Inspection on 06/09/05 for Moorhead

This inspection was carried out on 6th September 2005.

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 21/03/06

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 6th September 2005 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.V252039.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. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Moorhead Address 309/315 Whalley Road Accrington Lancashire BB5 5DF Telephone number Fax number Email 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.V252039.R01.S.doc Version 5.0 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 24th February 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.V252039.R01.S.doc Version 5.0 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 accommodated at this time. A tour of the communal area’s home took place. Over the course of the inspection 4 of the staff on duty, approximately 6 residents plus the senior care staff on duty were spoken to, and interaction between the residents and staff members were observed. The registered manager was not available at the time of the inspection, however, a ‘phone conversation did take place. 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. Records pertaining to these people were inspected. Policies and practices were also read. Six 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. What the service does well: One resident’s relative said “The staff are very attentive, tolerant and make visitors very welcome with a nice cuppa!” By observations made and speaking to residents and visitors it was felt that care staff knew resident’s needs well and that these were being met at the home. Another residents visitor said “I found that the staff at the home were attentive to my grandmother’s needs when she was ill, they spoke regularly on the ‘phone and managed the situation professionally. Consequently she has made a good recovery”. Many of the care staff team had considerable experience in caring for older people, and were well established, ensuring continuity for residents. Regular planned activities ensured that residents were stimulated and had opportunities to try new things. Staff spoken to were aware of the procedures to follow in order to protect the residents in their care. The home was clean, tidy, warm and free from offensive odours. Ten out of twelve care staff had completed training to ensure that care staff had the skills required to care for the residents. The remaining two staff were due to undertaking this training. Moorhead DS0000009447.V252039.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. Moorhead DS0000009447.V252039.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 Moorhead DS0000009447.V252039.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): OP1 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. EVIDENCE: The statement of purpose and service user guide had been updated since the last inspection. These documents now contained most of the information needed for a prospective resident to understand how the home was run and what facilities were offered. Minor amendments were needed in order to fully meet this standard. Moorhead DS0000009447.V252039.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, 8, 9 & 10 Care plans could contain more detail to ensure that all care needs were identified and care interventions documented. Care plans were being reviewed regularly to ensure that up to date information was available. Residents were treated with respect and dignity, and their right to privacy was being upheld. A new system was being introduced which would improve the procedural safety of the administration of resident’s medication. EVIDENCE: One resident said “ I like it here, they’re (the care staff) very kind”. Another resident said, “The carers are lovely”. The inspector looked at two residents care plans. Some information was available identifying resident’s care and health needs and how these should be met. These will be looked at again at the next inspection. Daily records were also seen. The care plan had been reviewed within the past month. There were records made of visits by medical professions, e.g., the doctor and the podiatrist. Residents were registered with a GP of their choice from the local practice. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 10 New seated weighing scales had recently been ordered. Monies to pay for these had been raised by a sponsored walk by residents and staff. From the inspector’s observations and speaking to residents and visitors it was felt that staff knew resident’s needs well and these were being met at the home. Residents were spoken to in a respectful and dignified manner by the care staff team on duty. Care staff were observed to ensure residents privacy by knocking on bedroom doors and whilst giving personal care. Care staff spoken to could give examples of how they made sure that resident’s privacy was ensured. One visitor to the home commented, “The residents shower room is open for visitors to use the toilet”. The inspector advised that one resident who prefers to sit in her wheelchair all day must have this documented in the care plan and a risk assessment completed accordingly. The inspector was advised that a new medication system (Venalink) and pharmacy supplier was being introduced. It was planned that a new drugs cabinet would be purchased. The controlled drugs administration book was seen and on some occasions a second signature had not been entered. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 11 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 A regular programme of planned activities ensured that residents had opportunities for their enjoyment, mental and physical stimulation. Meals were varied and provided a social occasion on a daily basis. EVIDENCE: A weekly activity programme was in evidence. This included activities such as movement to music, dominoes, quizzes, video’s and visiting entertainers. Residents spoken to told the inspector that they enjoyed participating in these activities. The inspector observed one resident decorating charity boxes with wrapping paper. There was a tuck shop in operation, enabling the residents to buy sweets and other miscellaneous items. In June 2005, the homes garden had been upgraded to include a decking area. The residents told the inspector how much they had enjoyed sitting out in this area during the summer. It is hoped that a fishpond will be built in the garden during the next few months. Service users meetings were being held every three months and minutes of these meetings were taken. The inspector noted that lunch served on the day of the inspection was a pleasant social occasion. Varied meals were offered to residents with different dietary needs. There was record made of meals served, however, on Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 12 occasions some meals had not been recorded. Residents told the inspector that there was a choice of meals always on offer. One resident said, “The food here is delicious”. Another said, “The food is very good”. The cook on duty had completed advance food hygiene training, and was committed to offering a good service to the residents at Moorhead. Although the kitchen looked tired, it was in an acceptable condition and all the appliances were working satisfactorily. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 13 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): 18 Staff spoken to knew how to protect the residents in their care. The written procedures for responding to an allegation of abuse were in place, and staff were aware of the procedures to follow. EVIDENCE: Two care staff spoken to by the inspector could define the different types of abuse. They knew what to do, if they had any concerns about resident’s wellbeing, and had an awareness of the whistle blowing policy. The inspector advised those staff that they could come to the Commission at any time if they had concerns. Documentation was in place for protecting residents from abuse of any kind. The inspector advised that policies of this kind should be signed and dated by the author and that all care staff sign to say they have read and understood the contents. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 14 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): 26 The layout and décor of the home was suitable for the residents accommodated and provided comfortable surroundings. The home was clean, tidy, warm and free from offensive odours. EVIDENCE: One resident said “I’ve got a lovely room with my own TV”. Another said, “My room is nice and comfy”. Bedrooms had been personalised and made to suit individuals needs and tastes. On the day of the inspection, the home was found to be clean, tidy, warm and odour free. The gardens to the front and rear of the home were well tended, and residents advised the inspector that they enjoyed sitting out on sunny days. The home appeared well maintained. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 15 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 & 28 The number of staff on duty should reflect the needs of the residents. This must be reviewed on a regular basis. Training had been undertaken to ensure that care staff had the skills to care for the residents. EVIDENCE: One visitor to the home commented, “In the early evening, when residents are being put to bed, there is not always sufficient care staff to leave a member of staff downstairs with the other residents or to answer the door”. Another wrote, “From 4pm onwards there are not sufficient staff numbers on duty”. This issue was discussed with the registered manager, as it had been an outstanding recommendation from the last inspection, and the inspector was advised that this situation was under regular review. The staffing rota was seen, there were 4 staff on duty at the time of the inspection, this included one extra staff member who was a new appointment, and was shadowing an experiences staff member. In the evening, there were two care staff on duty. At night time there was 1 wake and watch staff member and one sleep-in staff member on duty. Many of the care staff team had considerable experience in caring for older people, and were well established at Moorhead. There were cooks, cleaners and a handy man also employed. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 16 Out of the 12 care staff, 10 had completed their NVQ 2 training and 2 were undertaking this training at the time of the inspection. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 17 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): 37 & 38 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. EVIDENCE: There was a policy manual in place, however a number of these had not been reviewed and include out of date information. As previously mentioned, it was advised that policies should be signed and dated by the author and that care staff sign to say they have read and understood the contents. There was a weekly risk assessment of the building, completed by the registered manager. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 18 The registered manager and deputy of Moorhead had completed risk assessment and health and safety training courses. An independent body had undertaken a Fire risk assessment of the home. The homes fire system had last been independently checked on 1st September 2005. The last fire drill had been in May 2005. A combination keypad lock had been fitted to the front door since the last inspection to ensure the safety of residents. Accident records were seen, however in accordance with the Data Protection Act, one a form has been completed, they should be kept on each persons individual file, not kept in the book, as they were at the time of the 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. It was noted that a number of falls had been recorded during the night for two residents. The inspector discussed with the senior carer on duty how this was being managed and that increased nighttime checks must be included in the residents care plan. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 19 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 2 X X X X X 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 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 2 Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4,5 & 6 Requirement The statement of purpose and service user guide must be fully compliant as outlined in the Care Home Regulations. Timescale of 31/07/04 not fully met) All service users must have fully 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. Controlled Drugs Record Sheets must be fully and correctly completed at all times. Evening staffing levels be must reviewed and amended accordingly, to ensure service users needs are appropriately and safely met. The registered person shall ensure, that all parts of the home are so far as practicable, are free from hazards to health DS0000009447.V252039.R01.S.doc Timescale for action 30/12/05 2 OP7 15, 17(3a) 21/12/05 3 4 OP9 OP27 13(2) 18(1a) 06/12/05 21/12/05 5 OP38 13(4) 30/12/05 Moorhead Version 5.0 Page 21 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. 1 Refer to Standard OP37 Good Practice Recommendations The home policies and practices should be regularly reviewed and updated as needed. Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Moorhead DS0000009447.V252039.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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