Inspection on 01/04/08 for Moorfield House

This inspection was carried out on 1st April 2008.

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

The inspector 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

Moorfield House 03/04/07

Moorfield House 15/02/06

Moorfield House 30/09/05

Moorfield House 18/02/05

Moorfield House 20/08/04

Moorfield House 10/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Moorfield House 132 Liverpool Road Irlam Gtr Manchester M44 6FF Lead Inspector Adele Berriman Unannounced Inspection 1st April 2008 10:15 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 Moorfield House DS0000008336.V361520.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. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moorfield House Address 132 Liverpool Road Irlam Gtr Manchester M44 6FF 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) 0161 775 3348 Mr Stephen Brown Mrs Mary Brown Mrs Mary Brown Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd April 2007 Brief Description of the Service: Moorfield House is a large Victorian building, providing personal care and accommodation for up to twenty (20) service users within the category of old age (OP), not falling within any other category. The home is registered in the name of Mr and Mrs Brown. Mrs Brown is also the registered manager of the home. The home is located in Irlam, on the corner of Moorfield Road and Liverpool Road, close to local shops and the main Warrington to Manchester bus route. The home comprises of 16 single bedrooms and two double bedrooms. Twelve of the single bedrooms offer en-suite facilities and are located on the ground floor. Parking facilities are available to the rear of the property. A landscaped raised patio area and conservatory had been constructed to the front of the home since the last inspection. Fees charged for this service range from £390 to £410 per week. There are no additional charges made to residents. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use the service experience adequate quality outcomes. An unannounced visited was made to the home on 1 1st April 2008, between 10:15am and 7:40pm. The manager was on holiday at the time of the visit and the inspection was conducted by a senior carer and the assistant manager. During the visit a selection of records, care plans, policies and procedures were examined and a tour of some areas of the building took place. Observations were made of the activity around the home and several residents and two visiting relatives gave their views on the service. Prior to the inspection taking place, survey forms were sent to the service for residents and staff to complete. Two residents and seven staff completed and returned survey forms. The manager of the service was sent an Annual Quality Assurance Assessment (AQAA) for completion to tell us what they feel they do well, what they feel they could do better and how they feel they have improved in the last 12 months. The AQAA had not been returned at the time we asked for it. The two relatives said that they were very happy with the service their partners received whilst living at the home and felt that they could visit at any time. Residents said they were happy with support they received from the staff team. One person said “lovely staff” and another said “kind staff, I feel safe”. All residents said that they knew who to talk to if they were not happy and knew how to make a complaint about the service. No complaints had been recorded at the service since the previous inspection and the service had not reported any safeguarding issues. Residents indicated that they liked the food served at the home. Comments included “good food” and “I enjoy the food.” Staff who completed a survey form stated that they felt they always had the right support, experience and knowledge to meet the different needs of the people who use the service. Two staff commented that they would like to have more time to spend with the residents. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Improvements should be made to the detail of information recorded about people’s needs and wishes in their care plans. Up to date information about medical appointments and visits from healthcare professionals needs to be recorded. Failure to keep detailed up to date records may result in a person not receiving the care and support they require. Improvements need to be made to the process of risk assessing all known risks to ensure the health, safety and wellbeing of individuals. Failure to demonstrate that all known risks to activities, equipment and situations have been considered may result in people being put at risk from unnecessary harm. Bathroom and shower facilities need to be fully accessible and free from hazards to ensure that residents have safe access to the facilities at all time. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 7 Safe recruitment procedures need to be demonstrated in staff files to ensure that only people suitable to work with vulnerable people are employed. 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. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents’ needs are assessed prior to moving into the home. The assessment process would benefit from recording greater detail, so the service can be sure it can fully meet the person’s needs. EVIDENCE: Staff stated that prior to a person moving into the home, the manager or assistant manager visits them to carry out an initial assessment of their needs. The purpose of the assessment is to ensure that the facilities are available at Moorfield House to meet their needs and wishes. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 10 The outcome of the initial assessment is recorded on a pre-printed preadmission form. The format gave the opportunity for the assessor to record the person’s personal information, neuro-sensory level, prosthesis appliances, degrees of independence, dental health, foot care, recent falls history, continence, personal history and their ability to maintain a safe environment. The files of more recently admitted residents contained a pre-admission assessment. The format did not give an opportunity to record people’s needs in detail. The service would benefit from reviewing their pre-admission format to give the opportunity to record more information about specific care, cultural, spiritual and religious needs to ensure that they are fully aware of people’s needs and wishes. The home did not provide intermediate care facilities. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents’ needs and wishes were not fully demonstrated in individual care plans and risk assessments. Without detailed information, staff may not be aware of what support needs to be delivered. EVIDENCE: The care plan files of four residents were examined. They contained an assessment of daily living that gave the opportunity to record people’s needs and wishes relating to aspects of their day to day life. Staff stated that, following a requirement from the previous inspection, social histories were being developed with residents and all care plans and assessments had been indexed in the residents’ files. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 12 Not all sections of people’s care plan files contained detailed information. For example, the sections relating to ‘working and playing’ contained little information to demonstrate that people’s social and recreational needs had been fully assessed and the section titled ‘expressing sexuality’ stated “none expressed” on all four files examined. It is strongly recommended that people’s needs and wishes are written in more detail to ensure that all aspects of residents’ care are demonstrated. Care plan records demonstrated that residents had access to local healthcare professionals. There was evidence of GP, chiropodist/podiatrist, district nurse and physiotherapist visits for residents and also evidence that residents were attending hospital appointments. Not all of these records were up to date. For example, staff stated that the most recent visit from the chiropodist for some residents was 11th March 2008 but the information in the residents’ care plans stated that the last visit was 19th October 2007. All information relating to medical appointments and the outcome must be recorded in full to ensure that up to date records are maintained and that residents receive the support they require. There was evidence that care plans were being reviewed on a monthly basis. Individual risk assessments relating to residents were available in the care plan files. These assessments included moving and handling and nutritional needs. There was no evidence to demonstrate that these assessments were being reviewed or updated on a regular basis. One resident was seen to be seated throughout the visit in a recliner chair. Staff stated that the resident was unable to move the chair independently or make their wishes known in relation to the seating position. No risk assessment was available to demonstrate that all aspects of this seating arrangement or the decision making regarding the seating arrangement had been considered. It is essential that all identified risks must be considered, documented and reviewed on a regular basis. This is to ensure that people’s needs are met in a manner that protects their health, safety and wellbeing. Policies and procedures were in place for the appropriate receipt, recording, storage, handling and administration of medication. Medication was stored appropriately. Although no controlled drugs were in use at the time of the visit, an appropriate cabinet for the storage of this medication was awaiting installation. Medication Administration Records (MAR’s) were in use for staff to record the management of medication. Six of these records were examined, all of which were completed appropriately. Staff responsible for the administration of medication stated that, since the last inspection, they had attended a medication training course. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 13 During the visit staff were observed supporting residents in a manner that maintained individuals’ privacy and dignity. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 ,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Activities were offered, but opportunities need to be developed for residents when their choices and wishes are fully assessed as part of the care planning process. EVIDENCE: Following a recommendation from the last inspection report, more social activities had been introduced for residents. These included dominoes, cards, painting by numbers, fortnightly exercise class, bingo, a weekly video/DVD evening with buffet on a Saturday. An entertainer visits every few months. Staff stated that a weekly quiz had commenced with questions from the 1920’s upwards and it appeared to be popular with the residents. The member of staff responsible for the quiz stated that the questions in the quiz generated a lot of discussion and informed staff of individuals’ likes and dislikes through the discussion. Representatives from local Church of England and Roman Catholic churches visit the service on a weekly basis to enable residents to maintain their faith. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 15 Residents spoken to during the visit said that they were happy with the activities provided and both residents who completed a survey form stated that there were always activities arranged for them to participate in. No activities took place during the visit. The home had an ‘open’ visiting policy. visit entering and leaving the building. visited on a regular basis and feel able stated that they were always kept up to relative’s life. Several visitors were seen during the Two of these visitors stated that they to visit at any time of the day. Both date with what was happening in their A board displaying the menu for the day was positioned outside the dining room. Staff stated that, following a recommendation from the previous report, residents are asked weekly for their choice of two meals served at lunch and teatime. In the event of a person not wanting a particular meal on the day, an alternative would be provided. During the visit residents spoke positively about the food served. These comments included “enjoy the food” and “good food here.” One resident who completed a survey form stated they always liked the food and one person stated they usually did. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents were comfortable raising concerns and complaints about the service. There were shortfalls in the management and recording of complaints. EVIDENCE: A copy of the complaints procedure was available in the foyer of the home. Staff stated that the procedure, along with other information in the service user guide, was in the process of being updated and it was planned that copies of the complaints procedure and service user guide would be available in all bedrooms. A file was available in the staff office to record any complaints about the service. No complaints had been recorded and staff said that they had not received any complaints about the service. During the visit a resident was seen to make a complaint about the temperature of the food she had been served at lunchtime. Staff investigated this complaint immediately and asked other residents for their views. It was positive to see that residents were being consulted and that residents spoke freely with their views. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 17 Staff stated that the complaint made would not be recorded as it had been dealt with immediately. A record of all complaints, investigations and their outcomes must be recorded to ensure that the service delivered is monitored. Failure to do so may result in complaints being made consistently and no action being taken. All residents and the two visitors spoken to during the visit, and the two residents who completed survey forms stated that they knew who to speak to if they were not happy or if they wanted to make a complaint. A copy of Salford Social Services joint agency safeguarding procedures was available to staff. Following the visit the manager stated that the services internal adult safeguarding policy was being updated to include more information. Staff stated that they had received training on safeguarding from the manager of the home. This training included the use of training videos. It is recommended in this report that staff have the opportunity to attend training around the Local Authority’s joint agency safeguarding procedures to ensure that they are aware of the most up to date guidance and procedures. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Overall, the standard of the environment provided a comfortable environment in which to live. Attention is needed to ensuring all facilities are accessible at all times and an appropriate cleaning schedule implemented to maintain the comfort of residents. EVIDENCE: There was evidence of ongoing redecoration and refurbishment of the home. Since the previous inspection, new dining room furniture and lounge chairs had been purchased, all corridors, lounges and the dining room had been decorated and new carpets had been fitted to the communal areas. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 19 Two lounges and a conservatory were available on the ground floor, all of which had views of the front garden and the main road. The areas provided residents with comfortable environments. Outside seating was available in the front garden patio area. A handy person was employed by the service to carry out maintenance around the building. On the day of the visit the handy person was gardening. A tour of some areas of the building took place. Several residents’ bedrooms were visited and were seen to contain their own effects that personalised their rooms. The ground floor bathroom was in need of tidying. A collection of towels, furniture and clothing made movement around the bathroom difficult and some items created tripping hazards. The level access shower in the corner of the room was not accessible due to clothing containers being stored. The bathroom on the first floor was not accessible as it was being used to store mattresses, equipment and bedding. All bathing and toilet facilities must be fully operational to ensure that residents have access to the facilities at all times. The assistant manager stated that the areas would be tidied immediately. The home was in need of cleaning. Domestic staff had been on sick leave for some time. The carpets needed vacuuming and several areas of the home needed cleaning. Staff stated that the central vacuum system had broken two days previously. It is essential that a regime is developed to ensure that regular cleaning of the home takes place to ensure that residents have access to a clean, comfortable environment at all time. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents’ needs were being met by a dedicated staff team. Records need to demonstrate that appropriate recruitment checks have been undertaken prior to a person starting employment. EVIDENCE: At the time of the visit two carers, two senior carers and a cook were on duty to meet the needs of the residents. Staff explained that, following a requirement made at the previous inspection, two senior carers were on duty between 8am and 4pm when the manager and the assistant manager were not on duty. Two carers and a senior carer were on duty between the hours of 4pm and 10pm to meet the needs of the residents and to serve the teatime meal. Residents spoke positively about the support that they received from the staff team. Comments included ‘kind staff, I feel safe’ and ‘lovely staff.’ Both service users who completed survey forms said that staff listen and act on what they say and that they always receive the care and support they need. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 21 During the visit staff were observed supporting residents in a positive manner and demonstrated a good awareness of individuals’ needs and wishes. Staff appeared very busy around the building. Due to sick leave, no domestic support was on duty to maintain the cleanliness of the home. One resident who completed a survey form stated that staff are always available when they needed them and one resident stated that they usually were. Six staff stated in their survey forms that there were usually enough staff on duty to meet the needs of the residents and one staff member said there sometimes was. One member of staff wrote “it would be nice to have more time to spend with each resident, as everything seems to be done quickly” and another wrote “sometimes it would be nice to have more time to talk and spend time with the residents.” It is essential that a regular review of staffing levels takes place to ensure that an appropriate number of staff are on duty to ensure that residents’ needs are met at all times. Six staff files were assessed. The majority of the files contained all the required information. One file contained only one written reference and another file contained a photocopy of a Criminal Record Bureau check that had been carried out by another organisation 11 months prior to the staff member commencing employment. Appropriate recruitment checks must be carried out to minimise the risk of people unsuitable for the role being employed. It was evident from observations made during the visit that some residents experienced varying degrees of confusion and behaviours associated with dementia. Staff confirmed this and stated that there were changes in the dependency levels and needs of the residents now using the service and that the manager intended to carry out some training with staff around dementia. All staff must have access to training related to meeting the needs of the residents they support. Failure to do so may result in a residents’ needs not being met. All staff stated in their survey forms that they were being given training that was relevant to their role, that helps them understand and meet individuals’ needs and that keeps them up to date with new ways of working. Not all training records were available during the visit. Some staff files demonstrated that the member of staff had participated in an induction into their role and had received training relating to moving and handling, infection control and first aid. Senior carers had attended a course on medication and training was planned relating to continence and diabetes. Detailed records of all training undertaken by staff should be maintained and be available for inspection at all times to demonstrate that appropriate training is offered to staff for their role. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 22 The majority of the care staff team had completed an National Vocational Qualification (NVQ), three staff were in the process of completing their award at the time of the visit. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Systems were in place for the management of the service. Senior staff at the home recognise what improvements they need to make to ensure the systems work well. EVIDENCE: The manager/proprietor of the service has many years’ experience in care home management. During the visit staff spoke positively about the support they received from the manager. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 24 On the day of the visit the manager of the service was on leave. The assistant manager was on a day off but came into the home in the afternoon. A senior carer conducted the visit. The assistant manager and the senior carer both demonstrated an awareness of person centred planning and demonstrated a commitment to their role and the development of the service. The assistant manager stated that no recent quality monitoring surveys had taken place. However, the senior carer on duty spoke about a recent quiz that had been introduced and the questions in the quiz had generated a lot of discussion with the residents and gave the opportunity for them to discuss their likes and dislikes. A procedure was in place for the safekeeping and management of residents’ monies. All monies were stored in a safe which only the manager and the assistant manager had access to. A detailed record of all transactions were maintained on a record sheet for each individual. Policies and procedures relating to the health, safety and wellbeing of all were available to staff. Accidents were being recorded in a manner that protected people’s personal details. Several residents had bed rails in use. Staff said that they carried out a visual check every time they are used. There were no risk assessments available to demonstrate that any risks relating to the use of bed rails had been considered. It is essential that all actions or pieces of equipment that could cause harm to people are assessed and actions taken to minimise any identified risks. Failure to carry out regular up to date risk assessments may result in a person being put at risk from unnecessary harm. Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x 2 x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP16 Regulation 22 Requirement A detailed record of all complaints, their investigation and outcomes must be maintained. All staff need to be aware of the need to record all complaints received about the service. Bathroom and shower facilities must be fully accessible so that residents are able to access them safely. So that residents benefit from living in a clean environment an appropriate cleaning regime must be introduced. All staff files must contain all of the information listed in schedule 3 of the Care Homes Regulations 2001 to demonstrate that appropriate pre-employment checks have been made. A risk assessment for the use of bed rails by individual residents must be carried out to ensure that all risk factors are identified and action taken to minimise the risk to the person’s health and wellbeing. Timescale for action 19/05/08 2 OP19 13 12/05/08 3 OP26 23 12/05/08 4 OP29 18 19/05/08 5 OP38 13 12/05/08 Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The current pre-admission assessment should be reviewed and updated to include more opportunity to record people’s specific needs and wishes, and also include an opportunity to record people’s needs and wishes relating to cultural, spiritual and religious preferences. All people using the service should have an up to date, detailed care plan. This will ensure that they receive the person centred support that meets their needs. It is recommended that staff have the opportunity to attend safeguarding training that informs them of the local social services procedures. The services policy for the management of violence and aggression should be reviewed and updated to ensure that that the information contained in the document is up to date. The manager should ensure that all people using the service should be supported by a staff team in sufficient numbers to reflect the needs and dependency levels of residents in the home. A regular review of the training needs of the staff team is required to ensure that are able to meet the changing needs of the residents. 2 3 4 OP7 OP19 OP19 5 OP27 6 OP30 Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Moorfield House DS0000008336.V361520.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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