Inspection on 30/08/07 for Moorend Place

This inspection was carried out on 30th August 2007.

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

Moorend Place 12/08/08

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

CARE HOMES FOR OLDER PEOPLE Moorend Place 34 Commonside Walkley Sheffield South Yorkshire S10 1GE Lead Inspector Marina Warwicker Key Unannounced Inspection 30th August 2007 06:30 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 Moorend Place DS0000069691.V346706.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. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moorend Place Address 34 Commonside Walkley Sheffield South Yorkshire S10 1GE 0114 268 0001 0114 268 4056 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) Southern Cross Healthcare (Focus) Limited Post Vacant Care Home 58 Category(ies) of Dementia (58) registration, with number of places Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Dementia - Code DE), maximum number of places: 58 places. The maximum number of service users who may be accommodated is 58. Not applicable Date of last inspection Brief Description of the Service: Moorend Place is a 58-bedded nursing home for adults. It provides care to people who are elderly and affected by mental infirmity. The home is situated in a residential area of Sheffield with good access to public services and amenities. It is built over two floors and separated into three units. There are stairs and a lift to access the different floor areas. The home is surrounded by gardens, which would benefit by landscaping. There is a car park to the front of the building for visitors. The weekly fee for the service is from £373 to £580. The acting manager explained that the fees are charged according to the dependency levels of the individuals and also according to the source of funding. The people living at the home pay from their pocket money for toiletries hairdressing, chiropody and any personal items. There is up to date information available regarding the service so that the people visiting the home are able to make an informed choice of home. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on Wednesday 30th August 2007 between 6.30am and 2pm. Five people who use the service, three relatives who were visiting and six staff who were on duty were consulted. A further ten relatives were contacted by post to obtain feedback about the service. Comments received from the surveys have been included in the body of the report. Time was spent observing and interacting with staff and the service users. The manager was present during the inspection. The premise was inspected which included bedrooms of people who live at the home and the communal areas inside and outdoors. Samples of records such as care plans, medication records, some service reports and staff recruitment and training files were checked. I would like to thank the people who use the service, the relatives, all the staff on duty and the acting manager for their contribution towards this inspection process. What the service does well: The information about the home was readily available for people so that when choosing the home they were able to make an informed decision. As part of the admission process the people had their needs assessed and contracts were set up by the home to inform them about the service they will receive. The staff working at the home showed respect for the people and maintained their dignity and privacy. With the help of their key workers and their representatives the people were able to choose their life style and social activities. The staff helped the people to maintain contact with their family and friends by reminding the people of their families and chatting to them using pictures they had of their past. The people at the home were offered a healthy, varied diet according to their needs. Some people were on special diet. These were made available to them. Staff were available to assist the people during mealtimes. The people living at the home and their representatives had access to a complaints policy. The people living at the home and the staff employed by the home are protected from abuse by the staff training and the home’s policies. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 6 The management and administration was based on transparency and respect to those who live at, work at and visit the home. They also ensured that health & safety was promoted at the home. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Moorend Place DS0000069691.V346706.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 Moorend Place DS0000069691.V346706.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Prospective people who wish to use the service and their representatives are able to access the information they need to choose the home which will meet the identified needs by them and the allocating officers. The people have their needs assessed and a contract set up to tell them about the service they will receive. EVIDENCE: Moorend Place has been registered with a new company since the last key inspection therefore as part of the first inspection under the present management the statement of purpose and the service user guide were checked. The information was up to date, relevant and reflected the present management of the home. Four care plans were checked to see whether the people have had needs assessments carried out prior to their admission. All Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 9 four care plans had copies of the assessments. In addition to the needs assessments, the home’s manager had visited the people before admission and completed assessments to help them prepare for the individuals’ admission. Two staff and three relatives confirmed this during the site visit. They also made the following comments. “Due to my X’s condition X was unable to come on trial visits, it would have upset X and us; so the staff agreed to give my X a trial period of about eight weeks. This was good. Every week we found how settled X was becoming.” “We found that Y needed time to get used to the staff and the home. This was helped by the social worker having a review after a month. We were able to say what was good and what could be improved and find out from the staff how Y was getting on with the others at the home. Y was not settled to start off with but now Y has made friends with the carers and seems fine.” Moorend Place DS0000069691.V346706.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The health and personal care, which the people who live at the home receive, in the main is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff working at the home. EVIDENCE: During direct observation it was noted that one of the people required one to one care of support. This was not arranged by the management and was causing problems with the staffing availability/ accessibility. The manager was informed of this and she agreed to deal with this by increasing the staffing levels and reviewing the needs of the individual regularly. Four care plans were checked and nine people living at the home were observed with regard to this outcome section. The people looked comfortable and supported by skilled staff. One of the staff said, “ During care plan reviews Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 11 the residents’ capacity for self care is looked at and the decision influences the way we give support.” This is a nursing home and named nurses take responsibility for areas such as tissue viability, continence care, palliative care and nutrition for updating training and supporting other nurses and carers. This system was not fully developed and therefore not used effectively. The staff surveys indicated that due to the change of management good practice ideas such as ‘link nurse systems’ had not been promoted. The information from the old care plans was being transferred into the new format and this contributed to some of the information not being included in the present plan of care. Discussion took place with the staff and the manager and concluded that this was a transitional phase and that in the next three months documentation would be up-dated. On the day of the site visit it was evident that the people living at the home were unable to manage their own medication therefore the nurses took on the responsibilities for the administration of medication. The care staff said that only the nurses dealt with medication. Medication Administration Sheets of four people were checked ad there was evidence that the doctor had regularly reviewed the medication for the individuals. The supplying pharmacist had visited the home and carried out audits of the management of medication. The manager said that the areas for improvement were being actioned by the nurses. The feedback from the surveys and the staff interviews confirmed that the people living at the home were treated with respect and addressed in the way they liked to be. The people were dressed in appropriate clothing and they looked dignified. The following comments were received. “The staff help my A to get dressed. My A does not always know the order clothing should worn. Clothes are always clean.” “Sometimes things get mixed up in the laundry, but the staff are very helpful and find the lost pair of tights and under wear. Generally we feel that the residents are dressed in clean clothing and made to look nice.” “It is always helpful when families bring in photos of the residents. This gives us an idea how they used to look and help them maintain their identity when helping them choose their clothes.” End of life care is an essential part of care in the home. Those staff who made comments said that they had learnt to deal with death and dying through their personal experiences and some others said that they were helped by working with others carers with experience. Some of the staff had not received formal training on palliative care, practical assistance and advice on bereavement. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People are able to choose their life style and social activity with the help of their key workers and their representatives. The people are helped by the staff to maintain contact with their family and friends. Social, cultural and recreational activities are not focused on the individual’s previous life style, their present needs and expectations. The people at the home are offered a healthy, varied diet according to their assessed requirements and their personal likes. EVIDENCE: A new social activities person had been appointed and the manager explained that with the help of the lead on dementia care from the company they were reviewing the leisure and social activities provided at the home. Some of the visitors said that the staff were welcoming and encouraged visitors. One relative said, “The care staff always ask my opinion about what my B likes and take notice of my views. I am very satisfied with the girls.” Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 13 Mealtime was observed. The staff were available to assist those who needed help. There was a choice of meals available for the people. The people were able to have a second helping if they so wished. Mealtime was treated as a social occasion and the staff chatted to people and created a relaxed atmosphere. Those people who required specialist diets were provided with them. Although the cook and the care staff knew the likes and dislikes of the people there wasn’t any formal documentation available for checking. During the visit to the kitchen the cook informed the inspector that the environmental health officer had visited and had given praise to the catering standards maintained by the kitchen staff. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The people living at the home and their representatives have access to an effective complaints procedure. The people living at the home and the staff employed by the home are protected from abuse by the staff training and awareness. The legal rights of the people are protected by the home’s policies and procedures. EVIDENCE: The surveys from the relatives confirmed that they were aware of the home’s complaints policy and they commented that they preferred to speak to the staff if they had concerns on a one to one basis rather than making it formal. The care staff said, “If anybody is unhappy we listen to the concern and put it right; then we tell the nurse to keep them informed.” “If a complaint is about management matters we ask the nurse to deal with it.” A nurse said that they avoid complaints by good communication and being sensitive to the peoples’ needs and their circumstances. One of the staff said, “Often families feel guilty for having to put their loved ones into a care home. Therefore we make sure we listen and show empathy and do our best to help sort out the problems.” Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 15 During conversation the manager outlined that her ethos was to promote a ‘no blame culture’ which help the staff to own up to any wrong doing and improve their practices through supervision and training. A record was kept of the complaints made. The care staff said that the relatives or independent advocates were involved when decisions had to be made with regards to protecting the rights of the people. During staff interviews it was established that the staff had a good understanding of abuse, neglect and discrimination. Some staff had attended training on Protection Of Vulnerable Adults and were able to verbalise the actions they would take when reporting an allegation of abuse. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the home enables the people to live in a safe and comfortable environment, which encourages their independence. EVIDENCE: There was evidence of routine maintenance, renewal of fabric and decoration of the premise. The old and worn furniture was being replaced and there was a programme for further work to upgrade the building. The grounds are safe but there needs to be work carried out to make it accessible and attractive. The manager said that there were plans for the work to take place. During the tour of the premise it was noted that it was kept clean and free from any offensive odours. There were plans to replace the bedroom carpets of those who were regularly incontinent. In the meantime the carpets were cleaned and kept dry for the people. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. A staff in the home are trained, skilled and most of the time in sufficient numbers to fulfil the aims of the home and meet the changing needs of the people living at the home. EVIDENCE: Staff rota was kept on each unit and amendments had been made since these were working documents. It was noted that additional staff were not scheduled promptly when a need arises. But this will be covered under a later section i.e. Management and Administration . Domestic staff were employed in sufficient numbers which contributed to the standard of meals and the cleanliness of the home. The majority of the care staff were given the opportunity to work towards NVQ level2. Some staff had completed NVQ level3. Four staff files were checked to ascertain whether the management had complied with the recruitment procedures. All four files had information to support that the manager was operating a thorough recruitment procedure. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 18 Four staff training matrices were checked and apart from a staff working predominantly on nights the others had attended appropriate training. Discussion took place with regards to night staff training. This will be checked through the action plan and also via the monthly Responsible Individual report. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The management and administration is based on transparency and respect to those who live, work and visit the home. They also ensure that as far as possible they promote health & safety at the home. EVIDENCE: The new manager is to obtain registration with the Commission for Social Care Inspection during this year. The staff saw the manager as someone who is not afraid to get her hands dirty. On the whole there was a positive atmosphere and some staff were getting used to the new management style. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 20 The monthly visit report by the Responsible Individual continues to be informative and also focuses on the positive aspects to provide encouragement to staff. The comments from the relatives and the staff confirmed that money was being invested in the home to make the home comfortable for the people. The following comments highlight the progress. “We don’t have to complain about the lumpy pillows. They seem to buy new ones these days.” “Due to a lot of them being incontinent there used to be a urine smell when you come on to the units, but there seems to be more domestics around and this may well be helping to keep the smell under control.” The general consensus was that the management were happy to spend money to improve the quality of life for those who live at Moorend place. However, the staffing levels need to be reflected by the dependency levels of the people who live at the home. There were records of staff supervisions. During interviews the staff said that they felt that they were supported and given opportunities to receive training by the present management. Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 OP12 Regulation 16 Requirement The staff must consult the relatives of the people living at the home and use the people’s life history when arranging activities. The people must be offered suitable activities reflecting their lifestyle. The manager must allocate an appropriate number of staff to meet the needs of the people living at the home. Immediate Timescale for action 23/10/07 2. OP27 18 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Moorend Place DS0000069691.V346706.R01.S.doc Version 5.2 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. 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