Inspection on 16/09/08 for Moorlands Care Home

This inspection was carried out on 16th September 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Moorlands Care Home 02/09/09

Moorlands Care Home 11/04/08

Moorlands Care Home 24/10/07

Moorlands Care Home 11/08/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/11/2008.

CARE HOMES FOR OLDER PEOPLE Moorlands Care Home 104 Church Lane Brinsley Nottinghamshire NG16 5AB Lead Inspector Mary O`Loughlin Unannounced Inspection 16th September 2008 09:30 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 Moorlands Care Home DS0000065350.V372350.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. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moorlands Care Home Address 104 Church Lane Brinsley Nottinghamshire NG16 5AB 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) 01773 781381 managermoorlands@regalcarehomes.com www.regalhomes.com Regal Care Homes Ltd Manager post vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (40) of places Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Regal Care Homes Limited is registered to provide personal care with nursing for service users of both sexes at Moorlands Care Home whose primary needs fall within the following categories :Old Age, not falling in any other category (OP) 10 2. 3. Dementia, over 65 years DE(E) 10 No one under the age of 65 years may be admitted to Moorlands Care Home The maximum number of service users to be accommodated at Moorlands Care Home is 40 11th April 2008 Date of last inspection Brief Description of the Service: Moorlands is a care home providing personal and nursing care for 40 older people and up to 10 people with Dementia. The home is run by a company called Regal Care based in Kent, who purchased the home in August 2005. The home is located in the village of Brinsley close to shops, pubs, the post office and other amenities. The home was opened in 1986 and consists of an extended domestic dwelling. 32 of the home’s bedrooms are single, and all of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors and there is a passenger and stair lift. The home has a large well-laid garden that is well maintained and easily accessible. There is car parking available for 20 cars Fees: £290 - £561 dependent on the individual’s needs assessment and funding arrangements. A copy of the most recent inspection report is made available with the homes statement of purpose. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. A review of all the information we have received about the home was considered in planning this visit including the Annual Quality Assurance Assessment (AQAA), and this helped decide what areas were looked at. The main method of inspection used was called ‘case tracking’ which involved selecting the care plans of 3 people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Members of staff, people who use the service and their relatives were spoken with as part of this visit. A partial tour was undertaken, which included looking at people’s bedrooms and communal areas of the home. As part of a multi agency approach to the issue of safeguarding vulnerable people following the last inspection, we obtained information from external professionals involved in the review and monitoring of practices in the home. We also met with people who live at the home and their relatives and advocates on three occasions. We sent out surveys to people who live at the home and their advocates to obtain their views on the service being provided. The quality rating for this service is 1 star this means that people who use the service experience adequate quality outcomes. What the service does well: People said, “The environment is very pleasant and safe”. “ I have found the care staff to be very caring and loving. My mother can be difficult and they deal with her with good humour and care.” The home provides trained nurses that are on duty throughout the 24hour period. The staff team have the skills and experience to deliver care in accordance with up to date practices. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 6 There is a robust system of recruitment that ensures people who may be unsuitable to work with vulnerable adults are not employed. There is support from trained professionals on the provision of activities for people at the home to ensure that people have opportunities for participating regardless of their degree of dementia or physical disabilities. People in the home benefit from improved infection control practices and safe management of medicines. What has improved since the last inspection? What they could do better: There must be more robust checks made to ensure that staff actually carry out the personal hygiene support and the required mobility assistance to ensure that people receive the care that is planned in accordance with their wishes. The management of alerting all the appropriate agencies and recording all incidents that affect peoples wellbeing must improve to ensure that people are Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 7 protected from harm in accordance with recognised practice in the safeguarding of adults. All staff recruited must have their recruitment file available in the home for inspection at all times. There must be more consideration for the peak times of activity in the home to ensure that people have their needs met at times that are suitable and in accordance with their wishes and best interests or in the case of incapacity in accordance with the wishes of their advocates. 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. Moorlands Care Home DS0000065350.V372350.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 Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3-4-6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of people. Intermediate care is not provided by the home. EVIDENCE: At the last inspection we found that people were admitted to the home without regard for their specialist needs. There was a lack of quality training for staff to ensure that they were aware of current good practice and the outcomes for people being admitted were poor. From discussions with the present acting manager and the provider we found that people are now only admitted when they are confident that staff have the Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 10 skills, ability and qualifications to meet the assessed needs of the person and the home’s registration conditions allow. We identified records of staff training that reflects staff are more skilled and we saw that people have access to appropriate care. People previously accommodated at the home who could not have their needs met have received a review by the social worker and access to suitable specialist services has been enabled or transfer to more suitable care arranged. No new admissions to the home were identified at this inspection. We sent out ten surveys to relatives of people at the home and eight were returned. We asked, “Do you feel that the care home meets the needs of your relative?” Seven people said usually and one said always. Comments include “ She has been well looked after within her nursing needs”, “I have always felt that my mothers needs are met”; We sent out ten surveys to people living at the home and five were returned. We asked, “do you receive the care and support you need?” two said always, two said usually and one said sometimes. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-8-9-10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning has improved and the management of medicines is safe. The delivery of personal care is not sufficiently robust to ensure that people have their hygiene and mobility needs met. EVIDENCE: Responses from surveys we sent to relatives of people living at the home included “not very good with personal hygiene”. Responses from people living at the home included “There never seems to be enough staff on duty at any one time. Some days work out better than others.” We saw improvement in how people have their care planned and saw that people are now consulted on their care and how it is to be delivered. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 12 The management of continence has shown some improvements in the way staff support people by ensuring they have the proper pads and equipment. The management of personal care has improved but shortfalls were still identified in this area, we spoke to one person who said they had not received a bath for some weeks and examination of personal care records upheld this. The person was being washed each day but his personal hygiene was not sufficiently met and nail care was poor. Staff are now more responsive as people’s conditions change and they are referred to appropriate specialists for assessment in a timely fashion, which ensures their safety and wellbeing. People who are at risk of developing pressure sores have suitable equipment to reduce the risk to their health, however the assessment tool which is used by the home differs from the local district nursing teams and we saw two opposing outcomes for each assessment tool for one individual, which is confusing and may not ensure that people are receiving appropriate responses to risks to their safety. One person with mobility problems had a care plan in place to describe how he was to be supported, however the daily records did not reflect what staff did to improve or maintain his mobility and he was not moved from his armchair for long periods and ate his meals in the armchair throughout the day. The management of medicines shows a lot of improvement has taken place, people now receive their medicines at the times prescribed and they are protected from any overly sedating medicines by suitable records of the usage and potential actions of these drugs which guides staff to monitor and report any adverse effects. External medicines are now held securely to protect people from harm. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-13-14-15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are ongoing to ensure that people at the home receive appropriate opportunities to take part in activities that suit them and their capabilities. The delivery of meals does not recognise the significance of the social aspect of mealtimes. EVIDENCE: We sent out ten surveys to relatives of people living in the home and eight were returned. We asked,” Does the care service support people to live the life they choose?” Three people said “always” and five people said “ usually”. Comments include “Non-dementia residents need a better quality of daily life.” We sent out ten surveys to people living at the home and five were returned. We asked, “Are there activities arranged by the home that you can take part in?” Two people said “usually”, one person said “always”, one said “never” and one did not comment. Comments included, “Not well enough”. We also asked “Do you like the meals at the home?” Three said usually and two said always. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 14 We looked at peoples care plans and saw that staff are now obtaining more information on the individual past and present interests of people to help them plan more suitable activities for people. The provider has appointed a qualified Occupational Therapist to spend time at the home and assist in the development of the activities for people. We saw records of a meeting that shows they are considering ways to improve the lives of people with dementia who have difficulty joining in activities, they plan to expand the roles of all staff to ensure they are recording interactions and events that everyone takes part in. Consultation with people is continuing to ensure the best outcomes are achieved for people at the home. We saw that the records of staff on duty did not consider the peak times of activity such as mornings, which may result in delays for some people when needing help to get up. People told us they were happy with the variety of food available and we identified that improvement has now ensured that each person is provided with meals at suitable intervals throughout the day. People requiring special aids for drinking were provided with them to assist them to manage their own drinks. The social aspect of food, its delivery and presentation has not changed, people mostly remain in their armchairs for meals and staff said that this was their choice. People we spoke with could not comment on this. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. People’s concerns are now being taken seriously but the management of the safeguarding of adults needs to be more robust to ensure staff understand their responsibilities. EVIDENCE: We sent out ten surveys to relatives of people living at the home and eight were returned. We asked “Do you know how to make a complaint about the care provided by the home, if you need to?” All eight people said, “Yes”. Comments include “Things have improved lately” We sent out ten surveys to people who live at the home and five were returned. We asked, “Do you know who to speak to if you are not happy?” two said “always”, two said “usually” and one said “never”. There were 3 complaints received prior to the last key inspection that resulted in interagency work through the safeguarding of adults, this is the framework within which all agencies work together in preventing and minimising the risk of abuse to vulnerable adults in Nottinghamshire. All external professionals involved in the care of people at the home and associated responsibilities for health have resulted in action to improve the standards of care that people are receiving at the home. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 16 As a result of the poor outcomes of care that people at the home were receiving Nottingham and Nottinghamshire Councils imposed a suspension on all admissions to the home until appropriate improvements were identified for the protection of people in the home. This suspension has now been lifted. NHS Primary Care Team specialists have attended the home and driven up standards of hygiene and care of continence. The primary care teams lead pharmacist attended the home and initiated formal medicine reviews for people through their Doctor. 3 inspections were undertaken by the Commissions pharmacist to ensure that the management of medicines was improved and safe. Local Authority reviewing officers visited the home and undertook a review of each person living there, which included communicating with each person’s relative or advocate. Since the last inspection the home has received 2 complaints, one that they referred under the safeguarding of adults procedures but failed to notify the Commission of this, the investigation is not completed at this time. The second complaint received by the home show they responded in a timely fashion and took appropriate action. There are now regular meetings held with relatives to ensure issues are being dealt with appropriately. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 17 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): 19-26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment and the control of infection are now suitably managed to protect people from any risk to their health and wellbeing. EVIDENCE: We sent out ten surveys to relatives of people living at the home and eight were returned. Comments include “ My main worry was general cleanliness. This has improved, more carpet cleaning etc.”, “The environment is very pleasant and safe”. We sent out ten surveys to people who live at the home and five were returned. We asked “Is the home fresh and clean?” Two people said “sometimes”, two said “usually” and one said “always”. One person commented, “Mostly a strong smell of stale urine”, Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 18 The Commission has received reports from the NHS Infection Control Nurses who visited the home and worked with staff to improve the standards of hygiene and protect people from infection. Recommendations that were made have been addressed and the home is now much safer for people. The Staff at the home have received training in infection control practices and there have been no outbreaks of infection reported. The partial tour of the building showed that the home is cleaner and safer for people, staff were seen wearing appropriate protective equipment and suitable hand hygiene was observed. The area manager acknowledges that the main lounge carpet is odorous; the acting manager told us that they are in the process of negotiating with the previous supplier and fitters of the carpet to renew the carpet and re-fit appropriately. The main lounge area was less cluttered and there are 2 separate areas as day space, one is being changed into a sensory room and the other is a small dining room. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-28-29-30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are benefiting from an improved staff team who are receiving training in up to date practices but the levels of staff at peak times of activity do not ensure that people’s needs are met appropriately. EVIDENCE: We sent out ten surveys to relatives of people who live at the home and eight were returned. We asked, “Do the care staff have the right skills and experience to look after people properly?” Seven people said “usually” and one person said “always”. Comments included, “Mother likes to be up early but three occasions last week, she had only just arrived downstairs for breakfast at 11.00 am” Long time care assistants are always caring and helpful.” “ I have found the care staff to be very caring and loving. My mother can be difficult and they deal with her with good humour and care.” “This has greatly improved during the day, when two trained nurses are available.” We sent out ten surveys to people who live at the home and five were returned. We asked “Do the staff listen and act on what you say?” All five people said yes. Comments include “There never seems to be enough staff on duty at any one time. Some days work out better than others.” Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 20 The recruitment records of 3 staff were examined, they had been sorted since the last inspection and weeded but they were yet to be in an orderly fashion, the manager is continuing to bring these up to standard. 2 of the files were complete and show robust practice with appropriate checks. The third person was employed at the head office and the records had not been sent to the home. The manager obtained these 24hrs post inspection. Staff at the home have been attending training locally and records show that a lot of training has been updated for long serving staff to ensure they are aware of current good practice when looking after older people. New staff showed me how they were receiving a thorough induction into their role, and said they were being supervised to ensure people were in safe hands at all times. The acting manager has completed work on planning training for all staff and monitoring their skills and competencies through supervision. Staff spoken with said there had been lots of improvement this year; the new acting manager was making a real difference. They said people in the home are happier, they always get their meals on time now and all get supper meals. The duty records did not show that consideration is given to numbers of staff at peak times of activity, which may result in delays in supporting people to get up at suitable times. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager is improving and developing systems that ensure the home is run in the best interests of people living there but there are shortfalls in the competency required to enable her to carry out her responsibilities to safeguard people. EVIDENCE: We sent out ten surveys to relatives of people who live at the home and eight were returned. Comments included “ All we can do is wait and see what the new manager is like.” “ Since the recent problems management has improved 100 ” We sent out ten surveys to people who live at the home and five were returned. One person commented, “ Saw conditions deteriorate just before Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 22 Regal took over, steady improvement since, especially since the new matron has arrived.” The acting manager was reminded at a meeting with us that she must apply to register with us, she confirmed that she has now made the request for the application to register. The acting manager was not fully conversant with her responsibilities around safeguarding adults having failed to notify us of a recent alert. The records of safeguarding adult alerts and outcomes were also not available. The records of newly appointed staff were not available on site as is required by law. All sections of the AQAA were completed and the information gives a reasonable picture of the current situation within the service. Staff told us they felt more supported by the new manager and found her approachable. There are improved systems for seeking the views of people at the home, each visitor is offered the opportunity to complete a survey and we saw how the acting manager uses this information to improve the service offered and write to the person to provide feedback on their comments. Regular committee meetings are now taking place where people can discuss how the home is run and suggest improvements. People at the home do not have their personal finances managed by any appointee at the home. There is provision to keep small sums of money to be held safely and the records of accounting were seen to be robust and protect people from any abuse. There is good improvement on how accidents are responded to, staff complete the required accident forms and then complete a record of the person’s wellbeing every 12 hours for 2 days to ensure that injuries do not go unnoticed. Staff have received refresher training in how to move people safely to safeguard them from harm. The management of Fire risk is appropriately assessed and monitoring of the equipment, alarms and drills is compliant with safety standards. Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 23 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 2 3 Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 24 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 OP8 Regulation 12 (1)(a) Requirement There must be proper provision for the health and welfare of people at the home by ensuring that; 1. Their personal hygiene is met. 2. They receive appropriate support to maintain and improve their mobility. Staff must be fully aware of their responsibilities when dealing with abuse or suspicion of abuse to ensure that people are suitably protected from harm. There must be suitable numbers of staff employed at peak times to ensure that people have their needs met in accordance with their wishes. Recruitment records must be available for inspection to ensure people are being protected by the homes practices. Records of any incident that affects the wellbeing of the people in the home and any related investigation and outcome must be reported to the Commission without delay. DS0000065350.V372350.R01.S.doc Timescale for action 31/10/08 2. OP18 13(6) 30/11/08 3. OP27 18(1)(a) 31/10/08 4. OP29 17 (3) (a)(b) 37 17 Schedule 3 (j) 31/10/08 5. OP31 31/10/08 Moorlands Care Home Version 5.2 Page 25 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 OP8 Good Practice Recommendations Look at the outcomes of the homes pressure sore risk assessment in line with recognised tools to ensure that risks do not go unnoticed and the format is compatible with other risk assessment tools. Look at ways to make mealtimes a more sociable and enjoyable experience for people. Continue to improve the opportunities for social and recreational activities for people according to their individual needs. Identifying photographs should be placed alongside medication chart to assist in ensuring medicines are safely administered to the right person. All medication chart medicine entries should carry full and accurate written dose directions to ensure medicines are given to people as intended by the prescriber. 2. 3. 4. 5. OP15 OP12 OP9 OP9 Moorlands Care Home DS0000065350.V372350.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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