Inspection on 20/09/05 for Moor Villa

This inspection was carried out on 20th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 15/04/08

Moor Villa 17/07/07

Moor Villa 02/10/06

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 20 September 2005 10:00am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Moor Villa Address 53 Moor Street Kirkham Lancashire PR4 2AU 01772 682 884 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Seedheeyan Mrs Harris Care home only 16 Category(ies) of DE Dementia (16) registration, with number of places Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 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 user’s choice. Aids and adaptation are provided as required and all service users have access to appropriate medical interventions. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two morning periods of different days and an afternoon period of another day. In total the inspection spanned a period of approximately eight hours. On one of the inspection visits, a Regulation Manager of the Commission For Social Care Inspection accompanied the inspector as there were concerns regarding the physical environment of the home. The inspector spoke briefly with a representative of the homeowner, the registered manager, deputy manager and a member of the senior care staff team. In addition, a number of residents were spoken with informally in a lounge area of the home and another resident was spoken with individually. Unfortunately conversation with the majority of these residents was limited because of difficulties with short-term memory loss however residents were observed to be very relaxed and comfortable in their environment and there was a very good relationship evident between residents and staff. A number of records and policies and procedures were also examined and a tour of the building took place that included communal areas, bedroom accommodation and kitchen and laundry facilities. The majority of the core standards regarding Care Homes for Older People had been assessed at the last inspection that took place in May 2005. The outstanding eight core standards were assessed at this inspection along with a reassessment of the requirement and recommendations identified at the last inspection. What the service does well: In the main this home continues to have a group of staff that have worked there a long time, know the residents well and work well together in providing a good quality of care. The staff group are also undertaking a variety of training to make sure they have sufficient skills and knowledge to address residents individual needs and requirements. The home has a good relationship with health care professionals to make sure that resident’s health care needs are met. Activities are kept flexible and generally arranged on an ‘ad-hoc’ basis to suit the needs of particular residents. People who live at the home are encouraged as far as possible to make choices for themselves regarding their daily lifestyle. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 6 Social relationships are encouraged and visitors are made welcome at any time of the resident’s choice. What has improved since the last inspection? What they could do better: Although the care of residents is good at this home, the internal and external environment of the building requires attention. In particular, a ground floor toilet area is in urgent need of refurbishment and repair to make it of an acceptable standard and work is also required to part of a floor and wall on the ground floor to ensure the area is safe and in good repair. Several other areas in the home were found to also require attention to ensure the home is comfortable and safe for service users and staff. The electrical instillation certificate in respect of the home is out of date and a re-inspection is required as a matter of urgency. The home’s registered manager should obtain a nationally recognised manager’s qualification in care and management and risk assessments should be undertaken regarding safe working practices. Improvements should also be made to the staff rota to make sure it contains accurate and up to date information. The recording of medication administered to service users should be improved. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 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. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 (Partially assessed). The home‘s Statement of Purpose and Service User Guide are now good in providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: Since the last inspection, significant improvement has been made to the Statement of Purpose and Service User Guide. The Statement of Purpose is now compliant with requirements and the Service User Guide is almost compliant. However the relevant qualifications and experience of the registered provider and registered manager should be incorporated in the Service User Guide. It is understood through discussion with the registered manager, that once these inclusions have been incorporated in the Service User Guide, all service users will be provided with newly amended copies of both documents. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8,9 & 10. Standard 7 was partially assessed. The health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The systems for the administration of medication are adequate however the recording of medication administered needs to be improved to ensure an accurate record is routinely maintained. Personal support is offered in a way as to promote and protect service users’ privacy and dignity. EVIDENCE: As recommended in the last inspection report, care plans have been further developed and are now more holistic in content. Some formal risk assessments have been undertaken however this task is currently not completed with regard to a number of service users files. The outcome of all risk assessments undertaken should be incorporated in the relevant care plan. The care plan review document should only reflect the outcome of the actual review process and other day-to-day information should be recorded elsewhere in the service user file. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 11 Service users at Moor Villa are encouraged to remain as independent as possible in respect of their chosen life style. However as the majority of service users accommodated have some degree of dementia, the support of staff is often required to maintain routine day-to-day activities. It was evidenced through discussion, observation and documentation that service users health care needs are fully met. There is a good relationship with health and social care professionals in order to maintain health and social well-being. This is achieved through the appropriate intervention of various medical professionals. All service users retain choice in respect of their General Practitioner and have access to appropriate medical interventions provided either `in-house` from the NHS ‘outside clinic’ or provision within the wider community. Following the involvement of the Commission For Social Care Inspection Pharmacist Inspector during an inspection visit in 2004, the system for ordering, administering and recording of medication at Moor Villa has improved. All staff with responsibility for medication administration has now received appropriate medication training and the home have a satisfactory policy and procedure document for the administration of medication. However the medication administration procedures identified in the document are not always consistently followed. On the day of this inspection, although the morning medication had been administered to service users this was not recorded on the medication record. It is clearly evident that the medication record in respect of each individual service user had not been completed immediately after the medication had been administered but was to be ‘blocked signed’ after medication had been administered to all service users. On another occasion the medication record indicated that a specific medication had been administered to a service user when in fact the medication had been discontinued and had not been administered. This indicates ‘copycat’ recording and staff not checking carefully the monitored dose medication prior to administration. It is essential that the drug administration record is completed in accordance with the home’s policy and procedure document to ensure an accurate record is maintained. The maintenance of service users privacy and dignity is given high priority at Moor Villa and respected at all times. As part of the induction process, all staff receive training 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. Personal mail is delivered to the individual resident as it arrives at the home and telephone contact is maintained through the use of a cordless hand set telephone that can be used in private in any area of the home. The preferred term of address of each service user is identified at the point of admission and always respected. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 14 The staff have 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 to support and enrich service users’ lives. EVIDENCE: During the course of the inspection it was observed that the routines of daily living and activities remain flexible to meet individually assessed needs. Service users are enabled as far as possible to exercise choice in all aspects of their daily life. Social relationships are encouraged either through family/friends visiting or social stimulation in the wider community. It was evidenced that the individual service user’s interests are recorded on the care plan and ‘in-house’ activities are provided on an ‘ad hoc’ basis that include bingo, board games and music. The visit of the hairdresser is seen as a social event that service users enjoy and staff will also take service users out in the local community either shopping or to the park if they so wish. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 13 As identified in the Statement of Purpose and Service User Guide, contact with family and friends is encouraged and service users are able to have visitors at any time of their choice as evidenced at previous inspections. Visitors are made welcome and can be entertained in the privacy of individual bedroom accommodation or in any communal area of the service users choice. A minister of the church also visits the home once a month to conduct a service and to speak with service users individually and at certain religious festivals, local school choirs visit the home to provide entertainment to service users accommodated. Wherever possible, service users at Moor Villa are encouraged to maintain control of their own financial affairs. However in reality the majority of service users accommodated require assistance in this task that is usually provided by family or an external advocate. Details of a local advocacy service are incorporated in the Statement Of Purpose and Service User Guide to enable service users or their family to independently access if required. All service users are encouraged to bring personal possessions into the home, which was evidenced, through observation. Service users, wherever possible, are made aware that documentation is held respect of themselves and of their right to contribute to or access this documentation. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 assessed in part. Further policies have been developed that help protect service users from abuse. EVIDENCE: Since the last inspection policies in respect of physical and verbal aggression and staff not becoming involved in the making or benefiting from service users wills has been developed. Although information is available in respect of service users monies and financial affairs, this should be extended to explain the processes adopted in the home and could also incorporate the process for service users to access their individual financial records. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,24,25 & Standards 21 & 26 were assessed in part. The overall quality of some areas of the home is poor and in need of urgent attention. Although this does not cause an immediate risk to service users it does not create a pleasing and pleasant environment. EVIDENCE: Although some improvements has been noted following an inspection of the building by the Fire Service earlier in the year, there remains outstanding environmental matters that need to be addressed. This is particular relevant to the bathroom and toilet areas of the home. The downstairs toilet close to the main lounge is currently not meeting registration standard and requires urgent attention including the window frame, tiling, door surround, flooring and toilet to ensure this room is comfortable, warm, safe and attractive for service users to use. The bathroom off the small internal lounge is in need of refurbishment to make it attractive and welcoming. The toilet in this area is not secure to the floor and Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 16 has some movement. There is no appropriate locking mechanism to the bathroom door to ensure privacy and the position of the current external handle is dangerous and could cause an injury to a service user. The toilet base in one of the bathrooms upstairs has been fitted with a bolt to the floor rather than being securely fitted and another bathroom upstairs does not have a radiator guard fitted. It was observed that in the corridor between the small internal lounge and main lounge there appeared to be an area of damp and it is strongly recommended that this is investigated and action taken to remedy any fault. In the same area it was noted that the floor near to the small lounge appears to be crumbling and is not a safe and smooth surface. This could potentially cause a service user to stumble or fall. Although it was noted that locks have now been fitted to the new doors in service user bedroom accommodation and a lock has been fitted to the cellar door, it is recommended that a new lock be also fitted to the external emersion heater cupboard door to ensure that service users cannot accidentally scald themselves on the emersion heater especially as the emersion heater cover was not close fitting all over. In addition, it is recommended that to ensure as far as possible the safety of service users, a window restrictor be fitted to the bedroom window in room 3 especially as this is a fairly low window that could be easily accessed. It is understood through discussion with the registered manager that a current service user does not wish to have a curtain covering on the sky light window in his bedroom accommodation. It is recommended that this be recorded and kept under regular review. It is expected that once this room becomes vacant, an appropriate window covering will be provided. In respect of the other bedroom with an uncovered sky light window, it is recommended that an appropriate covering be provided. It was noted that a new door has been provided to the vestibule area at the back of the property. However the external windows of the property is still in need of repair and repainting and this should be undertaken as soon as possible to prevent further deterioration. The programme of internal redecoration should continue and the maintenance plan should indicate the proposed timescale for the work to be undertaken and dated when the required work is completed. It is recommended that the internal call bell system in all service users accommodation be replaced by a call bell system with an accessible alarm facility and consideration should be given to replacing the remaining strip lighting to more domestic type lighting in service user accommodation. The walls and ceiling of the laundry area should be given some attention to ensure they are in good order and that the walls are readily cleanable. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 were partially assessed. The home in the main, enjoys a stable staff group who offer consistency of care to service users accommodated. Staff morale is high and staff have a good understanding of the service users support needs. Staff training has been given some priority. This will help provide staff with the skills and knowledge to provide a high quality service. EVIDENCE: A staff rota for a two week period was available at inspection that identified the actual members of staff on duty during each shift period. However the rota evidenced was incorrect in that it indicated that a member of staff had been off duty for the same two individual days in both weeks in addition to rest days. In practice, the member of staff had only been off one additional day during the first week and no additional day in the second week. This error would have been avoided if a separate rota had been made available for each week. In accordance with Schedule 4(7) The Care Homes Regulations 2001, ‘a copy of the duty roster of persons working at the care home and a record of whether the roster was actually recorded’ must be maintained. Staff training has been given some priority and further members of staff have completed or are undertaking nationally recognised NVQ training at various levels in additional to a variety of other training topics. Currently one member of staff has achieved a National Vocational Qualification Level 3 qualification in care and two further members of the care staff team have achieved an NVQ Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 18 Level 2 qualification. In addition, four members of staff have almost completed Level 3 of this award and a further member of staff is undertaking NVQ Level 2 accreditation. A further member of staff is undertaking the Registered Managers Award. Since the last inspection, the home’s induction-training programme made available to newly appointed staff, has been amended and is now compliant with the ‘Skills For Care’ specification in respect of induction standards. Through discussion with the registered manager and deputy manager, it was established a new member of staff has been appointed fairly recently. However there was only the Criminal Records Bureau clearance available in respect of this person available at the home. It is understood that the staff file in respect of this person was held elsewhere and therefore recruitment information, references and all clearances could not be evidenced. Whilst the registered manager gave her reassurance that all required documentation had been obtained and was found to be satisfactory prior to the person actually taking up employment at the home, all documentation required by regulation must be retained at the home at all times and available for inspection. It is essential that this staff member’s file be returned to the home and securely stored. Staff spoken with stated they really enjoyed working in the family type atmosphere of the home and still liked to ‘make service users happy’. It was clearly evident that staff spend time with service users that includes social activities and sitting and talking with residents to getting to know them well. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 38 Moor Villa has available a number of policy and procedure documents to ensure the health, safety and welfare of service users, visitors and members of staff. EVIDENCE: Service users at Moor Villa are encouraged, wherever possible, to remain financially independent for as long as they wish and have capacity to do so or alternatively assisted in this task by relatives or an advocate. Secure facilities are available for the safe keeping of monies and valuables held on behalf of service users with relevant records and receipts kept. Financial records observed at the time of inspection were seen to be up to date and appropriately recorded. Although there is a statement available in respect of the home’s philosophy with regard to service users monies, it is recommended that this be expanded to identify the actual processes adopted when attending to any monies of service users accommodated. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 20 Moor Villa has available a health and safety policy that was evidenced at the time of inspection and as recommended in the last inspection report, is now personalised to reflect the requirements of the home. The vast majority of the staff team have undertaken moving and handling training, first aid and fire safety training. In addition, staff who have responsibility for medication administration have received appropriate medication training. Since the last inspection, infection control training has also taken place and one member of staff has successfully completed the more advanced ‘First Aid At Work’ course. Although some risk assessments were available in respect of the internal environment of the home, as recommended in the last inspection report, further risk assessments should be undertaken in respect of all safe working practices. In the main, equipment is inspected and serviced on a regular basis and hot water outlets in all service users accommodation is tested on a weekly basis to ensure the maximum temperature delivered from hot water outlets remains constant. As observed, induction training that is compliant with ‘Skills For Care’ specifications is made available for all newly appointed staff that includes initial health and safety training. However it was noted that the electrical installation certificate was out of date and the electrical installation in the home should have been re-inspected by a qualified electrician in June 2005. It is essential that the required work is completed as soon as possible and the Commission For Social Care Inspection advised accordingly. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 1 x 1 2 x 3 3 2 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x x x 3 x x 2 Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 13(4)(a) Requirement Attention must be given to a floor area on the ground floor corridor to ensure it is a safe and smooth for service users to access. The toilet area to the ground floor of the building is not of an acceptable standard and must be refurbished as a matter of urgency. The area of apparent damp on the wall in the corridor on the ground floor of the building must be investigated and repaired as required. A radiator guard must be fitted to the radiator in an upstairs bathroom to prevent of accidental scalding. A dated staff rota for each working week must be maintained and kept in the home that clearly indicates the staff on duty during each shift period. All documents relating to the home required by regulation including staff files must be kept on the premises and available for inspection at all times. (Timescale of 30/09/04 re staff rotas not met). The electrical installation system Timescale for action 30/11/05 2. 21 23(2)(b) 31/12/05 3. 25 13(4)(a) 31/12/05 4. 27 17(2) 31/10/05 5. 38 13(4)(a) 31/10/05 Page 23 Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 must be re-inspected. The existing certificate is out of date. 6. 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 1 7 Good Practice Recommendations The qualifications and experience of the proprietor and registered manager should be incorporated in the Service Users Guide The process of developing relevant risk assessments in respect of service users should continue. Relevant outcomes of all individual risk assessments should be incorporated in the service users individual care plan. All medication administered should be recorded immediately after the medication has been given. Medication from the monitored dosage system should be carefully checked before being administered and the actual medication administered correctly recorded. The policy in respect of service users monies and valuables should be extended to identify the actual processes adopted and also inform that service users can have access to their personal financial records. Attention should be given to the external and internal area of the home. The maintenance plan should indicate the proposed timescale for the work to be undertaken and dated when the required work is completed. A lock should be provided to the emersion heater door and a bathroom door. Attention is required to the bathroom areas on the ground and first floor of the building. It is recommended that the intercom call system in all service user accommodation be replaced by a call bell system with an accessible alarm facility. A window covering should be fitted to skylight window in one bedroom. Considerstion should be given to replacing the remaining strip lighting to more domestic type lighting in service user accommodation. The walls and ceiling of the laundry room should be given some attention to ensure they are in good order. F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 24 3. 9 4. 18 5. 19 6. 7. 8. 9. 10. 21 22 24 25 26 Moor Villa 11. 12. 13. 14. 15. 28 31 33 38 At least 50 of the care staff team should have attained NVQ Level 2 by 2005. The registered manager should have obtained an NVQ in care and management or equivalent by 2005. Consideration could be given to introducing an external professionally recognised quality assurance system to supplement the internal process. A window restrictor should be provided in bedroom 3 and risk assessments undertaken in respect of all safe working practices. Moor Villa F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit 1, Tustin Court Portway 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 F57 F09 S9722 Moor Villa V248671 190905 Stage 4.doc Version 1.40 Page 26 - 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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