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Inspection on 17/11/05 for Moorleigh Nursing Home

Also see our care home review for Moorleigh Nursing Home for more information

This inspection was carried out on 17th November 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a clean, safe and comfortable environment for residents. The atmosphere is relaxed and friendly and residents were happy with the care they receive. Residents said staff were kind and caring and one resident said they are "marvellous". There are enough staff to meet residents needs and a very good training programme supports staff in understanding and meeting residents` needs. The home holds the Investors in People Award, the award recognises the commitment made to staff training and development.

What has improved since the last inspection?

The unguarded radiators have been replaced with Low Surface Temperature radiators. Door closing devices that are activated by the fire alarm system have been fitted to many of the bedrooms doors and more have been ordered so that residents who prefer to have their bedroom doors open are able to do this safely. A complaints log is now available giving details of any complaints received and the action taken to deal with them.

What the care home could do better:

One of the showers on the first floor is still regularly out of use because of problems caused by leaks despite the fact that several attempts have been made to find a permanent solution to this problem. While it is acknowledged that the home has the recommended number of bath/shower facilities for the number of residents without this shower efforts to find a solution should continue so that residents have a greater choice of bathing facilities.

CARE HOMES FOR OLDER PEOPLE Moorleigh Nursing Home 278 Gibson Lane Kippax Leeds Yorkshire LS25 7JN Lead Inspector Mary Bentley Unannounced Inspection 17th November 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 Moorleigh Nursing Home DS0000001358.V264872.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. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Moorleigh Nursing Home Address 278 Gibson Lane Kippax Leeds Yorkshire LS25 7JN 0113 2863247 0113 2872989 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) Brampton Meadow Limited Mrs Rosemarie Holt Care Home 36 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (36) of places Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for DE(E) is for the use of the service user named in the variation application V17005 only 8 June 2005 Date of last inspection Brief Description of the Service: Moorleigh is a detached property situated in the village of Kippax. It is next door to the Health Centre and within a short walking distance of local shops and amenities. The village has bus routes linking it with Leeds, Castleford and Wakefield. Moorleigh is registered as a Care Home with Nursing offering care to a maximum of 36 people over the age of 65. The home offers care to both male and female service users. Accommodation is provided in 32 single and 2 double rooms, 18 rooms have en-suite facilities. The home has extensive well maintained gardens, which are accessible to service users. Disabled access to the home is provided by means of a ramp. Car parking is provided at the front of the building. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second unannounced inspection of this home; the first inspection was also unannounced and took place in June 2005. There have been no further visits to the home until this unannounced inspection. One inspector carried out the inspection and spent approximately six hours in the home, before the visit time was spent planning the day. The purpose of this inspection was to assess the home against a predetermined selection of the National Minimum Standards for Older People and to check what progress had been made on meeting the requirements from the last inspection. The home prefers the term “resident” to “service user” therefore that is the terminology that will be used throughout this report. The methods used in this inspection included discussions with residents’, staff and management, examination of records, and a partial tour of the home. Comment cards were left at the home for residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. The home leaves some comment cards beside the visitors’ book so that they are easily available, none have been returned following this visit. What the service does well: What has improved since the last inspection? The unguarded radiators have been replaced with Low Surface Temperature radiators. Door closing devices that are activated by the fire alarm system have been fitted to many of the bedrooms doors and more have been ordered so that residents who prefer to have their bedroom doors open are able to do this safely. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 6 A complaints log is now available giving details of any complaints received and the action taken to deal with them. 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. Moorleigh Nursing Home DS0000001358.V264872.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 Moorleigh Nursing Home DS0000001358.V264872.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): Standard 6 does not apply to this home. Standards 3 and 5 were looked at during the June 2005 inspection. EVIDENCE: Moorleigh Nursing Home DS0000001358.V264872.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): 9 & 10 Residents are satisfied that their privacy and dignity are respected. Residents are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: None of the residents in the home administer their own medication however the necessary policies and procedures are available should the situation arise. Medicines are stored safely and the required records were available and up to date. The supplying pharmacist does an audit of homes medications systems every six months and no issues were identified during the most recent audit. The home is in the process of changing the systems for disposing of medicines to comply with recent changes to the law, the homes policies and procedures will need to be updated to reflect this change. During induction staff are given training on how to respect the privacy and dignity of residents and residents confirmed that their privacy and dignity are respected. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were looked at during the June 2005 inspection. EVIDENCE: Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Concerns and complaints are taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: A complaint log is now available and includes details of complaints and the action taken to deal with them. The home has had three complaints since the last inspection; they were dealt with appropriately and resolved. All staff have training on abuse and Adult Protection during their induction. Three staff had just attended training on Adult Protection procedures run by Social Services and they are now planning to share this information with all the staff team. Care staff spoken to understood what abuse was and knew how to report any concerns they might have. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 & 26. Moorleigh provides a clean, comfortable and safe environment for residents. EVIDENCE: The home was clean and there were no unpleasant smells. Residents’ bedrooms are decorated and furnished to a good standard and residents have their personal belongings around them. Low surface temperature radiators have been fitted in the rooms that had unguarded radiators. Door closing devices that are activated by the fire alarm have been fitted to many of the bedrooms doors; this allows residents to have their bedroom doors open without compromising fire safety measures. The deputy said that more had been ordered. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 13 During the last inspection new laundry equipment was being installed, the newly equipped laundry is now fully operational and the initial problems with noise, (the subject of one of the complaints), have been sorted. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 14 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, 29 & 30. The numbers and skill mix of staff were sufficient to meet the needs of the residents’. Residents are protected by good recruitment procedures. The home supports staff in meeting residents’ needs by providing suitable opportunities and support for training and development. EVIDENCE: The duty rosters for nursing and care staff were looked at and showed that there are adequate numbers of staff on duty, residents did not raise any concerns about the availability of staff to meet their needs. The National Minimum Standards recommend that 50 of care are qualified to NVQ (National Vocational Qualification) level 2 by December 2005, at Moorleigh 57 of care staff have achieved an NVQ at level 2 or above and the NVQ programme is ongoing. All the required checks are carried out before new staff start working in the home. All new staff have induction training covering safe working practices such as Fire, Moving & Handling, Health & Safety, First aid and food hygiene, when they have finished this they move on to the more detailed Skills for Care induction standards. The homes plans that all existing staff will also complete Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 15 the Skills for Care induction standards and they will then look at introducing the foundation training standards. Records are kept of all training, including induction, done by staff. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 16 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, 36, 37 & 38 Overall the home is well managed and residents benefit from an open and inclusive management approach, however the management team must make sure that systems such as those relating to staff supervision, appraisals and the quality assurance questionnaires are maintained. EVIDENCE: The Registered Manager continues to work towards completing the Registered Managers Award. She is a registered nurse and has several years experience in the care of older people. Much of the consultation that takes place with residents and their representatives is informal; the home continues to work on involving residents and/or their representatives in reviews of care plans with varying degrees of success. The home has developed a questionnaire that gives residents and/or their representatives the opportunity to share their views of the service. The Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 17 programme of issuing questionnaires has lapsed in recent months and this must be addressed as this provides a means of measuring the success of the home in meeting its stated aims and objectives and is essential to the ongoing development of the service. The system for supervision for care staff in well established however supervision for nursing staff tends to be informal and not recorded; this is an area that needs to be addressed as well as the programme of annual appraisals which has lapsed. Records are stored safety in the home. The concerns about health and safety issues identified during the last inspection have been dealt with; no concerns with health and safety were identified during this visit. Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 3 3 Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 19 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 OP21 Regulation 23(2)(j) Requirement The registered persons must make whatever arrangements are necessary to ensure that the first floor shower is returned to and maintained in working order. Previous timescales of 30/7/04, 25/02/05 & 03/08/05 not met. Nursing staff must receive supervision at least six times a year. Timescale for action 31/03/06 2 OP36 18 31/03/06 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 OP7 Good Practice Recommendations The manager should carry out a regular audit of the care records. Carried forward from the last inspection. The procedures for Homely Remedies should be discussed and agreed with residents’ General Practitioners. DS0000001358.V264872.R01.S.doc Version 5.0 Page 20 2. OP9 Moorleigh Nursing Home 3. 4. OP32 OP33 The policies and procedures relating to the safe management of medicines should be updated to reflect the new systems for disposing of medicines. Records of residents meetings should be maintained. Carried forward from the previous inspections. Consideration should be given to the implementation of a family contact sheet. Carried forward from previous inspections. All staff should have a formal appraisal at least once a year. 5 OP36 Moorleigh Nursing Home DS0000001358.V264872.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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