CARE HOMES FOR OLDER PEOPLE
Moorgate Hollow Nightingale Close Moorgate Rotherham South Yorkshire S60 2AB Lead Inspector
Ms Rosemary Reid Unannounced Inspection 12:30 24 February 2006
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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 Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 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. Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Moorgate Hollow Address Nightingale Close Moorgate Rotherham South Yorkshire S60 2AB 01709 838531 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) Rotherham Healthcare Limited Janet Elizabeth Walton Care Home 24 Category(ies) of Dementia (24), Mental disorder, excluding registration, with number learning disability or dementia (24) of places Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. This home is registered for 24 beds in the categories - Mental Disorder and Dementia from 60 years of age. 27th June 2005 Date of last inspection Brief Description of the Service: Moorgate Hollow is a purpose built residential care home for older people with dementia. The home is situated in the Moorgate area of Rotherham. Moorgate Hollow is located on the same site as Moorgate Croft and Moorgate Lodge. Moorgate Hollow provides a secure environment to its service users with an enclosed garden to the rear of the home and service users have also access to a patio garden. Moorgate Hollow and the other two homes are owned by the same private company (Rotherham Health Care Ltd). The registered provider is Mrs G Oliver. At the time of the inspection the appointed manager Mrs Walton had submitted an application to be the registered manager and was successfully registered on the 27th July 2005. The home provides accommodation for service users in single bedrooms at ground level. All bedrooms have en-suite facilities. The communal area consists of lounges and dining areas with kitchenettes facilities are also located on the ground floor. Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 24th February 2006 from 12:30 – 05:00pm. Mrs. Janet Walton is now the registered manager and she was available throughout the inspection. She has recently achieved the Registered Care Manager award. Four staff, four residents, two relatives were spoken with and the residents were observed during the inspection. A poster was placed in the entrance of the home to inform residents, staff and visitors to the home that an unannounced inspection was taking place. At the previous inspection comment cards and prepaid envelopes were left at the home so that service users or their representatives can contact the CSCI with their views about the home, one of which were returned immediately. At monitoring visits on the 15th January 2006 to the home relatives had been spoken with and had confirmed that they were satisfied with the level of care at Moorgate Hollow. All of the relatives spoken with had positive comments about the staff members and the care their relative received. There were no complaints received during this inspection. The inspection focused on the requirements from the previous inspection and monitoring visits, four residents files were case tracked along with medication, staffing rota and Adult Protection. What the service does well:
The manager has a background in training and the main focus since she has been in post has been training the staff group. Each staff member has a training profile. Inductions are undertaken and the majority of staff have NVQ level 2 in care or working to achieve the qualification and three care workers have NVQ level 3 with further courses booked. Residents and their families said that they were satisfied with the care that they receive. Care plans have been developed from comprehensive assessments and reviews are undertaken. The manager and the staff group do make every effort to comply with NMS for Older People and with good practice. Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 6 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. Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 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 Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection EVIDENCE: Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 The service users health, social and personal care needs had been taken care of by the staff group. The service users or their representative had been involved in the formulation of their care plans. Staff are working to the company’s policies for the administration of medication, which promotes the wellbeing of the residents. EVIDENCE: Four care plans were checked. Each service user had a care plan where health, social and personal care needs were documented. There were risk assessments identifying the risks and action to be taken to prevent accidents or incidents. There was evidence that there was family involvement within the care plans. Staff liaise with the staff on Rowena Ward, Rotherham Hospital and social workers. There is a formal review at six weeks and at three months Relatives spoken with said that the “staff are good with my mother”, “The bedrooms are lovely and the quality of care is good”, “staff are lovely”. Medications records were examined and found to be correct. Each resident has a medication reassessment at the six-week review. Should a resident require an advocate then the staff would contact relevant outside agencies for example Age Concern.
Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 These standards were not assessed at this inspection. EVIDENCE: Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 The home has policies and procedures to protect service users from abuse. In discussions with residents and relatives they stated they knew how to complain and who to complain to. The home has a clear complaints system, which service users and relatives have used to register their grievances and/or concerns. EVIDENCE: No complaints were recorded since the previous inspection. However, in the past the manager has taken action to resolve complaints and issues. No complaints were given to the inspector relatives and residents had only constructive comments to make about the manager and the staff group. However, at the monitoring visit there was a complaint from two relatives about laundry and this was discussed with the manager. She took action to resolve the problems. All staff has received training on Adult Protection matters and this is on going to ensure all new staff have the same training. During staff interviews it was evident that they understood, respected and promoted the rights of residents at Moorgate Hollow. Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Moorgate Hollow is a purpose built home. The bedrooms were clean, tidy and were personalised. The issues in the cleanliness of the environment have been resolved. EVIDENCE: Corridors have had new lighting fitted. Improvements had taken place in the cleanliness of the building and in the kitchen area of the home. All bedrooms are single occupancy and there was evidence that many of the residents had personalised their bedrooms. Bedrooms were clean tidy and did not have any offensive odours. At the previous inspection relatives said, “ my mother’s bedroom is very comfortable. She is very happy”. The manager said that bedrooms are redecorated when they become vacant. The home is served by a centralised kitchen and laundry, which also serves all three homes Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Staff were employed in sufficient numbers to meet the needs of service users in accordance with agreed staffing levels. A training and development programme was in place, which met the changing needs of service users. EVIDENCE: Rotas were examined and there was sufficient staff for the assessed needs of the residents. All staff undertake induction and then enrol on the NVQ level 2 course. There is a total of fifteen care staff twelve of which have NVQ level 2 with three who have NVQ level 3, which promotes staff development and competence. Training has taken place for example Adult Protection, Health & Safety, Infection Control, Moving & Handling and First Aid. Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 38 The health, safety and welfare of service users and staff are promoted and protected. The manager ensured that staff worked as a team and they receive regular staff supervision sessions EVIDENCE: An application to be the registered manager had been received and was being processed by the CSCI and since the inspection the manager has been registered. Her background has been in training in the care sector and is in the final stages of completion of the Registered Manager Award. Staff said that they felt supported and appreciated by her and the changes that have taken place. Staff said they received support and guidance on a daily basis and formal staff supervision sessions have been started. Monitoring visits take place on a monthly basis by the representative of the parent company. There are records for tests and repairs to the equipment and infrastructure, which confirmed the home’s systems and equipment was found to be satisfactory including recording water temperatures within the home.
Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 15 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 16 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. Standard Regulation Requirement Timescale for action 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 Moorgate Hollow DS0000066110.V287810.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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