CARE HOME ADULTS 18-65
Moorcroft Care Homes Ltd Moorcroft House 18 Laughton Road Thurcroft Rotherham South Yorkshire S66 9LP Lead Inspector
Valerie Hoyle Unannounced Inspection 17th January 2006 09:00 Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 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 Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 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 Adults 18-65. 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. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Moorcroft Care Homes Ltd Address 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) Moorcroft House 18 Laughton Road Thurcroft Rotherham South Yorkshire S66 9LP 0114 2488650 Moorcroft Care Homes Ltd Mrs Maureen Elizabeth Spencer Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Mrs Spencer to register on an appropriate management qualification course within the next 5 months to attain the qualification by 2005. 23rd August 2005 Date of last inspection Brief Description of the Service: Moorcroft House is a 3-bedded unit for adults with learning disabilities; it is registered to and managed by Mr and Mrs Spencer. A small staff team of seven enables Moorcroft House to provide a homely approach to care enhanced by the small size of the group and the ratio of one member of staff to one service user during the daytime. This ratio includes the provision of day-care. The owners provide a minibus for the home that allows the staff team to offer a variety of day trips as well as transport for shopping, appointments and wider contact with the local community. The building is a terraced property in the village of Thurcroft about 6 miles from Rotherham town centre. All service users have private accommodation for use as bedrooms and share the rest of the house that includes a dining room, large lounge, a dining kitchen, patio and garden. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second unannounced inspection of this inspection year. (2005/06) This unannounced inspection was conducted over 4 hours where a partial tour of the building was undertaken. The inspector examined three service users care plans and supporting documentation. Three service users and three staff were spoken to during the visit. The registered manager assisted with the process while examining records, policies and procedures. What the service does well: What has improved since the last inspection?
The registered manager has submitted her portfolio for assessment to gain her registered managers award, and continues to develop skills to ensure the quality of service is maintained. The staff at the home have achieved a quality kite mark ‘Investors In People’ that is recognition of their investment in training and developing the work force. The management and staff are commended for their efforts in achieving this award Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 6 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. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed at this inspection. EVIDENCE: There have been no new admissions of service users in Moorcroft since the previous inspection. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The home promotes philosophies to enable service users to meet their full potential, with clear care plan instructions and comprehensive risk assessments to maximise their safety and protection. EVIDENCE: There is a comprehensive individual plan for each service user, that is user friendly. They are well written with a daily entry made recording any significant events. These plans describe in detail the intervention required to meet their needs. Staff are aware of restrictions for one service user who requires one to one support while taking part in activities in the community. Risk assessments have been developed to ensure the safety of others when one service user uses his motorised scooter in the community and while being involved in shopping trips to the supermarket. There is clear evidence that service users care plans are regularly reviewed and annual reviews take place involving the placing authority. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 10 Each service has a weekly plan of activities including days when they attend college, and day care days when they have a choice of leisure activities supported by staff. Service users said that they had enjoyed a visit to ‘the deep’ at Hull the previous day. Other day care activities include shopping trips to Rotherham town centre and going to the gym. Regular house meetings are held to discuss issues relating to the running of the home and to agree activities. Minutes examined showed service users had been consulted about activities planned for over the Christmas period. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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 Social and leisure activities are provided at the home for service users, to maintain and develop independent living skills, supported by an informed staff group. Staff support contact with family although this is usually by telephone. EVIDENCE: Service users are encouraged and supported to maintain links with the local community. Two service users attend college and take part in woodwork and craft courses. One service user showed the inspector some items of woodwork that he had made at college including a small set of drawers and a DVD holder. One service user attends Mencap one day a week where he has a job; he said he enjoyed his work. Tuesdays at the home is classed as a training day and service users are encouraged and supported to undertake routine tasks around the home including cleaning their own bedrooms and doing their own washing and ironing. The inspector observed staff appropriately supporting service users to complete their tasks.
Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 12 Service users are integrated into the local community, and the registered providers provide transport to assist with this. Several staff are qualified to drive the people carrier and this is used for day care days and to drop service users at college or medical appointments. Service users are supported to maintain contact with family, although this is usually by a telephone call. One service user visited family at Christmas to deliver presents and have tea. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Staff provides sensitive personal support to ensure privacy dignity and independence is maintained for all service users. Medication policies and procedures are well managed and staff have the necessary skills to administer the medication to service users, ensuring the safety and protection of service users. EVIDENCE: Service users are generally independent with regard to their personal care, although staff provide support where needed with health care issues arranging appointments and escorting to doctors appointments. One service users mobility has deteriorated and the staff have made adjustments to the stairs, bathroom and toilet to ensure he can still maintain his independence. Staff support him when attending hydrotherapy sessions, with the agreement of the physiotherapist. An audit of medication stocks and records was examined and were found to be correct. Staff have received accredited medication training provided by a local college, to ensure they have the necessary skills and knowledge to undertake this task. The registered manager must ensure that new staff employed at the home attends the accredited medication training.
Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users are provided with information to enable them to raise concerns about the home and their care. Adult Abuse Policies and procedures and training of staff on abuse ensure the protection of service users from abuse EVIDENCE: The home has a complaints procedure that is available to service users and visitors that is kept in the home. The procedure is also referred to in the service users guide, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure. The registered manager has a copy of the Local Authorities Adult Protection procedures. They also have an Abuse Policy, which has been prepared by the owners and is incorporated into the homes policy and procedure manual. The registered manager reiterates the procedures at staff meetings and supervision and staff training files also confirms that they have attended training in adult protection. The registered manager ensures that all the necessary checks are carried out on new staff for the protection of vulnerable adults. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The home provides a well-maintained safe environment suitable for service users. The home provides a clean and hygienic environment to maintain the health and safety of service users. EVIDENCE: A partial tour of the building found it clean and free from odours. The home provides comfortable communal areas with one lounge and a dining area. The registered providers have made small adjustments to the toilet and stairs by adding handrails to assist with one service users mobility difficulties. There is a separate domestic kitchen with a breakfast table. The grounds were tidy, and accessible to the service users, the rear garden includes a patio area and small lawned area. The home is close to local amenities, and service users are able to access Rotherham town centre using the homes transport. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 16 Individual bedrooms are personalised to service users own interests and hobbies and are furnished appropriately including music centres and televisions. One service user has had his room decorated in the colours of his favourite football team. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Staff have the skills and knowledge to fulfil their roles within the home, and a stable staff group ensures continuity of care by staff that knows the service users. Recruitment policies are followed ensuring the safety and protection of service users. EVIDENCE: Staff rotas were examined and theses are divided into day care hours and hours to provide support to the three service users while they are at the home. This appears to be sufficient to ensure service users can maintain social and leisure pursuits. One member of staff has the responsibility for sleeping in at the home to ensure the safety of service users throughout the night. The inspector discussed the rotas with the registered manager, with regard to the staff gender mix to ensure sufficient cover to enable service users to maintain leisure activities. Two new staff has recently been employed at the home and they are expected to enrol on a NVQ Level 2 course as the home currently has less than the required 50 NVQ 2 qualified staff Discussion with the registered manager indicated that staff have not received any formal training to deal with challenging behaviour, therefore staff must
Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 18 attend a behaviour management course to ensure they have the necessary skills to deal appropriately with service users. This remains outstanding from the previous inspection. The staff at the home have achieved a quality kite mark ‘Investors In People’ that is recognition of their investment in training and developing the work force. The management and staff are commended for their efforts in achieving this award The registered manager was able to provide clear evidence that staff are recruited using the homes policies and procedures. Two staff file was examined and found they contained the required employment checks of two references and satisfactory CRB check, ensuring the safety and protection of residents. A selection of supervision files were examined, and these were comprehensively completed, demonstrating training and development is a high priority. Regular house meeting take place and service users are encouraged to attend these meeting. The inspector was able to examine the minuets from recent meetings held at the home. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home is well managed to ensure the safety and protection of the service users. The registered provider is able to demonstrate that she actively seeks the views of service users. Staff and service users follow health and safety procedures and records provide evidence of servicing of essential equipment EVIDENCE: The registered manager, who is also the joint owner of the home, has knowledge and experience of working with the service users. The manager has now completed the registered managers award and holds a nursing qualification. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 20 Quality assurance systems have been developed using a survey to gain the views of service users. House meetings are also used to ensure they play an active part in making decisions about how the home is run. The registered manager has the required Health and Safety policies and procedures and maintenance and service records examined were up to date and current to the services provided. Fire safety procedures are in place and service records were examined and were current. Staff training records examined indicated that fire training has taken place. Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 22 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 YA35 Regulation 18 Requirement The registered provider must ensure the staff have the necessary knowledge and skills in behaviour management. The registered manager must ensure that staff accesses the Learning Disability Award Framework training which provides underpinning knowledge for staff working with people with learning difficulties. (timescale 1 January 2006 not met) Timescale for action 01/04/06 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 YA32 Good Practice Recommendations The home must achieve 50 NVQ level 2 trained staff in 2005 Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Moorcroft Care Homes Ltd DS0000059245.V275688.R01.S.doc Version 5.1 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!