitable state of repair internally and arranged for woodwork such as doors and skirting boards to be re-painted. Details and dates of work to be included in the improvement plan to be sent to CSCI. The service must employ suitably qualified competent and experienced persons to work at the home in such numbers as appropriate to ensure the health and welfare of the residents. Timescale for action 24/11/06 2. OP19 23(2)(b)( d) 24/11/06 3. OP27 18(1)(a) 24/11/06 4. OP28 18(1)(a) (c) The service must ensure that all 24/11/06 staff receives the required training to enable 50 of staff to reach NVQ 2 levels. The service must make arrangements for the accurate reordering, administration and DS0000013725.V302594.R01.S.doc 5. OP37 17(1)(a) Schedule 3 24/11/06 Moor House (Woking) Version 5.2 Page 25 6. OP35 20 (3) disposal of medicines received into the home. The service must ensure so far as practicable that persons working at the home do not act as agent for the resident. The service manager must ensure make suitable arrangements for the prevention of the spread of infection by ensuring that all foodstuffs kept at the home are appropriately labelled and stored. The service manager must ensure that suitable facilities and accommodation, other than sleeping accommodation in particular the space currently used as the homes office meets health and safety spatial requirements. 24/11/06 7. OP38 13(3) 24/11/06 8. OP38 23(3)(a) 24/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP7 OP9 Good Practice Recommendations It was recommended that that ‘ILP’ folders be renewed. It was recommended that the home request the pharmacist to use the business stamp to confirm all drug returns. It was recommended that the garden gate be secured at all time to ensure security is maintained at a reasonable level. It was recommended that Welmede consider renew the homes kitchen units and work surfaces. It is recommended that an alternative bedside or bed be considered that does not require further improvisation. DS0000013725.V302594.R01.S.doc Version 5.2 Page 26 OP18 OP19 OP22 Moor House (Woking) 6. OP29 It is recommended to review all staff personnel files to establish whether they meet the required standards. Moor House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 House (Woking) DS0000013725.V302594.R01.S.doc Version 5.2 Page 28 - 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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