Inspection on 06/12/05 for Moor House (Woking)

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 Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Moor House (Woking) 24/08/06

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 Announced Inspection 6th December 2005 10:00 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 House (Woking) DS0000013725.V271892.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 House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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.V271892.R01.S.doc Version 5.0 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 24/06/05 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. Moor House (Woking) DS0000013725.V271892.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 two, to be undertaken by the Commission for Social Care Inspection (CSCI) year beginning April 2005. It was an announced inspection and took place over a period of 6hrs. Lead Inspector Damian Griffiths was assisted throughout the inspection by the Deputy Manager Mrs. Hanne White, representing the establishment and Mrs Caroline Burgess Manager ‘on-call’. A tour of the premises took place and the inspector was able to meet five residents and members of staff who were happy to contribute to the inspection report. A selection of documents and reports were sampled relating to the residents wellbeing including: the statement of purpose, resident’s contracts, care needs and the independence of residents at the home. Staff files were inspected for information about their recruitment process, skill mix, and training, pre-inspection reports were also received. The inspector would like to extend thanks to the staff and management at Moor House for their assistance and hospitality. What the service does well: What has improved since the last inspection? The registered manager was not available therefore the Deputy manager was in charge. The inspector was assisted by one of Welmede’s On-Call Managers 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. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 Page 6 Staff had provided consistent care and support to the residents ensuring their health and welfare. Suitable arrangements for the safe keeping of medicines were in place. The registered person had supplied all residents with a copy of their service users guide. 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) DS0000013725.V271892.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 House (Woking) DS0000013725.V271892.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): 1,2 and 3. The Statement of Purpose was well produced with easy to follow and userfriendly information but still remained incomplete. Residents were all provided with detailed contracts. A service user’s assessed needs had changed and the home had been unable to complete the proposed transfer to another home in order to meet her needs. EVIDENCE: The statement of purpose and service users guide was very well produced clearly printed in bold print and accompanied by photographs of residents showing the visitor areas of interest and activities. It did not contain details of staff training or qualifications although staff were well trained. The service users guide was without details of the last inspection report. A resident had received a new assessment of need and required nursing care. The resident had been waiting for a transfer to a more suitable home within the Welmede organisation. Care had been taken to ensure the least possible disruption occurred with the transfer by arranging regular visits to the proposed home. At the time of the inspection the transfer had not been Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 Page 9 successful, staff were under pressure to ensure the health and welfare of the services users was maintained. Six residents files were inspected and all had adequate contracts stating terms, conditions and fees agreed, details of other charges were also available. Service users with sight impairment consulted were satisfied with the level of detail available to them in the contract and the service users guide. Please see the recommendations and requirements section of this report. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9. Residents’ benefit from detailed care plans containing up-to-date and informative health care information. The administration of medication was seen to be safe and as stated in the homes own written policy and practice. EVIDENCE: The health and safety of the residents was evidenced and relevant risk assessments had been completed, such as, safe management of stairs in the home. The inspector discussed residents care plans with the manager and staff who were aware of the individual needs of the residents as recorded. Appointments were well documented including input from community health practitioners such as the GP, district nurses and dental checks. Details of staff administering medication to the residents were checked. The records were correct and tallied with the required dosages and staff were observed administering the medication safely. It was recommended that a syringe be used for ease of accurate measurement of liquid medication. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 Page 11 Please see the recommendations and requirements section of this report. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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 the following standard(s): 14. Residents were encouraged to exercise choice and control over their lives for as long as possible. EVIDENCE: One resident was still managing her own financial affairs and playing an active role in the running of the home by attending residents meetings at the home and as a representative when attending the area Welmede meetings. All residents were encouraged to exercise personal choice and residents consulted said that they had help and support to choose: what clothes to wear / buy, activities such as, attending a tea dance at the community centre or Church on Sunday all choices were recorded in the care plan folder. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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 the following standard(s): 16. The complaints procedure was accessible to residents, relatives and friends and the home had a copy of the Surrey Multi-Agency Procedures. EVIDENCE: The home has not received any complaints since the last inspection. Residents consulted had been informed of the inspection and confirmed that they were aware of the complaints system and were kept well informed. Residents were satisfied with the amount of information made available to them about the home and were very happy with the care and attention they received. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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 the following standard(s): Not Inspected. Not Inspected. EVIDENCE: Not Inspected. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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 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 and 29. The skill mix of staff was good, however due to a change in demand staff were under pressure. The recruitment practice and policy was in place but an oversight had occurred. EVIDENCE: Six staff files were inspected and showed that training was good and reflected the needs of the residents. A resident’s care needs had changed and it was observed to be stretching staff capacity to care. One to one attention that was required to ensure safety was observed. Despite good staff care being provided, the nature of the residents ‘assessed need’ could not be met within the Moor House environment and the home is seeking to transfer this service user to another establishment that can meet her needs. The home had responded well to this by working in partnership with the area social care practitioner and alternative homes had been identified. Additional staff had also been funded for night care only however current arrangements at the home were inadequate, the resident was in urgent need of transfer to meet her assessed need and ensure staff and residents health and welfare needs would be met. Volunteers and visitors offering a service to residents were required to provide a Criminal Records Bureau police check and these were in place however one staff file was found to be without a recent Criminal Record Bureau check. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 Page 16 Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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 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): 31,33,34 and 38. The management of the home was good at the time of the inspection but concern’s relating to staff pressure was reported. Quality Assurance monitoring of the service had not been completed. Residents’ benefit from an efficient and well run process of managing residents’ money. EVIDENCE: The deputy manager was in charge of the home and there was no indication of the return of the registered manager. The deputy manager had obtained a NVQ level 3. There were also three other staff vacancies presently filled by agency or Welmedes own ‘bank’ staff and pressure on staff to care adequately for all residents as previously stated was under question. The partial completion of a quality assurance monitoring process was in evidence but there had been no conclusion of this exercise. In order to establish whether there is a need for improvements to be made the exercise Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 Page 18 needs to include social care and health care practitioners as well as the service users and their representatives. One resident was able to continue to manage her own financial affairs. The other residents benefit from an excellent system of money management that entails each new shift leader signing the resident’s own cashbook, daily to register the existing amount. The health and Safety policies and procedures were all in place including RIDDOR, COSHH and insurances and certificates as required. Please see the recommendations and requirements section of this report. Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 x X X X X X X X X STAFFING Standard No Score 27 1 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 4 3 X X 3 Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 4(1a-c) 6(a) (b) Requirement Timescale for action 06/12/05 2. OP1 4(1a-c) 6(a) (b) 3. OP1 5(1) (2) The registered manager must ensure that the care home compiles with the terms of registration, as it is not registered for dementia care. Immediate Requirement: The Statement of Purpose must 06/03/06 be reviewed to include all details required of Regulation 4 and Schedule 1 of The Care Homes Regulations 2001. (as amended) This is the second time this requirement has been made and a new timescale has been agreed (Timescale of 05/07/05 not met) The registered person must 06/03/06 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 Regulations 2001 (as amended). This is the second time this requirement has been made and a new timescale has been agreed (Timescale of 05/07/05 not met) DS0000013725.V271892.R01.S.doc Version 5.0 Moor House (Woking) Page 21 4. OP3 12.1 5. OP29 19(4)(b) (i)sch2 6. OP33 24(1)(a) (b)(2)(3) 7. OP38 14.(1)(d) 12(1)(b) The registered manager must ensure that the care home is conducted to promote and make proper provision for the health, welfare, treatment and supervision of the residents and provide adequate staffing levels. Immediate Requirement: The registered manager must ensure that all staff have received the appropriate police checks, are suitably trained, including all agency staff. Immediate Requirement: The registered manager must establish and maintain a system for reviewing the quality of care at the home at appropriate intervals. The registered person must ensure that the she does not provide accommodation to a resident unless having regard to the assessment of care needs can ensure that the home is suitable for the purpose of promoting their safety, health and welfare. Immediate Requirement: 06/12/05 06/12/05 06/03/06 06/12/05 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 OP1 Good Practice Recommendations It was recommended that the summary from the last inspection report be made available the residents and the Inspection visit and subsequent new report be discussed at the next residents meeting. It was recommended that a syringe be used for ease of accurate measurement of liquid medication. 2. OP9 Moor House (Woking) DS0000013725.V271892.R01.S.doc Version 5.0 Page 22 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.V271892.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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