CARE HOMES FOR OLDER PEOPLE
Moor House (Woking) 13/14 Horsell Moor Woking Surrey GU12 4NH Lead Inspector
Mr Damian Griffiths Unannounced 24 June 2005 10:00am
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Moor House Address 13/14 Horsell Moor Woking Surrey GU12 4NH 01483 740108 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Welmede Housing Association Ltd Mrs Sujata Seegum Care Home 9 Category(ies) of LD(E) - Learning Disability over 65 (9) registration, with number of places PD(E) - Physical Disability over 65 (1) SI(E) - Sensory Impairment over 65 (6) Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 3. The age/age range of the persons to be accomodated will be : OVER 65 YEARS OF AGE Date of last inspection 22nd November 2004 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 accessable by lift. There are nine single bedrooms one of which has an en-suit bathroom. The Home has a number of communal areas for the 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 accessable to the residents. There is car parking at the front of the premises. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of two to be undertaken in the Commission for Social Care Inspection Year April 2005. It was an unannounced visit and took place over a period of 5 ½ hours. Lead Inspector Damian Griffiths was assisted throughout the inspection by Shift Leader Bernie Miller in the morning and the Registered Manager, Mrs Sujata Seegum, was available in the afternoon. The inspector met three residents and a Community Nurse who were happy to contribute to the inspection report. It is recommended that the reader should also look at the previous report that can be accessed by using the CSCI website details on the last page of this report. The inspectors would like to extend thanks to the residents, staff and the managers at Moor House for their time and hospitality. What the service does well: What has improved since the last inspection? Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 6 The care plans are clear and easily read. Following the last inspection, Moor house was required to produce more information in their ‘Statement of Purpose’ and the ‘Service Users Guide’. This has been reviewed and now includes details of the Manager’s qualification, her photograph and the details of the residents’ costs. The manager was not available in the morning. The inspector was assisted by Welmede’s On-call Manager in order to inspect the personnel files, as only Managers hold keys to the files. The system worked well and the On-Call Manager joined the Inspector and assisted by providing essential staff information as required at the last two inspections. 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 House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2, 3,4, and 5. Prospective residents would benefit from more detailed information in The Statement of Purpose and The Service Users Guide. The Manager will ensure a comprehensive care needs assessment is completed for every new resident. EVIDENCE: These requirements have been brought forward from the last inspection. The Statement of Purpose has been improved by including the Manager’s qualifications and photograph. Details of staff qualifications need to be included. The Service Users Guide must include details of a standard contract. At Moor House this has been provided in the form of a tenancy agreement detailing the requirements of the home and resident details and criteria. All residents are charged the same rent, however, any differences in costs due to care requirements needs to be included in a formal contract. Copies of the Service Users guide need to be available to each resident and their representatives. Information detailing extra costs; e.g., hairdressing, transport etc must be included. Copies must be made available in each resident’s room.
Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 9 Residents that are sight impaired would benefit from a taped recording of the service users guide and the statement of purpose. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9,10 and 11 The home works in partnership with health practitioners and provides a sensitive and caring approach. Assistance is given to residents to receive community health care services in the privacy of their own room. EVIDENCE: The health care input at Moor House comprised of routine health monitoring services. The inspector met a health care practitioner who confirmed there were no concerns about the care residents receive at the home. Staff observed working with residents were respectful and sensitive. Residents were addressed by first name and staff knocked before entering a residents room. Staff at Moor House ensure friends and family are able to stay in touch by operating an open house policy within the safety requirements. Residents at Moor House are supported by staff to make individual and specific funeral arrangements if they wish. Family or representatives are involved. Residents prefer to leave the responsibility to the manger to distribute all medication. The home uses a lockable metal filing cabinet to store
Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 11 paracetamol and other low-grade medical supplies. It is a requirement to ensure that all drugs are kept securely in the appropriate secured cabinet. The manager informed the inspector that she is will be renewing the folder containing residents medication details, residents photographs and will renew and date specimen signatures required to identify staff who are trained to administer medication. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 15 Residents at Moor House are supported to try new activities. Family and friends are welcomed to visit and can stay for afternoon tea or dinner. Residents are fully involved with decisions about the food they eat and the menus provided at Moor House. EVIDENCE: Shops, cinema and restaurants are close by and residents visit regularly. There is TV and radio at Moor House and some residents are involved in knitting, cookery and there is access to the Internet. The residents enjoy the use of the local day centre twice a week and retired professionals resident at Moor House are actively involved in assisting others. The home organises regular holidays for their residents. One resident who had never flown before, featured in Welmede’s newsletter following a trip to New York. Staff arrange weekly menus containing the residents choice of meals. If residents require a special diet there is access to a dietician. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 and 18 Resident’s legal rights are respected and protected. Staff at Moor House receive training in Protecting Vulnerable Adults. EVIDENCE: There is no record of any complaint being received since the last inspection. Care plans inspected contained records of residents being involved with independent solicitors who administer ‘Power of Attorney’. Financial procedures are in accordance with Welmede Housing Association Policy. Each resident has their own book containing all details of their financial transactions. Each has a petty cash box that is kept in a secure environment. Every shift leader must check residents’ finances are accounted for before the end of each daily shift. This is recorded in individual books kept for each resident. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26. The standard of the environment in this home is good, providing resident’s with an attractive and homely place to live. The home is fully accessible to residents who wish to use the variety of rooms that are available. The resident’s own rooms were personalised, private, clean and tidy. EVIDENCE: When the inspection of the premises was conducted, the home was clean and tidy. Residents were observed to be relaxed and at ease within their home environment. The home is pleasantly decorated and there is a selection of rooms for the residents to use. No problems or concerns were voiced about the condition of the home. Each room has a call bell system in the event of an emergency. All rooms have a washbasin and one room has an-en suit bathroom. Residents are provided with a hoist if required and grab rails are provided in all areas as required. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30. Residents at Moor House benefit from a dedicated staff team who are trained to use specialist equipment in accordance with clearly defined policies and procedures. Moor House recruitment system is adequate but needs to provide details of the care bank staff employed as specified in schedule 2 of the Care Regulations, and CRB records of all volunteers. EVIDENCE: There has been a marked improvement with the procedures put in place to assist the Inspector. An on-call manger is always available to provide access to staff files in the event that the Homes manager is not available at the time of the inspection. A sample of 3 staff files were inspected and all met the standard satisfactorily. There are two volunteers at the home. One has received clearance from the Criminal Records Bureau and the other CRB is still being processed. Requirement to produce a full list of CRB evidence for all volunteers was made. This requirement has been brought forward from the last inspection. Staff are supplemented by Welmede Housing Association’s own care bank staff whenever permanent staff are not available or if additional care needs arise. This ensures that social activities remain a priority and care bank staff work side by side with permanent staff on the three-shift system. A requirement has been made to ensure that the employment details of bank staff employed at Moor House are available for scrutiny as required.
Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 16 Three staff files selected showed the staff were Level 2 NVQ trained. Protection Of Vulnerable Adults training had been received and additional training requirements had been undertaken to ensure that staff were able to meet the assessed care needs of the residents, e.g. infection control and first-aid. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 and 37. Residents’ benefit from robust financial accounting systems used at Moor House. The home respects and recognises that each resident is a unique individual. Record keeping reflects the different needs of each resident are regularly reviewed. EVIDENCE: Residents financial records kept at the home were inspected. The systems in place at Moor House are thorough. Moor House has a written policy in place that is followed in detail. Each shift leader is required to verify that after each shift each individual resident’s finances kept at the home are in order and sign a separate account book to this effect. Files inspected showed that some residents have employed the services of a Solicitor to exercise Power of Attorney who will be responsible for independent scrutiny. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 18 A resident of Moor House attends monthly meetings with other representatives from Welmede Housing Association homes, to discuss issues that are important to them. A regular Welmede newsletter is produced. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 x x x 3 3 x 3 x Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? 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 1.1 Regulation 4(1)(a-c) 6 (a)(b) Requirement Timescale for action 05-07-05 2. 1.1 3. 29 4. 29 The Statement of Purpose must be reviewed to include all details required of Regulation 4 and Schedule 1 of The Care Homes Regulations 2001.(as amended) (Timescale of 22.01.05 not met) 5.(1)(2) The registered person must supply all residents with a copy of their service users guide. This will include extra costs and the tenancy agreement. It will be reviewed to ensure that it includes all information set out in reg 5 of the Care Homes Regulatios 2001 (as amended). (Timescale of 22.01.05 not met) 19(1)(a-c) The registered person must not Para 5 of employ a person at the home Schedule unless satisfied on reasonable 2 grounds as to the authenticity of the references refered in schedule 2 paragraph 5 of the Care Homes Standards 2001(as amended) as noted. (Timescale of 22.01.05 not met) 2(3) The registered person must carry 19(1)(a-c) out appropriate checks and 19(5)(b) obtain information on volunteers (c) to ensure the safety of the residents. (Timescale of 22.01.05 not met)
H58_s13725_Moor House_v239728 240605_stage4.doc 05-07-05 05-07-05 05-07-05 Moor House (Woking) Version 1.40 Page 21 5. 9 13 (2) The registered person must make suitable arragements for the safe keeping of medicines. 05-07-05 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 9 Good Practice Recommendations Files containing MARs and medication details need to be replaced and also date the specimen signatures of the staff. Moor House (Woking) H58_s13725_Moor House_v239728 240605_stage4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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
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