Inspection on 03/04/07 for Moorfield House

This inspection was carried out on 3rd April 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

Moorfield House 01/04/08

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 Ann Connolly Unannounced Inspection 3rd April 2007 10:00 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.V320416.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.V320416.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.V320416.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 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 Rd and Liverpool Rd. The home is 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 £370 to £400 per week. There are no additional charges made to residents. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the unannounced site visit which took place over two days. The first visit took place on 03/04/07 and a second visit had to be arranged as staff on duty at the time did not have access to the staff files. The manager was on annual leave and the assistant manager was on her day off. The second visit took place on 11/03/07. The inspection visits were carried out over a seven hour period and included talking with a number of residents, staff and management, visiting health care professionals and examining a number of records. Some time was also spent looking around the inside of the home. Not all standards were checked at this inspection and it is strongly advised that this report should be read together with the last report and any future inspection reports to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: During this inspection visit there was a lot of positive feedback from residents in the home, and the feedback forms from residents all commented highly of the services offered in the home. There was evidence of positive and open communication between staff, residents and the management. One resident who was spoken to said, “ Staff are great, they look after you, and they listen. You can see a doctor when you want”. Another resident said, “I like everything about being here. I like getting a nice bath and getting my hair done. The food is not too bad, we get what they give us but it’s ok. If I had a complaint I would tell the staff”. Staff were observed in positive communication with residents in the home. On the day of the inspection, one resident was worried about something, and a member of staff displayed kind and sensitive intervention to supporting this resident. She was observed taking time to comfort and explain the situation, and used positive methods of intervention. All residents appeared relaxed and comfortable in their environment. It was evident from discussion with staff that they had a very good understanding of the needs of the residents in the home. Staff who were interviewed seemed to have a good understanding of residents rights and that all residents had individual needs. The home demonstrated an understanding of the importance of working closely with prospective residents and their families or representatives when they are Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 6 preparing to go into a home. Prior to arranging an admission to the home the manager or senior staff member worked with prospective residents and their families to gain a full background history and to ask resident how they would like to be cared for and supported. The home were very good at making sure that they had sufficient information to ensure they could meet the needs of the resident and provide appropriate care. Training and development plans in the home provided evidence of ongoing training for staff to ensure that they had the necessary skills in order to meet the needs of residents in the home. All staff who were spoken to said that they had the opportunity to participate in a wide range of training. The building was maintained to a good standard. There was evidence of ongoing improvements and refurbishment. The assistant manager said that a new carpet was due to be fitted to the lounge and that new chairs were being ordered for lounge areas. Visiting health care professionals spoke highly of the staff team and said staff were very aware of the importance of helping residents to maintain privacy and dignity. One health care professional said that the staff in the home always provided appropriate assistance and support during their visits. What has improved since the last inspection? What they could do better: The home carried out a detailed assessment of care needs prior to arranging the admission of a service user, however, much of the information collected was not transferred onto the care plan file. The service would be more effective if all people using the service have an up to date care plan to ensure that they receive the right support to meet their needs an so that the staff had the information they need to help them to carry out their care tasks. More care should be taken by staff in ensuring they follow the correct policies and procedures when administering medication so that safe practice safeguards the well being of residents in the home. Staffing levels should be reviewed in light of the increasing dependency levels of residents in the home. The staff compliment should reflect the needs and dependency levels of residents. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 7 The management team must ensure that records are available for inspection at all times. The manager must notify the Commission of any event in the care home which adversely affects the well being or safety of any resident. Information provided in this way will be used to continually assess and monitor the service and form part of the Inspection. 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.V320416.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.V320416.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): 1, 3 AND 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are given sufficient information about the home to help them in making a decision about their care arrangement. Residents’ needs are assessed prior to admission to the home so they are confident their needs will be met, and the home is sure it can meet their personal needs. EVIDENCE: Moorfield House has a detailed prospectus and Service User’s Guide that provides details about the home and information on all the services provided. This information was made available in the reception area of the home and was well presented on a display stand, which made information about the home easily accessible to residents and visitors. Comments in the service user comments card were positive about the way in which the home had made sure Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 10 that information was provided prior to arranging their admission into the home. Resident files were examined and included the care manager assessment and the homes own assessment. The manager or assistant manager carries out the initial assessment of needs by visiting the prospective resident in their own home. This is good practice because residents are able to meet with the manager and staff in the security of their home to discuss any concerns, questions or anxieties. The manager said that residents are only admitted to the home when all the pre -admission assessments had been carried out, and that this enabled the manager and the staff to make an informed decision as to whether the home could meet the needs of the resident. Four care plan files were examined during this visit, and all of them contained a pre- admission assessment. The home intended to provide all prospective residents with a letter confirming that the home could meet their assessed needs. The letter was available in draft format at the time of this visit. The home did not provide intermediate care placements. Moorfield House DS0000008336.V320416.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Based on information provided, care plans did not provide full details of residents care needs and the interventions required to meet needs. Staff would have experienced difficulties in understanding and meeting the needs of residents. Medication systems and procedures were not fully adhered to and the methods used in the management of medication had the potential to place residents at risk. EVIDENCE: Four of the residents’ files were examined. these contained a detailed assessment of needs, however, the information compiled in the assessments had not been transferred into the care plans. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 12 On one care plan file it had been well documented that the resident had complex needs regarding communication and was deaf, however, none of this information had been transferred into the care plan. The care plan did not mention any hearing difficulties and there was no written information available to explain why the resident was not wearing a hearing aid. Observations during the visit indicated that this resident became restless and frustrated in her attempts to communicate with people.The outcome for this resident was that she experienced difficulties in communicating with people, and there were no strategies in place for staff to support her with her needs. One resident was experiencing problems with swollen legs, and on examination of the care plan, there was no mention of this care need or of the intervention required to address and meet this need. One care plan provided detailed information on how to support a resident to maintain mobility. However, through case tracking, it was noted that significant changes had occurred with the resident’s health care and as a result, a wheelchair had to be used for all mobility tasks. The information in the care plan was out of date and did not reflect the current care needs of this resident, and failed to provide the care staff with up to date guidance on how to support this resident. All people using the service must have an up to date, detailed care plan to ensure that they receive the care they need. The interaction between residents and staff was seen to be respectful. Staff were observed knocking and waiting for a response before entering residents’ bedrooms. Staff and residents were observed engaging in meaningful communication. Since the last inspection some improvements had been made with the way staff managed the administration of medication, however, some shortfalls remained and some bad practice was highlighted during this visit. The medication trolley was stored appropriately when not in use and secured to the wall in the dining room. Since the last visit by the Commission for Social care Inspection, photographs of residents had been included on the records to aids staff with identification. Records were maintained of the receipt and disposal of medication and there were sample specimen signatures of all staff responsible for the administration of medication. Some Medication Administration Records (MAR) had hand written entries. Where this practice is necessary, staff must ensure that the entry is checked and countersigned by a second member of staff to ensure accuracy of information. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 13 During this visit, it was noted that medication had been secondary dispensed into individual pots ready to hand out to residents. The member of staff responsible for this was immediately aware that this was bad practice and could potentially result in the administration of medication to the wrong person. When medication is administered, it is essential that the correct policies and procedures are followed and that medication is dispensed from the monitored dosage system (Venalink), direct to the resident and that records are signed immediately after. The supplying pharmacist visited the home on the 02/02/07 to audit medication in the home and no major issues were identified. The assistant manager said that all staff were scheduled to receive updated training in the administration of medication. Moorfield House DS0000008336.V320416.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities were offered, but these need to be expanded to ensure that the social, cultural and recreational needs of residents are met and . Residents were encouraged to take control over their own lifestyle and encouraged to maintain contact with family and friends. Meals served to residents were of a high quality providing a well presented and nutritionally balanced meal. EVIDENCE: There was an ‘open’ visiting policy in the home and residents confirmed that they were able to receive visitors at any time. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 15 It was clear from discussions with the residents that they were relaxed and settled in their environment and able to exercise choice. Positive comments were made about the way in which they felt that independence was encouraged. Residents said they could join in the organised activities if they chose to do so. One resident said. “ We have bingo, and on Saturday we had a special meal and a film, very nice”. Another resident said, “ You get your food made here, its very good. I used to go to church, but I can’t get there. They would take me, but I’m not up to it. Someone visits us from the church”. One resident said, “ We have activities, we do exercises and we have bingo, but not every day. It would be nice if they could manage to do it everyday. My visitors are always made welcome by the staff”. It was evident that some activities were offered to residents, however, during the two visits made to the home, there was no evidence of any activities taking place. Staff said that time was limited when there were just care staff on duty, and that in the absence of the manager and the assistant manager it was difficult to spend time with residents. A recommendation has been made to expand the activities offered to residents based on their individual needs and preferences. The meal served during the first visit was home cooked using fresh produce. The meal consisted of cheese and onion pie, vegetables and potatoes, followed by carrot cake and custard. On speaking with the cook, she confirmed that alternatives were offered where the main choice was not the resident’s favourite. Residents confirmed that there was always a choice available upon request. Discussion took place with the assistant manager about increasing the menu options so that residents had a real choice at mealtimes. Staff were observed providing appropriate, yet discrete interventions to those residents requiring additional help and support. All residents spoken to were complimentry about the meals served in the home. One resident said “the food is lovely, gorgeous food”. Moorfield House DS0000008336.V320416.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 and 18 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 to support residents in making a complaint and to protect them from abuse, however there were shortfalls in managing complaints appropriately and in following procedures. EVIDENCE: During this visit there was a positive open exchange of communication between residents and staff, and residents appeared confident in expressing their views openly. One resident said she would tell “ the staff or the manager”, if she had concerns. The complaints procedure was made available in the Service User Guide and a copy was available in the entrance hall. In the four feedback forms from residents, all made reference to the complaints procedure and stated that they would know what to do if they were not happy about something and knew how to make a complaint. The home held a file to record any complaints made about the service, however, there were no recent entries or records of investigation about a complaint that was made to the home in December 2006. In December 2006, the Commission received a complaint about practice issues involving a resident in the home. In January 2007 the Commission wrote to the home asking them to investigate the complaint using their own complaints procedure and to Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 17 respond directly to the complainant. The home were also asked to send a copy of the response to the Commission. At the time of this visit, the home had not maintained a record of any investigation into the complaint and had not responded to the complainant or the Commission. Management of complaints needs to be improved so that residents and their relatives, feel confident that the home takes all complaints seriously and are acted upon. All staff need to be aware of the complaints policy to ensure that procedures are followed appropriately. The assistant manager said that staff had received briefings on Adult Protection. The Multi Agency policy on Adult Protection was made available to all staff. During this visit, staff were able to demonstrate an understanding of issues about abuse. Some staff were more confident than others in explaining the procedures for reporting an allegation of abuse. It was noted that systems were in place to reinforce good practice in key areas of care practice. There was evidence that the manager uses the supervision process to reinforce training and to assess staff knowledge of key important areas of practice, for example understanding of Adult Protection. Moorfield House DS0000008336.V320416.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, the standard of the environment within the home was good and provided residents with an attractive and homely place to live in. EVIDENCE: There is an emphasis in this home on providing a homely environment. The home has a passenger lift and appropriate aids and adaptations to promote and encourage independence. The home is maintained to a good standard and there was evidence of ongoing maintenance and refurbishment. The manager said that new carpets were due to be fitted in the central lounge and that some of the lounge chairs were due to be re-placed. Residents benefit from a conservatory to the front of the building which overlooks the lawned areas and Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 19 provides access onto a patio area which provides a safe place for relaxation. Residents said how much they enjoyed the gardens. One resident said she enjoyed sitting in the garden with her visitors. The home’s policies and procedures in respect of infection control have recently been reviewed and there was evidence that staff receive training in infection control. There was a high standard of cleanliness throughout the home. All areas of the home were clean and free from any offensive odours. All residents spoke highly of the cleanliness of the home and statements in the feedback forms received from residents said that the home was ‘fresh and clean’. Moorfield House DS0000008336.V320416.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 and 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 hardworking staff team with a good skill mix. However, inconsistencies in providing sufficient staffing levels at all times could prevent residents receiving the appropriate care and attention. EVIDENCE: This inspection visit took place over two days. During the first visit on 02/04/07 the staff on duty appeared to experience difficulties in carrying out duties efficiently. Staff appeared rushed and there was little evidence of staff having sufficient time to spend with residents. On this visit the staff team consisted of 1 senior carer, 2 care assistants, a cook and a housekeeper supporting 19 residents. The manager was on annual leave and the assistant manager was on her day off. Staff said that the absence of a manager/assistant manager meant that there were additional duties, which resulted in the team becoming ‘stretched’. During this visit staff had used ‘short cuts’ in some areas of practice. For example, the senior member of staff said that she had not followed the procedures in the administration of medication in an effort to save time. This shortfall has been addressed in standard 9 and requirements have been made to address the shortfalls and bad practice. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 21 At one point during the first visit to the home, there were no care staff available on the ground floor, as staff were providing support to residents on the upper floor. Constant interruptions caused by the telephone meant that staff were called away from their care duties. On the second visit on 11/04/07 staffing levels were increased as the assistant manager was on duty with the staff team. There was visible evidence that this increase in staffing levels had a positive impact on the way in which residents were supported. All staff who were interviewed said that the dependency levels of residents had increased, and that many residents required the support of two carers. There was a general feeling from staff that it was sometimes difficult to spend quality time with residents due to the time demands of the job. The manager must ensure that all people using the service must be supported by a staff team in sufficient numbers to reflect the needs and dependency levels of residents in the home. The manager must review staffing levels in the home and the ratio of care staff to residents must be determined according to the assessed needs of residents. It was evident from comments made by visiting professionals that the staff team worked hard to meet the needs of residents. Two visiting health care professionals said that the staff were always helpful, and one person said she found the staff very professional in promoting the privacy and dignity of residents. All appointments and treatments for residents were carried out in the privacy of their own room. Another health care professional said that staff always provided support in carrying out treatments. Comments from residents were positive. All residents who were spoken to spoke highly of the staff team and observations during both visits provided evidence of positive interaction between the residents and staff team. The records of three staff were examined and contained the relevant Criminal Record Bureau (CRB) checks and references. The assistant manager said that the home was in the process of auditing all staff files to improve record keeping systems in the home. There was evidence of ongoing training and development, and staff files contained evidence of training. The staff team were being supported to improve their competence through completing their NVQ awards. There was evidence of recent training in infection control and manual handling. The assistant manager said that training in Adult Protection was scheduled for all staff. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, the residents benefit from a well managed home, and systems are in place ensure the home is run in the best interests of residents. EVIDENCE: During this visit, the assistant manager demonstrated her commitment to developing the service and to ensuring that staff have access to appropriate training. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 23 The residents in the home benefit from a committed staff team, and from the low turnover of staff. There was evidence of an open management style, and residents and staff are encouraged to make use of the ‘open door’ policy. At the heart of this style of management is a person centred approach where the focus is on how the individual service user wants their care needs to be met. All residents spoken to during the course of this inspection expressed satisfaction on the way the home was run and the quality of the services delivered by the staff in the home. All staff spoke highly of the informal and formal support that they received from the manager. There was evidence on staff files to indicate that staff received formal supervision. There was evidence of a monitoring programme for supervision and to review staff work performance, training needs and future targets. Information in the home’s pre-inspection questionnaire provided confirmation that all health and safety checks were current and up to date. Information confirmed that fire safety training was provided to all staff. Quality monitoring systems were evidenced which include feedback forms to residents and their relatives. The home had provided the Commission with information about the service in the pre inspection Questionnaire. However, some of this information should have been forwarded to the Commission at the time of the event using a Regulation 37 notification. The assistant manager is now aware that this is a requirement and should be included in managerial tasks. Discussions with the assistant manager provided evidence of an open and transparent management style where any issues highlighted in the inspection visit were seen as an opportunity to improve the service. There was a strong focus on developing the staff team and an emphasis on consulting with residents informally and formally in order to improve the service. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 24 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 X N/A 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 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 X 3 X 3 X 3 3 Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement All people using the service must have an up to date, detailed care plan. This will ensure that they receive the person centred support that meets their needs. When medication is administered to the people who use the service it must be clearly recorded and staff must follow policies and procedures in good practice to ensure that medication is administered safely. Staff should receive ongoing training in the administration of medication so that safe practice is reinforced. The manager must ensure that any complaint made under the complaints procedure is fully investigated and that policies and procedures are followed so that complainants are kept informed and are confident that all complaints are taken seriously. Timescale for action 10/05/07 2. OP9 13(2) 01/05/07 3 OP16 22(3) 01/05/07 Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 26 4 OP27 18(1)(a) The manager must ensure that all people using the service must be supported by a staff team in sufficient numbers to reflect the needs and dependency levels of residents in the home. 01/05/07 5 OP37 37 6 OP37 17(3)(b) The manager must notify the 01/05/07 Commission of any event in the care home which adversely affects the well being or safety of any resident. Records must be available for 01/05/07 inspection at all times. 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 OP15 OP12 Good Practice Recommendations People using the services should be able to choose from a menu which offers a choice of well balanced meals. People using the services should be able to choose from a range of activities that reflect their social, cultural and recreational interests. Moorfield House DS0000008336.V320416.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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.V320416.R01.S.doc Version 5.2 Page 28 - 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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