Inspection on 21/03/06 for Moorhead

This inspection was carried out on 21st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Moorhead 04/12/08

Moorhead 17/11/06

Moorhead 06/09/05

Moorhead 24/02/05

Moorhead 01/03/04

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 Moorhead 309/315 Whalley Road Accrington Lancashire BB5 5DF Lead Inspector Mrs Lynn Mitton Unannounced Inspection 21st March 2006 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 Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Moorhead Address 309/315 Whalley Road Accrington Lancashire BB5 5DF 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) 01254 232793 Mmr Care Limited Mrs Diane Hudson Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home must at all times, employ a suitably qualified and experienced manager, who is registered with the National Care Standards Commission The home is registered to provide personal care for service users who fall into the categories of Older People 6th September 2005 Date of last inspection Brief Description of the Service: Moorhead is a detached property within its own grounds, situated on a main road in Accrington. There are car parking spaces to the front of the home. There are attractive enclosed gardens accessible to service users. The home is registered to provide personal care and accommodation for up to 15 older people, over the age of 65. Communal accommodation comprises of two lounges and a separate dining room. Additional seating is also provided in the entrance hallway. The smaller lounge is a designated smoking area. Bedrooms are on three floors. There are 11 single and 2 double bedrooms, 8 of the single rooms and 1 of the double bedrooms have en-suite toilets. In addition, 4 of the single bedrooms have either have en-suite bath or shower. Various aids and adaptations are provided; including hand rails and grab rails. Staff are available, to provide assistance with personal care and support, in response to individual needs/wishes. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately 7 hours. There were 14 residents, plus 1 person receiving respite care accommodated at this time. A tour of the communal area’s home took place. Over the course of the inspection 3 of the staff on duty, approximately 6 residents plus registered manager were spoken to, and interactions between the residents and staff members were observed. Throughout the report there are various references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of service users and care staff. Records pertaining to these people were inspected. Policies and practices were also read. One resident’s relatives had completed the Commission’s comment card, and these indicated that overall they were pleased with the level of service received at Moorhead. The Commission had also received a very complimentary letter from a family member and written independently of the inspection, commenting on how well their mother had been cared for prior to her recent death, that nothing was too much trouble, that the home was well run and always clean and odour free. What the service does well: The admission procedure for new residents ensured that information about their care needs was obtained before they arrived. This enabled staff to have a clear understanding of what they needed to do for them. Residents had opportunities to maintain family links, and they valued this. Residents were given opportunities to exercise choice and control in their day to day living. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean, and mostly free from offensive odours. Staff training was given a high priority at Moorhead. The attitude of the staff and management is to run the home around the needs and choices of the residents. Residents and regular visitors to the home were consulted about the day-today running of the home. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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 Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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): OP1, OP3 & OP6 Written information provided in the statement of purpose and service user guide provided a clear picture of the homes facilities and services, enabling prospective residents to decide if the home was right for them. The admission procedure for new residents ensured that information about their care needs was obtained before they arrived. This enabled staff to have a clear understanding of what they needed to do for them. EVIDENCE: The statement of purpose and service user guide had been updated since the last inspection. These documents now contained information needed for a prospective resident to understand how the home was run and what facilities were offered. Assessments of need were completed prior to new residents being admitted. The inspector saw these on resident’s files. A copy of the homes admission agreement was seen on both care plans’ case tracked. Intermediate care is not offered at this home. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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): OP7 & OP9 All resident’s care and health needs must be appropriately recorded. EVIDENCE: The inspector looked at two residents care plans. On them was some information identifying the resident’s care and health needs and how these should be met. They should then be signed by the resident or their next of kin. A photograph of each resident must be on his or her file. The further development of the care plan format was discussed at the time of the inspection with the registered manager. The inspector noted that the new medication administration system was now in place and working satisfactorily. There were no controlled drugs being administered. The registered manager advised she was awaiting the delivery of a drugs trolley, as promised by the dispensing pharmacy. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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): OP13 & OP14 Residents had opportunities to maintain family links, and they valued this. Residents were given opportunities to exercise choice and control in their day to day living. EVIDENCE: One resident said; “ We get lots of visitors here”, another told the inspector, “Visitors can come anytime, they never turn anyone away”. The visitors book was being completed. The inspector noted that privacy was afforded to service users when visitors were discussing private matters. The visitors policy was seen. The inspector observed resident’s exercising choice and control over day-today elements of their lives, for example, getting up at different times and having a choice of meals at lunchtimes. Care staff were seen to respect residents choices and opinions. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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): OP16 All versions of the homes complaint procedure must be in accordance with this regulation. EVIDENCE: The complaints procedure was seen posted in the homes entrance foyer and minor discrepancies between that and other versions of the complaints procedures seen in the home were discussed with the registered manager. The last complaint recorded was in August 2004. The inspector and registered manager discussed how the homes “complaints and suggestions” book should also include space to record how the complaint was resolved/what action was taken. The inspector spoke to two care staff who advised the inspector of what they would do if a complaint was made to them. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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): OP19 The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean, and mostly free from offensive odours. EVIDENCE: The inspector and registered manager discussed the proposed plans to extend Moorhead with a further 10 beds. A tour of the home took place. Other than ongoing maintenance tasks, no refurbishment work had been undertaken since the last inspection. Cleaners were employed for 22 hours each week. The sleep-in room had been re-located and one radiator had been moved. All residents’ rooms were personalised. The odour management of two residents’ rooms was discussed. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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): OP29 & OP30 All procedures for recruitment of staff and checks to safeguard residents must be in place. Staff training was given a high priority at Moorhead. EVIDENCE: Two care staff’s personnel files were examined and it was found that they mostly had the information required to evidence that staff had been employed in accordance of that required by the Commission. Omissions were discussed with the registered manager. The inspector was advised that a trainee care staff had been employed to complete such tasks as playing games with the residents, answer the front door and make drinks for residents and visitors. The inspector was advised that all care staff except one had obtained NVQ2 training qualification. A training matrix was in place and this needed updating in order to demonstrate that all care staff had recently completed fire safety training. All care staff were undertaking Infection control training, this would be completed by June. 4 care staff were due to undertake moving and handling training in April. 4 care staff had completed safe administration of medication training. Some care staff needed to complete their health and safety training and food hygiene training. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 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): OP31, OP33, OP35, OP 37 & OP38 The attitude of the staff and management is to run the home around the needs and choices of the residents. Residents and regular visitors to the home were consulted about the day-today running of the home. Policies and practices must be reviewed and updated as required in order to make sure that correct information is available to staff. Risk assessments and a management framework must be completed to enable residents to take responsible risks. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 15 EVIDENCE: The inspector was advised that the registered manager had completed the Advance Management City & Guilds 3253 training qualification. The registered manager was very experienced in meeting the needs of older people. The inspector was advised that a service users, visitors and visiting professionals survey had been very recently sent out – its findings had not yet been collated nor published. The registered manager was not appointee for any resident, the inspector was advised that all other residents finances were dealt with by the residents themselves, their next of kin or families. From the last inspection, the inspector noted that the homes policies and practices had not been dated nor signed off by the registered manager. Also from the last inspection, risk assessments on care plans did not explain in detail, how, once the risk had been identified, the risk was to be managed and what action to be taken in order to minimise the risk. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 16 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 X 9 10 11 2 X X X X X X X STAFFING Standard No Score 27 28 29 30 3 X X X X 2 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 18 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 1. OP7 15, All service users must have fully 28/07/06 17(3a) completed care plans in place. The service users, and their family must be fully involved in the ongoing development of these care plans, and agreed and signed. Care plans must set out in detail the action which needs to be taken by the care staff to ensure how all aspects of health, personal and social care needs are met. 2. OP29 19 The registered person must 28/07/06 operate a thorough recruitment process at all times. 3. OP38 13(4) The registered person shall 28/07/06 ensure, that all parts of the home are so far as practicable, are free from hazards to health and safety, unnecessary risks are identified and eliminated. (Risk assessments) 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 Good Practice Recommendations Standard 1. OP19 Odour management procedures should be reviewed. 2. OP37 The home policies and practices should be regularly reviewed and updated as needed. Moorhead DS0000009447.V281558.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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