Inspection on 02/10/06 for Moor Villa

This inspection was carried out on 2nd October 2006.

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

Other inspections for this house

Moor Villa 15/04/08

Moor Villa 17/07/07

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 09:30 2 October 2006 nd 02/10/06 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.V310096.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.V310096.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.V310096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Moor Villa is registered accommodate up to 16 service users 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 small separate lounge area. Individual bedroom accommodation is located on the ground and first floor of the property and comprises of 8 single bedrooms and 4 shared rooms. 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 service users choice. Aids and adaptation are provided as required and all service users have access to appropriate medical interventions. The fees for residential care at Moor Villa range from £293 00 - £330.00 per week. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place during the morning and afternoon of a weekday and in total spanned a period of seven hours. Twenty-two of the core standards identified in the National Minimum Standards- Care Homes For Older People were assessed along with a reassessment of the requirements and recommendations identified at the last inspection. The inspector spoke with the home’s registered manager, deputy manager and a member of the care staff team. In addition, five service users were spoken with individually and several other service users were spoken with collectively in a lounge area of the home. However, discussion with a number of the service users spoken with was limited because of the effects of the dementia. A number of records and procedures were also examined and a tour of the building took place that included communal areas of the home, some bedroom accommodation and laundry and kitchen facilities. On this occasion, no Commission For Social Care Inspection comment cards were completed and returned. . What the service does well: What has improved since the last inspection? At the last inspection a number of serious concerns were identified with regard to the building that required urgent attention. These have now been put right. A further number of staff have successfully completed various levels of nationally recognised training for care staff. This has helped improve the skills Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 6 and abilities of staff in providing a good quality service. All staff have also now completed additional training that includes health and safety training and dementia care training. Moor Villa has developed ways of finding out the views of people living at the home and the views of their relatives and friends to make sure that the home is meeting service users expectations. In addition, Moor Villa has recently applied for the ‘Investor In People’ award. This will provide an external assessment of the home and assess how it is meeting service users and staffs needs. 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 Villa DS0000009722.V310096.R01.S.doc Version 5.2 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 Villa DS0000009722.V310096.R01.S.doc Version 5.2 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 in part and 3 Quality in this outcome group is poor. This judgement has been made using available evidence including a visit to the service. Although Moor Villa has good systems in place for assessing prospective service users strengths and needs prior to admission, this does not always ensure that it is only service users who have been assessed as requiring a specialist dementia care home are admitted. This potentially places service users who do not require a specialist dementia care home in inappropriate accommodation. EVIDENCE: As recommended at the last inspection, the relevant qualifications and experience of the registered provider and registered manager have now been incorporated in the home’s Service User Guide. This booklet is provided to all service users to tell them about the home and the services and facilities provided. Moor Villa Care Home is only registered to accommodate new service users that have a diagnosis of dementia. The home is not registered to accommodate Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 9 older people who have a functional mental illness. Since the last inspection, five new service users have been admitted. Three of these recently admitted service users were ‘case tracked’ during the course of the site visit. This means that all the information relating to that individual person is looked at to make sure there was enough information prior to admission for the registered manager to make a judgement if the home could provide the level of service required. The registered manager at Moor Villa confirmed that she had visited and assessed all three service users in their previous care home prior to making a judgement that Moor Villa could offer appropriate accommodation. Whilst it could be confirmed from records that one of the service users recently admitted had a diagnosis of dementia, there was no evidence that the remaining two-service users had ever being diagnosed as having dementia. From discussion with these two service users, there was little obvious evidence of dementia. Instead, limited memory loss or physical frailty was far more evident. It is essential that only service users that have a definite diagnosis of dementia and a recent reassessment of their current needs and requirements, the outcome of which indicates that the level of care required can only be provided in a specialist dementia care home be admitted. This will ensure that in future, only people assessed as requiring specialist accommodation in the category of care the home is registered to accommodate are admitted. It was also noted that the pre admission assessment forms had not been signed or dated when completed. It is important that all documents are signed and dated to clarify ownership and responsibility for the assessment undertaken. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 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): 7,8,9 & 10 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Although there is a consistent care planning system in place this does not necessarily provide staff with the information they need to ensure a consistent service is provided. The health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The system for the administration and recording of medication is generally good however the record of medication administered should be improved to ensure an accurate record is maintained. Personal support is offered in such a way as to promote and protect service users privacy and dignity. EVIDENCE: Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 11 Since the last inspection, the individual service user’s care plan that tells staff what the service user can do independently or what help and assistance is required, has been reviewed. The care plans now only contain relevant information. Any other required information is now rightly recorded elsewhere. Whilst this has improved the actual care plan, the detail written in the care plan should be more comprehensive in order to explain to staff exactly what is required. One service user spoken with explained that care staff did not always attend to his needs in the same way. One carer would do things one way and another carer would do things differently. Consequently this service user did not feel there was consistency of care from staff when providing the assistance he required. Some of the initial care plans observed were limited in content. Although there was recorded evidence that the initial care plan had been reviewed, there was nothing to indicate that the care plan had been amended to include further information about that person that staff had observed since admission to the home. It is important that the views of all staff are considered when reviewing the individual care plans and that care plans are actually amended as required. All care plans should detail the individual’s holistic wants and needs including health, personal and social care needs. It was also noted that although a risk had been identified, the ‘risk assessment’ was, on occasions, a statement of the risk rather than an assessment of how the risk could be eliminated or minimised. It is important that there is an individual risk assessment in place for all identified risks in respect of individual service users. Once the risk assessment has been completed, the significant outcomes should be incorporated in the care plan and reviewed on a regular basis to ensure that the information remains relevant and current. It was confirmed through discussion with staff and some service users that the health care needs of service users are well met. There is a good relationship with health care professionals in order to maintain health and social well being of service users accommodated. This is achieved through the appropriate intervention of a variety of medical professionals either visiting Moor Villa or health care provision in the local community. One service user commented that ‘they will always get a doctor for you when needed and you are taken to the G.P. or hospital appointments’ In the main there are good systems in place for the administration and recording of medication. However examination of the drug administration record revealed that there were dose omissions without explanation. Through speaking with the deputy manager, it became evident that there was a valid explanation for the dose omissions but this had not been recorded. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 12 In order to ensure an accurate and complete account of drug administration, it is imperative that the reason a drug is not given or taken be clearly recorded. This should be indicated by the codes used by the home. If an appropriate code is not normally in use, an alternative one could be devised and staff provided with training in the use of the new code. All staff with responsibility for the administration and recording of medication has received appropriate medication training and the home has a satisfactory policy and procedures for the administration of medication. Observations during the course of the site visit confirmed that the maintenance of service users privacy and dignity is upheld. From discussion with the deputy manager, it is understood that as part of the induction training all newly appointed staff receive guidance on how to respect service users privacy and dignity. Personal care is provided in the privacy of individual bedroom accommodation that can also be used for private consultation and to entertain visitors. Service users spoken with all thought that their privacy and dignity was well respected while living at Moor Villa. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14, & 15. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Staff has a good understanding of service users support needs. This is evident from the positive relationships that have been formed between staff and service users. Service users are encouraged to maintain contact with family and friends and links with the community are good. Dietary needs of service users are well catered for with a balanced and varied selection of foods available that meets service users taste and choice. EVIDENCE: Service users at Moor Villa are encouraged to remain as independent as possible with regard to their chosen life style. However in reality as the majority of service users have a form of dementia, the support of staff is often required to maintain day-to-day activities. It was observed that the routines of daily living are kept as flexible as possible to meet individual needs and requirements. From observation of the service Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 14 user meetings minutes, there was evidence of discussion with service users about planned outings and activities. ‘In house’ activities that include ball games, board games, bingo, music, old films, knitting, writing and word games are provide generally on an ‘ad hoc’ basis to meet individual needs. Regular manicures are very much enjoyed by a number of residents and the visit of the hairdresser is seen as a social event that service users enjoy. Outings in the local community are usually decided on the day that includes visiting the local shops or a visit to the park. However each service user has choice to become involved in any particular activity. One service user commented that he didn’t really want to go anywhere or do anything, “I am happy doing nothing and enjoying my retirement” Service users are encouraged to maintain contact with their family and friends who visit at any time of the service users choice. Visitors are made welcome and can be entertained in the privacy of individual bedroom accommodation or any communal area of the home. A minister of the church also visits Moor Villa every four weeks to conduct a service and to speak with service users and at religious festivals local school choirs visit the home to provide entertainment for service users. Where possible service users are enabled to maintain control of their own financial affairs. However in reality the majority of service users accommodated require some assistance that is usually provided by a family member. Details of local advocacy services are detailed in the home’s Statement of Purpose and Service Users Guide that service users or their family can access independently. Service users spoken with all stated that they enjoyed their meals at Moor Villa. One resident stated, “ the meals are very good, there is a lot of variety and to be quite honest, you cannot grumble about the food here. You can have a different choice from the menu, they are very obliging, will bring an alternative, no problem”. Staff spoken with also confirmed that although there is a set menu, this is very flexible and in effect service users can choose what they want at mealtimes. Specialist diets in respect of medical, cultural or religious requirements can be catered for and a record of foods served to each individual service user is maintained. As previously observed, meal times at Moor Villa are viewed as a social occasion. There was good interaction between service users and staff and the atmosphere was relaxed and comfortable. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints procedure with some evidence that service users feel their views are listened to and acted upon. Staff have a good understanding and knowledge of Adult Protection issues that helps to protect service users from abuse. EVIDENCE: As recommended at the last inspection, the home’s policy in respect of service users monies and valuables has now been extended to show how service users monies and valuables held in safekeeping are protected. Moor Villa Care Home has a complaints procedure and adult abuse policy that is compliant with all requirements and recommendations. Although no complaints have been raised for a considerable period of time, through discussion with the deputy manager it is understood that a record would be maintained of any complaint made that included details of the investigation and any action taken. Two service users spoken with both confirmed that they were aware of the home’s complaint procedure and knew what to do if they had a complaint including talking to the registered manager. One service user stated that he thought any complaint would be “looked into” and that “Christine (the registered manager) is very good, very moderate and does not flair up”. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 16 There are a variety of policy and procedures available for the protection of service users. These include an Adult Protection Policy based on the ‘No Secrets In Lancashire multi agency document and a whistle blowing policy to protect service users from abuse or discrimination. It is understood that all staff have now undertaken adult abuse training. Discussion with a member of the care staff team confirmed that she was aware of her responsibility in reporting any allegation of alleged abuse. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The standard of the environment is in this home requires improvement to ensure it is an attractive, safe and comfortable place to live EVIDENCE: At the last inspection a number of serious concerns were identified with regard to the physical environment at Moor Villa. The homeowner has attended to the areas of serious concern and some of the recommendations made to make sure the environment was of an acceptable standard for service users to live. However a small number of outstanding issues remain. In addition, a number of further issues were identified at this inspection. As identified at the last inspection, it is recommended that the existing intercom system in all service users accommodation be replaced by a call bell system with an accessible alarm facility. It is also recommended that consideration be given to replacing Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 18 the remaining strip lighting to more domestic type lighting in service user accommodation At this inspection it was noted that a radiator in a landing area of the home was not fitted with a radiator guard. It is understood that the original guard was damaged and has not been replaced. It is essential for the protection of service users and to protect from accidental injury that this radiator guard is replaced as a matter of urgency. All radiators in service user accommodation must be provided with a radiator guard at all times. In addition, the ground floor bathroom is not provided with an appropriate locking mechanism to protect the privacy and dignity of service users accommodated. This should also be provided as a matter of urgency. This issue was of particular concern to one service user who stated that when bathing or using the toilet anybody else could “walk in”. It was observed that the chairs in the small lounge area were quite grubby and dirty and required cleaning. Attention should be given to all soft furnishings on a regular basis and especially when it is obvious they require cleaning. This would ensure a clean and pleasant environment and maintain hygiene standards. Moor Villa is an older property that will require constant maintenance. The outside of the building is in a poor state of repair. Attention is required to a number of windows and again it was noted that the external rendering to the home, windows and guttering all require repair and repainting to prevent further deterioration and to provide a pleasant environment for service users to live. The programme of internal redecoration should also continue. Moor Villa care home has a variety of policies and procedures in place for the control of infection and safe handling of clinical waste. In addition, all staff have received infection control training. Laundry facilities are sited in the yard area and do not intrude on service users. Since the last inspection the walls and ceiling of the laundry room have been given some attention to ensure they are in good order. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome group is poor. This judgement has been made using available evidence including a visit to the service. Recruitment practices are inadequate that puts service users at risk. Moor Villa has in the main, a stable staff group that provide consistency of care to service users accommodated. Staff are provided with a variety of training to increase their skills and knowledge and to enable a good quality service to be offered. However induction training should be provided within a limited time scale to ensure newly appointed staff have adequate initial training. EVIDENCE: Since the last inspection one new member of staff has been appointed. Observation of this staff member’s personal file confirmed that an application form has been completed and a formal interview had taken place. However, although the applicant had nominated two referees, there was no indication that the registered manager had actually written to the referees to request an up to date reference. The only information available was two ‘open’ references relating to periods in 2004 and early 2005 which was some time before the applicant had submitted an application to Moor Villa. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 20 By accepting these ‘open’ references it could not be confirmed that they were genuine and there is a possibility that the applicant provided the references himself. It was also noted that a Criminal Records Bureau clearance was not submitted until the newly appointed member of staff had been in employment at the home for eight months. The registered manager explained that she was aware that the applicant had an existing Criminal Records Bureau clearance and therefore did not reapply for a new Criminal Records Bureau clearance in relation to the employment at Moor Villa Care Home. This action potentially left service users at risk. It is requested that new references are requested from the referees nominated that include, requesting information with regard to the applicant’s dates of employment, work performance and reason for leaving that employment. Please supply The Commission for Social Care Inspection with this information. All homeowners and registered managers were advised of the procedures to be followed when appointing new staff and the requirement to obtain a new Criminal Records Bureau clearance in respect of any new employee. Any new employee must not take up employment at the home until a full Criminal Records Bureau clearance has been received and deemed to be satisfactory. In exceptional circumstances, an employee may take up employment but only after a full Criminal Records Bureau clearance has been submitted and a POVA First clearance has been received and deemed to be satisfactory. In these instances, the new employee must be supervised at all time by an experienced member of staff until the full Criminal Records Bureau clearance has been received and receive appropriate training. Moor Villa staffing levels are determined in accordance with the assessed needs of service users accommodated. Additional staff are on duty during peek times of activity and there are designated night staff. One service user commented that, “there always seems to be enough staff from what I can see” A weekly staff rota is now available indicating which staff are on duty for any given period. However the rota for the week of the site visit was incorrect. A number of staff were indicated as having worked certain periods of time. For example, the handyman and casual staff were shown on the rota but discussion with the deputy manager confirmed that they had not actually worked that particular week. As stated on previous inspection reports, it is essential that the weekly staff rota is accurate and clearly identifies the actual staff on duty during each period of the waking day and night time period. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 21 There is now a clear commitment to staff training at Moor Villa Care Home. Currently one member of the care staff team has achieved a nationally recognised NVQ 4 qualification in care, has recently completed the Registered Managers Award and is waiting for the outcome of the final assessment. Three further members of staff have completed NVQ Level 3, and two people are waiting to commence NVQ Levels two and three respectively. All care staff have recently undertaken a modular dementia care course that is externally assessed as well as additional training in respect of health and safety issues. Service users spoken with all gave positive comments about the staff group. One service user said that “the people are very nice here nothing to grumble about” and another service user commented that “it’s like home from home, quite and peaceful, staff are very pleasant. They are not a bit officious, friendly without being over friendly, you can ask anything and get a sensible reply”. Another service user said, “There is a very friendly atmosphere here”. A member of staff spoken with who has worked at the home for a considerable period of time also spoke positively about the staff group saying that “ everybody has a more positive attitude and everybody has been given different responsibility, it is working well within the staff team”. It was noted that the most recently appointed member of staff had commenced induction training to National Training Organisation specifications. This training is specific to newly appointed care staff and should be provided within the first six weeks of employment at the home. However this member of staff has now been employed at Moor Villa for over twelve months and has still not completed the induction-training programme. In order to ensure that newly appointed staff have the required skills and abilities, it is essential that the induction-training programme be completed within the recommended time scale. If there are any problems in completing the course, the reason could be discussed during individual supervision and recorded. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The registered manager at Moor Villa is competent and experienced and provides clear leadership throughout the home. However the registered manager 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 service users and staff. Systems are in place to ensure the health and safety of service users, staff and visitors. EVIDENCE: Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 23 The registered manager is competent and experienced but does not wish to pursue an NVQ Level 4 qualification (or equivalent) in care and management. This potentially leaves service users at possible risk. Current best practice principles, understood through an advanced level of care and management training cannot be assimilated or cascaded to staff or staff performance effectively evaluated. The registered manager does however undertake short course training that includes the recent dementia care course. Formal systems for service users consultation are limited because of the cognitive impairment of the majority of service users accommodated. However informal verbal systems along with service user meetings are clearly evident. This suits the requirements of current service users accommodated. Likewise informal verbal discussion is used to elicit the views and opinions of friends and relatives and in order to identify how the home is achieving goals for service users. Although no relatives or friends were visiting during the course of this site visit, previous discussion with service users relatives and friends confirmed there was a good relationship with staff at the home and if they wanted to talk with staff about anything, somebody was always available and helpful. Moor Villa has recently applied for the ‘Investor In People’ and is currently undergoing assessment. This will provide an external evaluation of how the home is meeting needs. There are good systems in place to ensure service users financial interests are safeguarded. Wherever possible service users are encouraged to remain financially independent. However where a service user requires assistance with their personal allowance this is provided. Written records of financial transactions were accurate and up to date with receipts kept. Secure facilities are provided for the safe storage of service users monies and valuables. Moor Villa has a personalised health and safety policy and procedures that all staff are required to read and practice. From discussion with the deputy manager and a member of the care staff team it was confirmed that all staff have undertake mandatory health and safety training that includes infection control, first aid, moving and handling, and fire safety. A number of environmental risk assessment have now been completed and a Fire Service inspection and Health and Safety inspection have recently taken place. Recommendations made have been put into practice. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 24 Systems are in place to check annually the risk of Legionalla, and equipment is regularly serviced that was evidenced during the site visit. The electrical installation certificate is now also up to date. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement Timescale for action 31/10/06 2. OP25 3. 4. OP25 OP29 Only individuals that have a definite diagnose of dementia and have been assessed as requiring a specialist dementia care home can be admitted to Moor Villa. 12(4)(a) The ground floor bathroom must 31/10/06 be provided with an appropriate locking mechanism to protect the privacy and dignity of service users. 13(4)(a)(c The radiator in an upstairs 31/10/06 ) corridor must be provided with a radiator guard. 19(1)(b)(c Newly appointed staff must only 31/10/06 ) commence employment when all the required references and clearances have been requested and received and deemed to be satisfactory. Please advise CSCI of the outcome of the request for further references in respect of the most recently appointed employee. Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 Good Practice Recommendations All pre admission assessment documents should be signed and dated by the person undertaking the assessment on the day of the assessment. Care plans should be more developed and risk assessments completed when a risk has been identified and recorded. Care plans should always be amended as new information becomes available. The drug administration records should always be completed accurately. If a service user does not have their medication for any reason, the appropriate code should be used to indicate this. The chairs in the small lounge area should be cleaned to maintain hygiene standards and to provide a clean and pleasing environment. Attention should also be given to a number of windows and the external rendering, windows and guttering all require repair and repainting. It is recommended that the intercom call system in service user accommodation be replaced by a call bell system with an accessible alarm facility. Consideration should be given to replacing the remaining strip lighting to more domestic type lighting in service user accommodation. The weekly staff rota should accurately reflect the actual staff on duty for any given period of the day. Induction Training should be provided within the first six weeks of employment. The Registered Manager should obtained an NVQ 4 in care and management (or equivalent). OP7 3. OP9 4. OP19 5. 6. 7. 8. 9. OP22 OP25 OP27 OP30 OP31 Moor Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Villa DS0000009722.V310096.R01.S.doc Version 5.2 Page 29 - 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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