Inspection on 15/04/08 for Moor Villa

This inspection was carried out on 15th April 2008.

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 Villa 17/07/07

Moor Villa 02/10/06

Moor Villa 20/09/05

Moor Villa 17/05/05

Moor Villa 18/08/04

Moor Villa 16/06/04

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

CARE HOMES FOR OLDER PEOPLE Moor Villa 53 Moor Street Kirkham Lancashire PR4 2AU Lead Inspector Denise Upton Unannounced Inspection 15th April 2008 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 Villa DS0000009722.V360788.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 Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moor Villa Address 53 Moor Street Kirkham Lancashire PR4 2AU 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) 01772 682884 Mrs Savitree Seedheeyan Mrs Christine Harris Care Home 16 Category(ies) of Dementia (16) registration, with number of places Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Moor Villa is registered to accommodate up to 16 older people of either sex who have a diagnoses of dementia. The home is conveniently located on a main thoroughfare of the town and in close proximity to local community services and resources. Moor Villa is a detached property with communal space consisting of a large combined lounge/dining room and a smaller separate lounge area. Individual bedroom accommodation is located on the ground and first floor of the property and comprises of eight single bedrooms and four shared bedrooms. Although en-suite accommodation is not provided, there are sufficient bathroom and toilet facilities to fulfil the requirements of the standard. Visitors are made welcome at any time of the residents choice. Aids and adaptations are provided as required and all people living at the home have access to appropriate medical interventions. The fees for residential care at Moor Villa currently range from £336.00£380.00 per week. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience an adequate quality outcome. A key unannounced inspection, which included a visit to the home, took place over a mid-week day and in total lasted a period of approximately seven and a half hours. At the time of the inspection there were 15 people accommodated at Moor Villa. The inspection comprised of talking individually with two residents, a member of the care staff team, the deputy manager and the registered manager at the home. An observation of the internal and external environment of the home took place along with looking at the residents’ care records and other documents. As part of the inspection process the inspector used “case tracking” as a means of gathering information. This process allows to the inspector to focus on a small group of people living at the home. A period of time was also spent in the lounge. During this time there were general observations made of interaction between residents, staff and management. Prior to the inspection the registered manager completed a questionnaire about various aspects of the care home, which provided some information. However this questionnaire was not completed in sufficient detail to give a comprehensive account of what was happening in the home. Prior to the site visit, satisfaction questionnaires were also sent to the home for the residents, staff and relatives to ‘have their say’ as to how the home was meeting residents needs and requirements. However on this occasion, no completed questionnaires were returned. What the service does well: The daily routines were flexible and designed to meet the wishes and capabilities of each resident accommodated. Activities were arranged in line with the needs and choices of the residents, which included trips out into the local area. Varied and well-presented meals were served. Residents spoken to described the meals as “excellent” and “a good variation”. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 6 Residents spoken to felt they had a good standard of care and the staff respected their rights to privacy and dignity. One resident said he had no concerns about privacy and dignity and that, “staff were good”. Moor Villa has a group of staff that have worked at the home together for a long time and know the residents needs and requirements very well. Good relationships have been formed between residents and staff that help’s to create a comfortable and relaxed environment. Staff training is given priority to ensure that all care needs are well met. What has improved since the last inspection? What they could do better: Most of the environment at the home both inside and outside still requires attention as a matter of urgency, to make sure it provides a pleasant, comfortable and attractive place to live. There are still serious concerns especially about some radiator covers that are meant to protect residents from accidentally hurting themselves, being broken and the emergency call bell system not working in one bedroom. There is a requirement that the registered homeowner produces a monthly report as to the conduct of the home. This has not been happening. The Annual Quality Assurance Assessment (AQAA) should be completed in full and detailed information provided as requested. A new form for care planning has been introduced that does not provide as much relevant detail as previous care plans. All care plans should be clear and detailed in order to inform staff of the exact requirements of each person living at the home. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Moor Villa DS0000009722.V360788.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 Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. Admission and assessment procedures are in place to ensure that the home can meet individual needs, however prospective residents are not informed in writing that there current needs and requirements could be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records of two recently admitted residents were examined and each had assessment details recorded. Since the last inspection there has been improvement in recording the level of detail obtained. This ensured that staff had a good understanding into what the needs of these prospective residents were and how they could be met. In some instances the home does not receive Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 10 assessment information from a placing authority. The manager is aware of these issues and makes sure they carry out their own assessment to ensure that the prospective resident’s needs could be met by the home. One way identified in the AQAA that could improve the pre admission assessment information was to “Insist on more information both written and verbal regarding service user’s needs, especially from our local hospital”. To help address this issue, where ever possible the prospective resident and their family are asked for as much information as possible although sometimes the prospective resident cannot contribute very much because of lack of cognitive ability. The two recently admitted residents were individually spoken with. Although neither of these people could confirm that they had been involved in the pre admission assessment process to give their views of the support they required, both stated that their needs and requirements were being met. One person said, “I can tell the staff what I want”. Another person said, “I am settled at Moor Villa, I don’t want to move again. Whilst it was apparent that the needs of these people were being met, there is a requirement that any person who has been assessed for possible admission to the home must receive some written information confirming the outcome of the pre admission assessment and to confirm that their current needs could be met. This should be provided prior to admission. There was no evidence that this had occurred. Standard 6 was not assessed, as Moor Villa does not provide intermediate care. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 & 10 Quality in this outcome area is good. There is a care planning system in place with evidence of regular review. However risk assessments are not always in place to explain how or why judgements had been made. The health care needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication in this home is well managed promoting good health. Personal support is provided in such a way as to promote and protect residents’ privacy, dignity and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 12 From the case files seen, it was evident each resident had a plan of care, based on their assessment of needs. The topics covered in the care plans were, in the main, comprehensive however the format of the care plan has recently changed but the more detailed information on the ‘old’ care plan had not consistently been transferred to the new format. In consequence, the new written information provided to staff did always not provide as much detail as previously. From discussion with the deputy manager, it is understood that this will be addressed with either the current care plans updated to provide more detailed information or the ‘old’ care plan format reinstated. Some risk assessments were in place but the outcome information was not always transferred to the care plan. In respect of one person, whilst a specific risk had been identified during the pre admission assessment, a formal risk assessment in respect of that issue had not been completed. From discussion with the deputy manager, it is understood that the issue identified is no longer an area of concern, however a formal risk assessment should have been completed at the time of admission when the issue had been identified. There was clear evidence that monthly reviews are taking place with care plans amended. However it was sometimes difficult to be clear when the care plan had been amended as amendments had frequently not been signed or dated. It is essential that any required documents be signed and dated by the person making the entry to take ownership of the entry and to confirm that an accurate record has been made. Both of the residents individually spoken with could not remember being involved in or having had explained to them the content of their care plan. However the deputy manager said that the content of the care plan had been discussed with each of the resident’s. Neither of these care plans had been signed by the resident to confirm there understanding and acceptance of the content. It is strongly recommended that wherever possible, the care plan be developed in full consultation with the individual resident and the resident asked to sign the document as acknowledgement. In rare instances when this is not appropriate or where the resident does not have mental capacity to understand or sign their care plan, this should be recorded. Likewise any proposed amendment to the existing care plan should, if possible, be discussed with the individual resident to ascertain their views and ensure that the resident is accepting of the proposed change. It was however very evident during the course of the site visit that staff were very aware of each resident’s individual needs and responded with sensitivity and care. The atmosphere was warm, supportive and residents were clearly relaxed and comfortable both with each other and the staff group. The two residents individually spoken with both spoke positively of the staff group with one person saying of the manager, “Christine (Registered Manager) is good, Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 13 she will listen and try to sort things out”. Discussion with a member of the care staff team, confirmed that they were very aware of the content of the care plans and felt well equipped to carry out the tasks required. The health care needs of resident’s are well met. A record is maintained of all health care appointments or visits to the home by health care professionals. The information is clearly recorded and information transferred to the care plan. There is close liaison with General Practitioners, District Nurses and Community Psychiatric Nurses to ensure that people living at the home receive the attention they need. Nutritional records are kept to ensure good health and the resident’s weight is monitored monthly. Policies and procedures were in place to cover all aspects of the management of medicines however it is understood that the policy and procedures are about to be updated to reflect current practice. The home operated a monitored dosage system for the administration of medication, which was dispensed into cassette trays by a local pharmacist. Appropriate records were maintained in respect to the receipt, administration and disposal of medication and all staff designated to administer medication had received accredited training. Updated medication training has been arranged to take place in May 2008.There are no controlled drugs being administered by the home at present however senior staff are aware of the specific requirements with regard to the recording and administration of controlled drugs. The home has a good relationship with the local pharmacist who supplies medication to the home and a review of medication in respect of all residents, is carried out annually by the General Practitioner pharmacist. The residents spoken with felt the staff respected their rights to privacy and dignity. One person said that privacy and dignity was “respected” and that staff, “were good” and that he had no concerns at all. This was also confirmed by observing members of staff during their daily routines including how they engaged with and talked to residents. This was carried out with sensitivity and patience on all occasions. Residents interacted and communicated well with staff members and appeared relaxed and comfortable. Staff were encouraging participation with others in a way in which did not infringe their dignity. Staff receive training in respect of maintaining privacy and dignity during induction training, National Vocational Qualification (NVQ) training and through on-going informal supervision. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. Residents are encouraged to keep in regular contact with family and friends in order to maintain family and friendship links. The routines of daily living are kept flexible to enable people who live at the home to enjoy the lifestyle of their choice. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets people’s tastes and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As at previous site visits, it was observed that residents at Moor Villa continue to be encouraged to remain as independent as possible with regard to their Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 15 chosen life style. However as the majority of people living at the home have some form of dementia, the support of staff is often required to maintain dayto-day social activities. During the course of this site visit, three ladies were seen to be sitting and ‘chatting’ informally in one of the resident’s bedrooms. This activity was clearly being enjoyed. Members of staff appeared to have relationships based on a good understanding of each person’s background, needs and preferences. Particularly during the winter months when it is more difficult for residents to go out in the bad weather, a number of activity games had been introduced to promote some exercise and aid coordination. These include a beanbag game and a balloon game. Residents have also enjoyed a recently purchased reminisce activity that has prompted memories and discussion about every day objects from the past. Residents who chose too made Easter cards and decorated eggs with the assistance of staff. This led to a competition being held. It is understood that an outing to Blackpool is being arranged and one to one walks out in the local community take place when the weather allows. A minority of residents can access the local community independently and this is encouraged. A member of care staff spoken with explained that every week she helped a resident collect his pension and then they had a drink in a local café. This weekly event was very much enjoyed by the resident concerned. Residents also continue to enjoy sing songs, board games, bingo, music, and old films, that are provided generally on an ‘ad hoc’ basis to meet individual needs. The ladies living at the home also enjoy ‘pampering’ sessions including hand and nail care. Outside entertainers sometimes provide entertainment during the various parties that take place. Recently residents who were able to express a preference said they would like a magnetic dartboard and snap cards. These were purchased and are now being enjoyed. Ministers of various churches also visit Moor Villa on a regular basis to conduct a service and to speak with residents and at religious festivals local school choirs visit the home to provide entertainment for people who live there. A church visitor also visits an individual resident on a weekly basis Although during this site visit there were no relatives/friends visiting, relatives have in the past confirmed that they were always kept up to date with information regarding their family member living at the home and were always made very welcome whatever time of the day or evening they choose to visit. A resident spoken with said that his friends could visit at any time but this was more difficult as he was now out of the area where he had previously lived. Never the less this person stated that he was happy living at Moor Villa and did not want to move anywhere else. Where possible residents are encouraged and enabled to maintain control of their own financial affairs for as long as possible. However in reality the vast majority of people living at the home require some assistance in this task that Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 16 is usually provided by an external advocate or family member. Details of local advocacy services are detailed in the home’s Statement of Purpose and Service Users Guide that residents or their family can access independently. There was seen to be a varied menu, which is flexible to meet the individual needs of residents living in the home. Members of staff were clearly aware of the individual likes and dislikes of residents, so that they could make sure people get the right meals for them. Mealtimes are viewed as a social event and residents were talking comfortably with each other and with staff during the midday meal. Any assistance required was provided discretely and sensitively to ensure the dignity of the resident was not compromised. Residents were heard to say that they were enjoying the meal provided. Both residents individually spoken with stated that they enjoyed the meals with one person saying that the food was “excellent” and the other person saying that there was “good variation”. Specialist dietary needs are catered for and a dietician has been involved in the past who provided specialist advice that had been followed. Following on from this, three members of staff attended a course organised by the dietician that focused on foods and menu planning appropriate for rest homes. It is understood that the information provided during this course had been informative and useful. It was noted that although a record is kept of what had been eaten as per menu that included any changes to the proposed menu i.e. fish for meat, there was no record available to identify if an individual had eaten something different from the changed menu. It is recommended that a record be kept to identify what has been actually eaten by any person who has chosen and eaten a different meal. This would ensure that an accurate record is kept. Drinks and snacks were served throughout the day and at other times on request. One resident was observed asking for a drink during the visit that was promptly served by staff. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system and there is evidence that residents accommodated have their views listened to and acted upon. Arrangements for protecting residents from abuse are in place in order to prevent against risk of harm or abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Moor Villa has available a complaint procedure that fulfils the requirements of this Standard. This information is also contained in the Statement of Purpose and Service User Guide. No complaints have been recorded for a considerable period of time. The member of care staff spoken with was familiar with the home’s complaint procedure and both residents confirmed that they would speak with staff if they had any concerns or complaints. An Adult Abuse Policy and procedures based on the Department Of Health ‘No Secrets’ document is available and compliant with the requirements of Regulation. In addition, all staff have completed adult abuse training with Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 18 refresher training in respect of this topic arranged to take place in May 2008. This training helps to ensure that staff have a thorough understanding of adult abuse issues to protect both residents and themselves. Since the last inspection, one adult protection investigation has taken place. This did not involve any staff at the home but was concerning two residents living at Moor Villa. The homeowner and registered manager acted promptly and appropriately and cooperated fully in the investigation. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 25 & 26 Quality in this outcome area is adequate. At this present time, although a number of bedrooms have been provided with new furniture and refurbished, the general physical environment in this home still requires substantial improvement in order to provided an attractive and comfortable place for people to live This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the course of the site visit, all resident accommodation was observed. As recommended at the last inspection, carpets in communal areas have now been made closer fitting to help prevent accidental injury and the outdoor tool Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 20 shed is now kept locked when not in use. It is also understood that a screen was provided in the shared bedroom to ensure privacy, however the occupants of this bedroom did not want it and it has now been removed. Although some refurbishment has taken place to three bedrooms that have been re painted and provided with new furniture, curtains and bedding, substantial improvement is still required to the internal and external environment of the home to make sure that the home is a comfortable and attractive place to live. Another bedroom is in the process of refurbishment. From discussion with the registered manager it is understood that new furniture has been delivered to refurbish a further bedroom and additional furniture ordered for another bedroom. Whilst this is improving some of the bedroom accommodation the remaining resident accommodation still requires attention to provide an attractive place to live. For example, the external window frames, exterior walls and paintwork of the home all require urgent repair and redecoration. This has been highlighted in several previous reports however only minimal work been has ever been completed. We were told that a quote has now been accepted to undertake external repair and redecoration however no date has been arranged for the work to commence. We were also told that it was planned that a new floor and redecoration was to take place to the small lounge, the main lounge and corridors redecorated and provided with a new carpet and new floor covering to the downstairs bathroom. Whilst this is to be commended, often at Moor Villa any proposed environmental work is very slow to take place with no firm date arranged for the work to commence or be completed. This leaves residents living in accommodation that is not as homely, attractive or welcoming as it could be. As highlighted in the last inspection report, the downstairs bathroom is bleak and uninviting and does not present as a comfortable or attractive place to be. It was recommended that consideration be given to replacing the existing facilities in this bathroom to provide a more homely and inviting bathroom environment that was designed around the needs and capabilities of residents accommodated. From discussion with the registered manager, it is understood that the only planned improvement to this bathroom is to provide new flooring. There are no plans to replace the existing bathroom suite or to provide a modern and attractive bathroom environment. This should be reconsidered. All resident accommodation should be modern, comfortable and well decorated including the bathroom, so that it provides a well-designed bathing facility and decorated to a good standard for the comfort and convenience of people who live at the home. It has been recommended in several previous inspection reports that the existing intercom system in resident accommodation be replaced by a call bell system with an accessible alarm facility. This has not been done. At the last Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 21 inspection in an occupied bedroom on the ground floor of the building, the intercom in that room had been removed completely. It was explained that this was the result of the occupant banging her head on the unit when in bed. A different resident is now occupying this bedroom and the intercom system has been replaced however the unit is not working. When activated, there is no sound or other means of identification to the alarm panel to alert staff that assistance is required. . This remains a serious concern. As identified in the previous inspection report, there is a requirement that “suitable adaptations are made, and such support, equipment and facilities as may be required are provided for service users who are old, infirm or physically disabled”. It is also specified in the National Minimum Standards, Care Homes for Older People that, “Call systems with an accessible alarm facility are provided in every room”. It is essential that this equipment is repaired as a matter of urgency and serious consideration should be given to replacing the existing system with one of a more modern design and function. The recommendation that the remaining strip lighting be replaced by more domestic type lighting in resident accommodation has still yet to considered. It was noted that in a number of bedrooms, radiator covers were in poor condition or not very securely attached to the wall. In these situations residents would not necessarily be protected from accidentally burning themselves on the radiator or injury from a radiator guard that is broken. This must be addressed as a matter of urgency in order to protect vulnerable people. All radiator guards must be of sound construction, well maintained and firmly attached to the wall. Policies and procedures are in place for the control of infection and all staff have undertaken infection control training. Laundry facilities are sited in the yard area and do not intrude on people living at the home. Both residents spoken with were satisfied with their bedroom accommodation and communal areas of the home. One recently admitted resident explained that staff had purchased a new flat screen television for his bedroom that he was very pleased with. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. There are sufficient staff on duty to meet the needs of people using the service. People living at the home are protected well by the recruitment procedures. There is a staff training and development programme in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new staff appointments since the last inspection. This means that the staff team are consistent and know the needs of each individual resident very well. Comments from residents included, “staff are fine”, and “staff are OK, always there if you need them”. We looked at duty rotas and discussed staffing levels with the manager. The rotas show there should be sufficient staff on duty to make sure resident’s are supported and their needs are met. Residents and staff spoken with all felt that there were Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 23 sufficient staff on duty at any one time to ensure that the needs and requirements of people living at the home could be adequately met. Although no new staff have been appointed for a substantial period of time, Moor Villa has a robust recruitment system in place. This ensures that all appropriate references and clearances including the POVA (Protection of Vulnerable Adults) clearance are obtained and deemed to be satisfactory before any new employee is allowed to take up employment at the home. There is also an induction-training programme in place that is compliant with nationally recognised, ‘Skills for Care’ induction standards for newly appointed care staff. Staff training remains high on the agenda at Moor Villa. Currently ten of the eleven members of the care staff team have achieved at minimum a National Vocational Qualification (NVQ) Level 2 in care. The remaining member of staff is currently undertaking this award. This well exceeds the minimum recommendations for the number of care staff in any care home with this qualification. Two members of staff have also successfully achieved the more advanced Level 3 of this award and a three further people are currently undertaking this qualification. A further member of staff has successfully completed NVQ Level 4 and the deputy manager has obtained the Registered Managers Award. This is highly commendable. Staff have undertaken a variety of other training that has included health and safety training. A range of further refresher training is planned to take place in the very near future that includes, dementia care, POVA, risk assessment, challenging behaviour, medication and infection control. A member of the care staff team spoken with explained the recent training that she had undertaken and how this had helped to provide a good service to people living at the home. The same carer stated she felt very well supported and that the staff team “work well together and looked after each other”. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate The registered manager at Moor Villa is competent and experienced but should obtain a nationally recognised care managers’ qualification to ensure she has the required skills and abilities to manage the care home. The home regularly reviews aspects of its performance through a programme of self-review and consultation seeking the views of residents/relatives and staff. Although the homeowner visits the home on a regular basis, no written report is produced that comments on the conduct of the home. Systems are in place to ensure the health and safety of residents, staff and visitors. This judgement has been made using available evidence including a visit to this service. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager has overall responsibility for the management of the home and is experienced in managing Moor Villa. However until recently, the registered manager has been reluctant to undertake the Registered Managers Award. It is expected that all managers of care home would achieve this award to ensure that they have the abilities and skills to manage a care home. Since the last inspection, the registered manager at Moor Villa has commenced this course of study. This should be completed as soon as possible. The registered manager had also undertaken periodic training to update her knowledge and skills. The registered manager has also completed the Annual Quality Assurance Assessment (AQAA) that all care homes have to complete and submit on an annual basis. This gave some information about the care home but not all the information requested was provided in sufficient detail. Therefore it was difficult to be clear about the current situation regarding the running of the care home, what was working well and any difficulties from the limited information provided. Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff. There was a good rapport evident between staff and residents and between residents themselves. A programme of staff supervision was in place and records were seen during the inspection. However the way supervision was recorded could be improved to provide more detail. There was a tick box system for staff to identify personal care tasks undertaken that was completed prior to formal supervision. The deputy manager explained that the outcome of this is discussed at supervision. However, it was unclear what the outcome of the discussion had been and what action, if any was required. When writing supervision notes there should be an audit of topics that were discussed including intended outcomes identified in previous supervision notes and some indication if the objectives had been achieved. At minimum, formal supervision should cover the philosophy of care in the home, all aspects of practice and career development needs. This would ensure that a good record is maintained of staff development. As identified in previous inspection reports, formal systems, to find out what residents think about living at the home and the care and support they receive, are limited because of the cognitive impairment of the majority of people living at the home. However there is an ongoing quality monitoring system in place Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 26 carried out wherever possible through informal discussion with all users of the service including staff. Residents prefer to sit and chat with staff on a daily basis either individually or in a small group, often during the course of some sort of social activity that is taking place. This suits the needs of current residents. Likewise informal verbal discussion when relatives/friends visit the home is the preferred way to elicit the views and opinions of friends and relatives about how the home is achieving goals for people living there. The deputy manager also stated that other visitors such as doctors or district nurses are also occasionally informally asked for their views when visiting the home. Whilst this method of quality assurance is effective at this present time, consideration should be given to how resident’s current views are incorporated in to the Service User Guide when this document is annually reviewed. It was also evident that resident meeting take place, usually on a two monthly basis. The carer who conducts these meetings explained that all residents are encouraged to attend although generally it is the same people who are interested. Although resident meeting notes were available these could be more detailed. The written record should identify each resident that attended and a clear indication of what each resident said. In the minutes observed it was difficult to be certain if the written record was what residents had actually said or if the minutes reflected the carer’s thoughts on what residents liked or wanted. In several previous inspection reports, the homeowner has been informed that there is a requirement that he must conduct a monthly visit to the home and produce a written report about the conduct of the home. Although the registered manager confirmed that the homeowner does visit the home on a regular basis, written reports have not been provided. Monthly written reports must be produced covering a range of topics including the views and opinions of residents or their representative, what staff feel about the home and the outcome of the inspection of the building and some of the records held at the home. There remains a good system in place to ensure residents financial interests are safeguarded. Wherever possible residents are encouraged to remain financially independent. However in reality, because of cognitive impairment, the majority of residents require assistance with their financial affairs and an independent attorney is appointed. Where the home retains small amounts of personal monies in safe keeping for day-to-day needs, written records of financial transactions are maintained. Although the records were accurate and up to date with receipts kept, it was noted that when a resident received monies, they only sign the financial record once in a month rather than on each individual receipt of monies. It is recommended that each time a resident receive any money they are asked to sign the financial record to acknowledge Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 27 of receipt of the monies provided. Secure facilities are provided for the safe storage of resident’s monies and valuables. There was a set of health and safety policies and procedures available, which included the safe storage of hazardous substances. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Staff had also completed an infection control course. Arrangements have been made for all staff to receive annual updated health and safety training within the next few weeks. Documentation was seen during the inspection which, confirmed gas and electrical safety systems were serviced at regular intervals and the inspection of small appliances had taken place. The accident record is also maintained. Although accidents are recorded the current form used to record accidents is not really appropriate to the service and should be replaced with a more appropriate record. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 1 X 2 1 X X 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 29 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 OP3 Regulation 14(d) Requirement Timescale for action 31/05/08 2 OP22 13(4) 3 OP25 13 (4)(a) 4. OP31 26(4) All prospective residents must receive written conformation of the outcome of the pre admission and whether their current needs could be met at the home. All resident accommodation must 15/05/08 be provided with an adequate call bell system. (Timescale of 24/08/07 not met) All radiators in resident 15/05/08 accommodation must be provided with a radiator guard that is of sound construction, well maintained and firmly attached to the wall. (Timescale of 24/08/07 not met) The registered provider must 31/05/08 produce a monthly written report as to the conduct of the home. Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 30 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 OP7 Good Practice Recommendations All care plans and reviews of care plans should be signed and dated when an entry is made. Care plans should be signed by the resident/representative wherever possible as acknowledgement of the content. Formal written risk assessments should always be undertaken when a risk has been identified. Outcomes of the risk assessment should be incorporated in the care plan. Written care plans should be in sufficient detail to enable staff to provide a consistent, holistic service. A record should be kept of what each resident has actually eaten at mealtimes. Serious attention should be given to both the internal and external environment of the home to ensure a comfortable, attractive and well-maintained environment is provided. All old bedroom furniture should be replaced to provide a homely and attractive bedroom environment. The remaining strip lighting should be replaced with more domestic type lighting especially in bedroom accommodation and communal areas of the home. It is recommended that the ground floor bathroom/toilet facilities should be replaced and the room upgraded to provide a homely and inviting facility that is designed round the needs of residents accommodated. The registered manager should complete the Registered Managers Award as soon as possible. Written resident meeting minutes should detail who said what and outcomes of the meeting. Resident’s should sign their individual financial record each time monies are given. Staff supervision records should be more detailed. An accident record in a format that is suitable for a care home should be used. 2. OP7 3 4. OP15 OP19 5. 6. OP25 OP26 7 8 9 10 11 OP31 OP33 OP35 OP36 OP38 Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Moor Villa DS0000009722.V360788.R01.S.doc Version 5.2 Page 32 - 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. 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