Inspection on 31/01/06 for Moorlands Nursing Home

This inspection was carried out on 31st January 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

Moorlands Nursing Home 11/11/08

Moorlands Nursing Home 11/03/08

Moorlands Nursing Home 10/10/06

Moorlands Nursing Home 07/07/05

Moorlands Nursing Home 14/12/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Moorlands Nursing Home Macdonald Road Lightwater Surrey GU18 5US Lead Inspector Pat Collins Unannounced Inspection 12:10 31 January 2006 st 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 Nursing Home DS0000061257.V250873.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. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Moorlands Nursing Home Address Macdonald Road Lightwater Surrey GU18 5US 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) 01206 828 290 01206 828 291 Moorlands (Lightwater) Ltd Ms Kathleen Henrietta Buckley Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (1), Terminally ill (1) of places Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user to be accommodated within category Physical Disability (PD) One named service user to be accommodated within category Terminal Illness (TI) 07 July 2005 Date of last inspection Brief Description of the Service: Moorlands Nursing Home is a care home for older people. Service provision includes permanent, convalescent, respite and palliative care. The home is one of a group of seven care homes operated by the same organisation in Surrey. The home is part of a wider network of homes operated nationally by this organisation. The building dates back to the early 1900’s and is set in its own grounds. It has been modernised and converted over the years, retaining original features, which adds character to the environment. Bedroom accommodation is arranged on two floors, accessible by stairs and a passenger lift. Single and shared occupancy bedrooms are provided of which twenty-five are en suite. The home has two large communal lounges and a dining room on the ground floor. These are tastefully decorated and comfortably furnished and overlook attractive garden areas. A full time registered nurse-manager is responsible for the home’s management, providing leadership and direction to the staff team, which includes qualified nurses. The home is situated within one mile of Lightwater village and is easily accessible to all community amenities. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the home by the Commission for Social Care Inspection (CSCI) in the year April 2005 and March 2006. This inspection was unannounced, meaning staff and service users were not notified in advance of it taking place. One inspector carried out the inspection over a six and a half hour period. The home’s registered manager and deputy manager were present throughout the inspection. The regional director, who is the named responsible individual, was present for the latter part. The inspection process involved follow up of requirements from the last inspection report. Practice observations were undertaken focusing on meal times, medication and social care activities. A partial tour of the premises was also carried out and record keeping was sampled. Discussion took place with managers, three nurses and three care assistants. Six service users were also consulted as part of the process. The inspector also spoke with a visiting podiatrist and a relative. Information contained in three comment cards received after the inspection also informed the inspection outcomes. The inspector would like to express appreciation to all service users and staff for their hospitality and co-operation during the inspection and thank those who contributed information. What the service does well: The atmosphere of the home was warm and welcoming at the time of the inspection. Staff on duty were aware of service users care needs. Feedback from individual service users demonstrated overall satisfaction with standard of care and the day-to-day operation and management of the home. Contact between service users and their families and friends was facilitated and encouraged. Positive links existed between the home and the local community and arrangements in place for meeting religious needs. An activities coordinator was employed and a stimulating programme of activities was on offer. Service users enjoyed group activities in the lounge on the day of the inspection. The environment was stimulating and the activity organiser was observed to encourage and promote social interaction between service users. A service user and her relative were consulted on their return from a shopping trip. Both expressed positive comments about the home. The environment was well maintained, clean and odour control was well managed. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 6 Medication practices were mostly satisfactory. Staff were observed to be respectful in their approach towards service users, demonstrating patience and kindness. They ensured provision of assistance where necessary to service users at meal times. What has improved since the last inspection? What they could do better: Observation of care documents confirmed this was an area for further development. It was evident that management had made progress in raising standards of record keeping and in care planning though further improvement was required. Observations identified some omissions in generating care plans from risk assessments relating to nutrition, pressure sore prevention and falls. Attention was drawn also to the need to record specialist advice specific to manual handling practices in a care plan. The importance of documenting equipment essential for meeting individual needs in care plans was discussed. This was necessary for promoting safe practice and continuity of care. Minor shortfalls in practice were specific to infection control and medication practices. Also in relation to pressure sore prevention assessments it was evident that nurses and management required further training in the use of the corporate tool for this purpose. The requirement for variation of the home’s conditions of registration was discussed. This was necessary to reflect a significant change in service provision, specifically changes in the primary condition of individuals accommodated. Also to enable management to flexibly respond to market demands. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 7 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. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 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 Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4. The inspector was impressed by the availability and quality of written information about the home. Prospective service users, with the help of their family and friends, were enabled to make an informed choice on whether the home would be a suitable place to live. Admissions were based on comprehensive needs assessments. EVIDENCE: The home’s Statement of Purpose and Service Users Guide documents were accessible to prospective service users and their representatives. These were held in a binder on a table near the main entrance, together with other relevant informative documents. These included the latest inspection report, complaint procedure and quality assurance feedback. The Statement of Purpose contained all statutory elements. A copy of the Service Users Guide was available in all bedrooms. The home admits privately funded service users and those sponsored by social services. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 10 A completed pre-admission assessment form was available on the file sampled. This comprehensively detailed a full assessment of needs carried out prior to admission to be assured needs could be met. Individuals referred through agencies funding their care had copies of care management (health and social services) assessments and related care plans on file, also obtained prior to admission. The admission procedures included assessment of risk of developing pressure sores, also nutrition, falls and manual handling risk assessments. Records included history of medical issues and of community health care professionals’ involvement in the care of service users. Relatives were consulted where appropriate for the purpose of obtaining a social history. Details of personal interests and likes and dislikes were also collated. Service users admitted on an emergency basis were stated to be also subject to comprehensive assessment processes. Shortfalls in care documents sampled relating to risk assessments and care planning were discussed with management and nurses. The manager informed the inspector that internal auditing systems had identified the need for improvement in this area of the homes activities. Whilst this was recognised by management it was also emphasised to the inspector that significant strides had been made recently in raising standards. It was positive to note that admission procedures ensured service users relatives/representatives wishes were established relating to preferences for involvement in care planning. This was with permission of service users where practicable. Discussed was the benefit of clarifying also the desired frequency of that involvement. This will offer opportunity to those who wish to engage in discussions with nurses about the care of their relative/friend in a constructive, positive forum. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9. Evidence gathered demonstrated that these standards were nearly met. Service users health, personal and social care needs were mostly documented. Improvement was necessary to risk assessment and risk management record keeping and to elements of infection control practice. Medication practices were mostly satisfactory. EVIDENCE: Consultation with service users able to express their views confirmed general satisfaction with the standard of their care; also with the day-to-day operation of the home. Practice observations confirmed due care and attention to the appearance and dress of service users. Positive relationships were noted to have been formed between individual service users and staff members. Responsibility for care planning was delegated to named nurses who were responsible for care planning for up to ten service users. The care documentation sampled was well organised and mostly comprehensive. This included needs and various risk assessments. A computer generated care plan had been modified to reflect individual needs. The care plan format was stated to be a relatively recent development. Review periods for care plans were variable and not all at least monthly as required. Observation made of records Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 12 identified some shortfalls in record keeping specific to nursing care. It was identified that care plans were missing though record index’s indicated their existence. On occasions care plans had not been generated, though necessary, from outcomes of nutritional, pressure sore and moving and handling risk assessments. The need to produce a care plan specific to the professional advice obtained for moving and handling a service user being nursed in bed was also identified. For another individual a care plan was not in place to address assessed needs for maintaining mobility. Discussions with management included practice for ensuring service users were adequately hydrated. It was noted that fluid balance charts were available, their use based on clinical judgement. Weight monitoring practices were noted and records of weights were maintained. The assessment tool used to aid identification of risk of developing pressure sores was incomplete on a number of files sampled. Consultation with managers and nurses in this matter identified further training was necessary in the use of this tool. Despite this shortcoming observations demonstrated sound professional and clinical judgements by nurses and managers for the prevention and management of pressure sores. A range of pressure relieving mattresses and cushions were available. The incidence of pressure sores occurring in the home at the time of the inspection was low. An effective treatment plan was in place for an individual with a pressure sore present on admission. Wound care refresher training for nurses was being planned in consultation with a tissue viability specialist nurse. Individual nurses were stated to have made their own arrangements to update their practice and had received training in the past from medical supplies representatives. Service users were registered with general practitioners (GP). A summary of the outcome of GP’s visits was maintained individually in service users records. Feedback in a comment card returned by a GP confirmed clear communication and effective partnership arrangements between the home and that GP. The GP was satisfied with the overall care provided by the home to his /her patients. Information received however suggested the need to clarify GP’s expectations of senior staff when they visit. The GP perceived that there was not always a senior member of staff on duty to confer with. The records demonstrated that there is always a senior member of staff on duty however. A qualified podiatrist present in the home at the time of the inspection stated staff had a clear understanding of the care needs of service users; also any specialist advice she gave was incorporated into care plans. In her experience when she visited there was always a senior member of staff available to consult. Observations confirmed satisfactory practice specific to prevention of cross infection. Universal infection control procedures were being followed. Sluice Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 13 rooms were clean and sluice machines were operational and being used. Protective clothing and gloves were accessible to staff and suitably disposed of after use. Attention was drawn to the need to discreetly mark toothbrushes belonging to service users in shared bedrooms. These were kept in separate, unmarked holders by washbasins. Medication management was underpinned by clear, unambiguous corporate policies and procedures. Medicines and keys were stored securely. Medication storage was at a premium however and provision did not include a clinical room. Separate lockable storage was provided for medicines for internal use and those requiring cool storage. Suitable storage was available for controlled drugs. Observations identified omissions in dating eye drops when opened. Discussion took place with the manager regarding the practice for prescribed creams for external use being stored on open shelves in bedrooms. A risk assessment specific to this practice is recommended. Attention was drawn also to pots of cream in two bedrooms, one of which was a shared room, without pharmacy labels. A monitored dosage medication system was used. A recent change of supplier was noted and staff were in the process of changing over from the old system to the new one. For these reason photographs of service users had not yet been transferred to the new MARR charts. This deputy manager confirmed her intention to imminently do so. Medication administration practices observed were satisfactory. It was positive to note a system of assessed practice for medication administration for all new nurses as part of their induction programme. The standard of record keeping at the home ensured an audit trail of medication and complete accountability for medication practices. Suitable disposal arrangements for medication were in place. Though a homely remedies list of medication was noted the deputy manager confirmed a limited stock held, as medication was mostly individually prescribed. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 Management and staff demonstrated strong commitment to the provision of an enabling environment, which promoted opportunities for service users to lead fulfilling lifestyles. The therapeutic value of regular contact with family and friends was recognised in the home’s operation and visitors made welcomed at the time of the inspection. Service users were offered and encouraged to maximise individual capacity, enabling personal autonomy and choice. EVIDENCE: The care records sampled contained information regarding service users social, cultural, religious and recreational interests. A full time activities coordinator was employed and was on duty at the time of the inspection. Though time pressures inhibited direct consultation with the activities coordinator on this occasion, observations concluded provision made of a varied, stimulating activities programme. Records confirmed a budget available for funding activity materials, equipment and for entertainment and social events. This budget was supplemented by fund raising activities coordinated by staff and some relatives. At the time of the inspector’s arrival, service users had just finished a group exercise session with the home’s physiotherapist. In the afternoon activities in the dining room were facilitated by the home’s activities organiser. These Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 15 included a game of bingo and art and crafts. The atmosphere in the lounge where these activities took place was stimulating. There was much laughter and the service users involved appeared to benefit from the lively conversation. Other service users were sat either in their bedrooms or in other lounges. Some were unoccupied others were watching televisions or reading. Staff were observed to ensure regular observation visits to these individuals. During the inspection service users received visitors, who were able to come and go as they pleased. Some met with their visitors in their bedrooms and some met in lounges. Relationships between staff and visitors on the day of the inspection were appropriately informal and friendly. No restrictive practices were observed. Nurses and care staff were courteous and respectful towards service users. A number of the staff employed were from overseas and English was not their first language. Staff on duty had varying levels of command and comprehension of the English language. The manager stated the home’s policy was for staff to speak in English at all times when on duty. It was confirmed this policy was regularly reinforced through verbal reminders at handover and staff meetings. At the time of the inspection the manager was investigating a complaint from a relative in which it was alleged that staff had been disrespectful to service users by communicating with each other in their own language. Staff communicated in English in the presence of the inspector. The manager advised the inspector of arrangements for staff to attend college for English lessons. It was stated that places were limited however. A conversation later with a care assistant who had difficulty in communicating in English confirmed she was not enrolled on a language course and was unaware of the opportunity to do so. Care practice was observed to maximise independence at meal times. Effort was made to promote and maintain eating skills through verbal prompting and provision of suitable aids. Staff assisting service users to eat were patient and encouraging in their approach and attitude. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home’s complaint policy was to welcome comments and suggestions from service users and visitors and to promptly respond to complaints to seek a suitable resolution. A copy of the complaint procedure was included in the service users guide issued to all service users and their representatives. A record of complaints was maintained. EVIDENCE: The home had a comprehensive complaint procedure a copy of which had been issued to all service users and/or their representatives. A copy was also displayed in the entrance hall and complaint/suggestion forms were openly accessible in this location. Discussions with the manager confirmed informal communication systems operating to inform her of dissatisfaction expressed by either service users or visitors and of action taken by staff in response. The home had a complaints/compliments folder. There were records of two written complaints received by the manager since the last inspection. One was currently under investigation and the progress of the investigation discussed at the time of the inspection. The complainant and the care manager had recently met with the manager to agree an action plan and discuss the issues. The other complaint had been fully investigated and the regional manager and the manager had met jointly with the complainant to discuss expectations and action proposed. Whilst the Commission for Social Care Inspection had been made aware of these two complaints the investigations were carried out under the home’s complaint procedure. The complaint procedure was operating effectively. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 17 The home holds regular service user support meetings. Family members/representatives of service users were encouraged to attend, in order that they had opportunity to express their views and raise general issues. An open door policy was operating for service users and relatives/visitors to raise any concerns with the manager. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. The environment was overall safe, well maintained, clean and comfortable. Facilities were suitable to ensure the home was ‘fit’ for its stated purpose. EVIDENCE: The grounds included car-parking facilities. The large garden was safe and well maintained and accessible to service users. There were plans under discussion to further enhance the garden environment later this year. The entrance hall/reception area was warm and welcoming and details of the person in charge were displayed. Communal areas were spacious, attractively decorated and comfortable. The dining room included a coffee lounge and was used also for activities. Bedroom accommodation, some with en suite toilet facilities and two with en suite showers, was mostly single occupancy, though some shared bedrooms were available. These were supplied with privacy curtains or screens. Bedrooms were comfortably furnished in compliance with the national minimum standards. Though locks were not routinely fitted to bedroom doors Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 19 and a lockable facility not provided as standard in bedrooms, the manager stated that admission procedures routinely offer the option of both facilities. Suitable aids, adaptations and equipment were provided to meet the individual needs of service users with physical or sensory impairments. Bedrails and bed bumpers were also available, subject to written consent and robust assessment of risk. Whilst a number of service users were accommodated with varying degrees of dementia, the design and layout of the premises was not intended to provide a specialist dementia care environment. The home would not be suitable for people requiring a secure garden. Telephone facilities were available for service users’ use and the emergency call system was accessible. A positive additional feature linked to the call system was the facility to activate a light outside rooms, which served to enhance privacy. This light indicated staff were engaging in the delivery of personal care. This facility was also useful for quickly locating staff if necessary. Suitable bathing facilities were provided comprising of two wet rooms and a height adjustable bath with hoist. Moving and handling equipment also included sling hoists and other aids. One of the wet rooms was used by the hairdresser and contained two basins fitted with shower sprays. Staff facilities and lockers were available and a multi – purpose room used for meetings and staff training. Catering facilities were not inspected on this occasion. Sluice facilities were available, one on each floor. The laundry equipment comprised of three washing machines and two industrial dryers and a smaller dryer. The laundry assistant was on long-term leave and interim arrangements were in place to cover laundry duties. There had been recent problems with clothing being put away in wrong wardrobes, mainly at weekends. The manager advised this had been reviewed and an agreed action plan was in place to remedy this problem. The manager confirmed consideration being given to the purchase of individual laundry bags for service users’ personal laundry items. The domestic assistant deployed on laundry duties at the time of the inspection confirmed she had received training in manual and handling and in COSHH. Procedures and practices in the laundry minimised risk of cross infection. A Housekeeper was responsible for the home’s domestic staff. A good standard of cleanliness and hygiene was observed in all areas inspected and odour control was well managed. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The staff training programme demonstrated a rolling programme of statutory training. Some service specific training needs were unmet and an action plan for this training was in place. EVIDENCE: The organisation had a regional training manager responsible for ensuring the staff training programme meets statutory and service specific training needs. All training is provided free of cost to employees who are paid whilst attending training courses. Staff were encouraged and enabled to take responsibility for their own professional development. Discussions with staff confirmed clarity of their roles and responsibilities. There was evidence of core training needs being met through the home’s training programme. A training audit tool had been used to identify team and individual future training needs and an action plan produced to ensure training needs were met. Dementia awareness training was planned for the team. A recent development was a training package produced to further develop the knowledge and skills of managers. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 38 Overall the management of the home was considered to be efficient, based on all available information. The requirement at the time of the last inspection for application to be made for variation of the home’s conditions of registration had not been met. Discussions with management confirmed this was now being addressed. Business management procedures appeared effective and quality assurance systems were operating. EVIDENCE: The management structure comprised of a senior group of managers who were suitably experienced and qualified to ensure competence in the performance of their roles and responsibilities. A deputy nurse/manager, a senior sister, and managers responsible for housekeeping, catering, maintenance and administration services supported the home manager. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 22 The home manager was a registered general nurse with extensive, relevant clinical and management qualifications and experience. The manager was registered with the Commission for Social Care Inspection. Observations suggested a cohesive management group and that overall management and administration systems were effective. Discussion took place with the regional manager and the home manager on the outstanding requirement to vary the home’s conditions of registration. This was necessary on the basis of a significant change in service provision, namely a number of service users accommodated stated to have a diagnosis of dementia. It was agreed that application would be made following a fundamental review of categories to ensure these are suitable for the home’s current operational and marketing needs. Consultation with management, staff and individual service users confirmed quality audit and monitoring systems were operating. These served to measure the home’s performance and success in meeting its stated purpose and service aims and objectives. The latest annual service users feedback from questionnaires sent to service users last year was not seen on this occasion. The manager informed the inspector that there was an annual development plan in place for the home. The regional director carried out monthly provider visits in accordance with statutory requirements and reports generated from these visits were sent to the manager and CSCI. The manager informed the inspector of her responsibility for the home’s budget. A capital expenditure five-year plan was managed by head office. Observations confirmed employer and public liability insurance was in place. Requirements made in respect of health and safety shortfalls at the time of the last inspection had been met. The central record of staff training indicated that staff were in receipt of a programme of training to ensure safe working practices. No other records were viewed in relation to standard 38 on this occasion. A tour of the premises confirmed that the environment was mostly free of hazards. Radiators were covered and windows suitably restricted. Hot water temperatures in bathrooms/bedrooms were sampled and found not to be excessively hot. Attention was drawn to the need to securely store products used by the hairdresser on an open shelf in the room used for this purpose. Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 X X X 2 Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 24 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 OP30OP8O P7OP3 Regulation 12(1) 13(4) 15(2) Requirement Timescale for action 31/03/06 2 OP9OP8 13(2)(3) 3 OP30OP8 14(1)(a) 18(1)(a) 4 OP31 CSA2000 sct15 For admission assessment procedures to include all relevant risk assessments in accordance with the organisations policies and procedures. Risk management must be underpinned by care plans and risk assessments and care plans regularly reviewed in line with Regulations 12(1)(a), 13(4)(c) and 15(2)(b) of The Care Homes Regulations 2001. For eye drops to be marked with 01/02/06 the date of opening and pharmacist labels to be on external creams and ointments stored in service users bedrooms. Nursing staff must receive 31/03/06 additional training to support them in interpreting the pressure sore risk assessment tool in use. Additionally all staff require dementia care awareness training. For submission of an application 01/05/06 for variation of the home’s categories of registration to reflect significant change in the DS0000061257.V250873.R01.S.doc Version 5.1 Moorlands Nursing Home Page 25 5 OP38 13(4) 6 OP30OP1 13(4) home’s operation. The storage of external creams 07/02/06 and ointments on open shelves in bedrooms should be subject to risk assessment. For hairdressing products to be 07/02/06 securely stored when not in use. 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 OP3OP16 Good Practice Recommendations To clarify relatives/advocates (where appropriate) preferences for their involvement in the process for reviewing care plans. This practice offers a constructive approach to addressing any queries and concerns and could be further developed. There should be a discreet method for identifying toothbrushes for service users occupying shared bedrooms. 2 OP8 Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Moorlands Nursing Home DS0000061257.V250873.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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