CARE HOMES FOR OLDER PEOPLE
Moorleigh Nursing Home 278 Gibson Lane Kippax Leeds Yorkshire LS25 7JN Lead Inspector
Sue Dunn Key Unannounced Inspection 27th February 2007 11:15 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.V331116.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. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 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.V331116.R01.S.doc Version 5.2 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 17th November 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 wellmaintained 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.V331116.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcomes for service users. The inspection report is divided into separate sections with judgements made for each outcome group. The judgements reflect how well the service delivers outcomes to the people using the service. The categories are “excellent”, “good”, “adequate” and “poor”. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in 29th November 2005. The manager completed a pre-inspection questionnaire and this information with information supplied by the home during the course of the year was used as part of the inspection process. Questionnaire leaflets were sent to the home to be given to relatives and service users. Twelve had been completed and returned providing useful information about the home. One inspector carried out the inspection visit, which started at 11:15 am and finished at 18:30 pm. During the visit there was a tour of the building, documentation was examined, service users, a visitor, the staff and manager were spoken with and routines and practices were observed. The care files of three service users were closely examined and information cross- referenced from the above sources. The current fees for care were between £525 and £595 per week. Personal toiletries and clothing, chiropody, hairdressing and newspapers were not included in the fees. What the service does well:
All the survey leaflets had been completed by relatives who made the following comments: ‘Staff look after residents well making sure they are clean and comfortable’ ‘My relative is always clean, comfortable and well cared for despite poor health’ ‘My mother is well fed, always very clean and tidy, there is a friendly and homely environment and prompt attention is given to medical issues’ ‘Moorleigh is a caring and happy nursing home’. Nobody could say how they felt the home might be improved.
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 6 The care files were orderly and consistent in layout and showed that where possible service users and their relatives had been involved in the care planning. The care file for a person with dementia included a brief personal profile with names of family members to enable staff to recognise names that were significant for the resident. There was also a care plan describing an effective way to divert the lady if she became agitated. This is good practice, which could be developed further. It was apparent that the management team were open to ideas and suggestions, which would improve the way care was given. People who chose to spend time in their rooms, who were able to make their wishes known, had their personal possessions close to hand. They had TV remote controls to hand and bedroom doors were opened and closed on request to allow contact with the rest of the home or privacy. Survey results about the food were positive, ‘The food is nice and well presented’, ‘The food always looks appetising’. Special diets were catered for in a way which does not discriminate against those unable to eat the standard ingredients. Everyone felt satisfied with the complaints procedure and the way any concerns were handled. Comments were made such as: ‘‘nothing is ever too much trouble’, Any concerns are dealt with promptly’, ‘The Managers, carers and nurses are all very helpful, problems are sorted out ASAP’. Many of the bedrooms were spacious with plenty of space for personal belongings. The proprietors had plans to increase the size of smaller rooms and install en suite facilities. The home had a good system for reporting and tracking the progress of any repairs to ensure any problems were rectified speedily. The laundering of bed linen and personal clothing was done to a high standard. The home had a thorough recruitment and selection process with all staff having CRB checks undertaken before working with service users. Staff training is given high priority and the home’s trainer ensures staff are competent before she will validate their training records. Survey responses said ‘Staff do the best job they can under difficult circumstances’, ‘care is given with warmth and kindness,’ staff are approachable, friendly and informative’. The manager and deputy were described as ‘a good well balanced team’ who were supportive of staff and listened to their views. Both were receptive to suggestions made during the inspection visit. The manager was approaching the completion of the NVQ4 Managers Award. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
The contract was said to be supported by the service user guide, which everyone received. This was very informative but could be improved by producing a summary in a larger print format with more visual appeal for service users. Service users should have the number of the room they are to occupy shown on the contract. Wherever possible information about social, intellectual and spiritual needs should be obtained as part of the pre admission assessment. This shows the diversity of each person and the needs the home will be required to meet. If this has not been possible it should be recorded on the assessment form. One of the care plans inspected had not been amended when the review notes showed a change. This could have led to the person’s needs being overlooked. The care plan is designed to guide current practice and should be amended to reflect any changes identified in the review process. Care files should include care plans to cover social, intellectual and spiritual needs to allow a more personalised approach to social and recreational activities. This would provide more guidance for key workers. Medication records must only be signed after medication has been seen to be taken avoiding the necessity of altering the records if medication is refused. Nurses must record their findings when they carry out checks on pressure relieving mattresses to show evidence that people are adequately protected from the risk of pressure sores. It is recommended that tables be laid as simply as possible avoiding patterned mats and crockery and using contrasting colours to reduce the distractions for people with dementia. The laundry area must be cleaned regularly to keep the area free from an accumulation of dust and debris, which increases the risk of cross infection.
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 8 The manager should introduce a system for the periodic checking of CRB’s for existing staff. 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. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 9 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.V331116.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3, 4 and 5 (6 N/A) Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to this service, discussion with service users and a visitor, and examination of documentation. Prospective service users had their needs assessed and were given the opportunity to visit the home to be able to make an informed choice about moving in. The service user guide, contract and pre admission assessments could be improved with some further work, as discussed. EVIDENCE: All the people who returned surveys said they had received a contract. The contract from the home was brief giving the fees and describing the type of room to be occupied. It did not show the number of the room or what the fees covered.
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 11 The contract was said to be supported by the service user guide, which everyone received. This was very informative but could be improved by producing a summary in a larger print format with more visual appeal for service users. Service users should have the number of the room they are to occupy shown on the contract. Prospective service users or their representatives are given the opportunity to visit the home before admission. The care file of a person recently admitted to the home from hospital showed a pre admission assessment had been carried out. Wherever possible this should include information about social, intellectual and spiritual needs, or state if this has not been possible. This is a part of the care the home will be required to provide if needs are to be met. There was a note in the file to show that the home had tried to obtain more personal background history after admission. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service, examination of documentation, discussion with the manager, staff and service users. Care files were orderly with health and personal care plans seen in each file and written evidence that the plans were reviewed monthly. This could be improved by ensuring the changes recorded in the review notes are also transferred to the care plan, to avoid the risk of information being overlooked. The principles of dignity and privacy were put into practice. EVIDENCE: The care files were orderly and consistent in layout. Each had a recent photograph, factual information and care plans, which covered all physical care needs. The care plans were completed by the nurses and showed that families and,
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 13 Where possible, service users had been consulted about the plan. They were also responsible for the daily record keeping. The emphasis of the care plans and daily recording focused on peoples’ physical and health care with little to show how other needs were to be met. It was clear from speaking to staff and observing service users that people were cared for according to their different needs and preferences. Relatives said ‘staff look after residents well making sure they are clean and comfortable’, ‘my relative is always clean and comfortable despite poor health’, ‘my mother is always very clean and tidy…there is a friendly and homely environment’. Daily blood sugar monitoring records were seen in the files of people with diabetes and treatment was discussed with GPs if there were any difficulties. An example was given of one person who refused to have blood sugar monitoring checks carried out and so an agreed compromise had been reached, with nursing staff during the day using their discretion if they observed anything which raised their concerns. Night staff continued to monitor blood sugar level with the same frequency. Care plans were reviewed every month and records made to show any changes. This had not, in one case, led to the care plan being changed, which could have led to the person’s needs being overlooked. The care plan is designed to guide current practice and must be amended to reflect any changes identified in the review process. The deputy manager had recognised the direct, hands on part played by care staff and was in the process of developing a system to allow care staff to record the care and support they gave during the course of each day. This hopefully will give a more rounded picture of the quality of life for each person in the home. The care file for a person with dementia included a brief personal profile with names of family members to enable staff to recognise names that were significant for the resident. There was also a care plan describing an effective way to divert the lady if she became agitated. This is good practice, which could be developed further. There was evidence in the files of the working relationships with other health professionals such as occupational therapists, physiotherapists, speech therapists, mental health specialists, tissue viability nurses, dental and optical services and specialist consultants. The manager said the home has good support from community nursing services and that staff were doing some distanced learning about the Liverpool care pathways approach to caring for people during the last stage of their
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 14 lives. They are currently supported by the Macmillan nursing service when people are in the last stage of a terminal illness. The manager said during this time a member of staff is allocated to sit with the service user, but there are no formal arrangements for increasing staffing to ensure the other service users needs continue to be met. The local health centre is situated next to the home and two GP’s make routine weekly visits to the home with others responding to any necessary callouts to the home. A relative said ‘the home gives prompt attention to any medical issues’ One service user described the GP as ‘very nice’. The nurse was observed giving the lunchtime medication. The medication is distributed between two trolleys, one for upstairs and one for down to reduce the volume and time taken for each person to receive their medication. The home uses a monitored dosage pre-packed system for medicines. Trained nursing staff take responsibility for the checking, monitoring and administration of medication. Medication records should only be signed after the medication has been accepted and taken. One service user managed his own inhalers. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 15 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 and 14 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, examination of documentation, discussion with service users, staff, the manager, survey information and observation. More could be done to reflect social, cultural and spiritual needs in the written documentation in each of the care plans. The managers were able to explain what they did for each person but this was not recorded. The home’s programme of activities could be improved by making it more person centred and by providing a care plan to guide key workers. The home provided a varied and nutritious diet. EVIDENCE: The care files did not include care plans to cover social, intellectual and spiritual needs. An attempt had been made to gain some background information about the people whose files were inspected but this did not
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 16 appear to be used to lead activities specifically focussed at individuals and their interests. The inspection took place on a day when a regular entertainer visited but he had not arrived and nobody was sure why. There did not appear to be any alternative provision made to fill such gaps and nothing happening to provide stimulation. However, a relative said ‘residents are constantly talked to by staff, even poorly residents are encouraged to take part in activities’. ‘They have parties and nice events going on for residents’. A member of staff had the role of coordinating activities and organised a weekly programme of activities in which people could choose to participate. It was said that she also spent one to one time with service users. Each service user had a key worker. The key workers could do more to improve the quality of life of the people in their care. For example one person who liked to watch TV would benefit from a weekly TV Times if arrangements could be made to collect it, another could have been kept informed when favourite sports were on the TV. People who chose to spend time in their rooms, who were able to make their wishes known, had their personal possessions close to hand. They had TV remote controls to hand and bedroom doors were opened and closed on request to allow contact with the rest of the home or privacy. The managers described the considerable work they had done to try to support one person who wished to attend a keep fit group. Unfortunately the staff let themselves down by not providing written evidence of this in the records and care plans seen. Everyone had chosen the same dish at lunchtime, corned beef hash, which was said to be a favourite. The alternative was salad. The teatime menu was misleading as it only gave one type of sandwich each day, when in fact people could state their preferences. Special diets were catered for in a way which did not discriminate against those unable to eat the standard ingredients. Survey results were positive, ‘The food is nice and well presented’, and ‘The food always looks appetising’. It is recommended that tables be laid as simply as possible avoiding patterned mats and crockery and using contrasting colours to reduce the distractions for people with dementia. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, survey results, discussion with service users and the managers and observation. Service users were protected from abuse by the home’s policies, procedures and staff training programme. There were copies of the complaints procedure around the home and everyone who responded to the survey knew how to complain and had confidence their concerns would be dealt with promptly. EVIDENCE: Everyone said they were aware of the complaints procedure, a copy of which was on the notice board in the entrance hall and in the service user guide. Comments were made such as: ‘‘nothing is ever too much trouble’, Any concerns are dealt with promptly’, ‘The Managers, carers and nurses are all very helpful, problems are sorted out ASAP’. Staff cover adult abuse in their induction-training programme and discuss their understanding of this with the trainer before their training booklet is signed to show they are competent.
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The design and layout of the home provided a clean, safe and homely environment. Facilities for service users were being upgraded with an ongoing programme of refurbishment and redecoration. Repairs were carried out speedily. EVIDENCE: There was a clean fresh odour on entering the home. An ongoing programme of redecoration had created a well-lit welcoming appearance to the corridors. Decorative work was still in progress.
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 19 The proprietor pointed out that the corridor doors had been widened to allow easier access for wheelchairs. Handrails had been fitted to either side of the corridors for the benefit of service users and to provide some protection to the walls from passing wheelchairs. He had plans to build an extension, which will add extra bedrooms and allow the smaller bedrooms to be enlarged without changing the overall capacity of the home. Most of the rooms seen were spacious in size allowing plenty of space for personal belongings. One person said how much she appreciated the en-suite toilet and hand washbasin, which had recently been installed, in her room. All bedrooms were fitted with locks, which allowed staff to access the rooms in an emergency. It was said that only two people had keys to their rooms. Health and Safety check records were examined. The records showed that the maintenance person inspected bedrails monthly and the pressure relieving mattress pumps. The nurses were said to check the mattresses but did not record their findings. Records showed that hoists had been inspected, showerheads were bleach cleaned, extractors cleaned monthly and dishwashers and wheelchairs were checked. Individual record sheets in the maintenance book provided a system for reporting and tracking the progress of any faults and repairs required. The laundry area was well ordered but needed more careful upkeep of the floor area to keep it clean and avoid the risk of cross infection. Laundering of bed linen and personal clothing was of a high standard as was apparent from observation of the bedding and the way service users were dressed. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, examination of documentation, discussion with staff, the manager and service users, survey results and observation. Staff in the home were trained, skilled and in sufficient numbers to meet the needs of service users. EVIDENCE: The home had a thorough recruitment and selection process with all staff having Criminal Records Bureau (CRB) checks undertaken before working with service users. There is not currently a system for the periodic rechecking of CRB’s for existing staff. This is recommended. One care worker described the interview which was by a panel of two people. She said it was thorough and the questions related to the job. She said the induction training was ‘ lengthy, it involved videos, questions and the completion of an induction book’. The induction book was based on ‘Skills for Care’. The minutes of the staff meetings were examined. These covered practice issues and work priorities.
Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 21 The training officer showed the induction and training records, training plan for the next few months and explained how she gives one to one time to staff to ensure they are competent and fully understand their roles and responsibilities. Nineteen staff had achieved NVQ2, four were doing the award for the under 25’s and 8 more were in the process of being inducted onto the course. An NVQ assessor was visiting staff in the home on the day of the visit. Returned survey forms described staff as follows: - ‘Staff do the best job they can under difficult circumstances’, ‘care is given with warmth and kindness’, ‘staff are approachable, friendly and informative’. A care worker said the staff practices were good but felt that it was sometimes ‘hard to do the job well’ if staff phoned in sick at short notice. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 22 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): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, examination of documentation, discussion with the manager, proprietor, staff, service users, feedback from relatives and observation. The management of the home was based on openness and respect and with quality assurances systems giving users of the service the opportunity to express their views. The manager has the experience and skills to manage the home and was confident she will achieve the management award by June 2007. Health and safety monitoring and records showed that the Health and Safety of staff and service users was protected. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager and deputy were described as ‘a good well balanced team’ who were supportive of staff and listened to their views. Both were receptive to suggestions made during the inspection visit and there was evidence to show that policies and procedures were reviewed. The manager, a trained nurse with many years of experience, has yet to achieve the manager’s award. She said she was close to completion and it was agreed she would complete it before the end of June 2007. The home does not handle any personal monies though one person who handles her own finances may on occasions ask for cash to be held in the safe. This is double checked when putting in and taking out of the safe. The electrical safety certificate for the wiring, which lasts for five years was last issued in October 2002, so will be due again this year. The Landlord’s Gas safety certificate was checked and up to date. Electrical appliance (PAT) tests were the responsibility of the maintenance man who checked everything annually and the appliances of anyone coming into the home in the interim. The proprietors had introduced a quality assurance system and were processing the results of the returned customer satisfaction questionnaires. Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 2 3 4 4 2 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 3 3 Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 25 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. 2 3 Standard OP2 OP9 OP12 Regulation 5 13 15 Requirement Contracts given to service users must include the number of the room to be occupied Medication records must only be signed after medication has been seen to be taken The care plans must include guidance on how social, intellectual and spiritual needs are to be met with evidence of this recorded in daily notes Nursing staff who check pressure mattresses must record the results of their findings The laundry room must be kept free from dust and debris to reduce the risk of cross infection Timescale for action 30/04/07 31/03/07 30/04/07 4 5 OP22 13,17 13 30/04/07 30/04/07 OP26 Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 26 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 2 3. 4. Refer to Standard OP1 OP4 OP7 OP15 Good Practice Recommendations The service user guide could be improved by producing a summary in a format suited to the people for whom it is intended Pre admission assessments should, where possible, include information about social, intellectual and spiritual needs Care plans should be amended to reflect any changes recorded in the review notes. It is recommended that tables be laid as simply as possible avoiding patterned mats and crockery and using contrasting colours to reduce the distractions for people with dementia The manager should introduce a system to periodically check CRB’s for existing staff 5 OP29 Moorleigh Nursing Home DS0000001358.V331116.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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
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