Inspection on 08/06/05 for Moorleigh Nursing Home

This inspection was carried out on 8th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Moorleigh Nursing Home 24/02/09

Moorleigh Nursing Home 27/02/07

Moorleigh Nursing Home 17/11/05

Moorleigh Nursing Home 25/11/04

Moorleigh Nursing Home 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Moorleigh 278 Gibson Lane Kippax Leeds LS25 7JN Lead Inspector Mary Bentley Unannounced 8 June 2005, 10.45am 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 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 J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Moorleigh Address 278 Gibson Lane, Kippax, Leeds LS25 7JN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2863247 0113 2872989 Brampton Meadow Ltd Mrs Rosemarie Holt Care Home with Nursing 36 Category(ies) of Old Age (36) Dementia Over 65 (1) registration, with number of places Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The place for DE(E) is for the use of the service user named in the variation application V17005 only Date of last inspection 25 Nov. 2004 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 J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the CSCI is required to undertake a minimum of two inspections of all regulated care homes. This was the first inspection of this home for the 2005/2006 inspection year. The inspection was unannounced and carried out by one inspector who spent six hours in the home. Prior to the visit time was spent planning how the inspection would be carried out. 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, which took place in November 2004. 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 care records, indirect observation of care practices and a partial tour of the home. Comment cards were left at the home for distribution to 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 will be shared with the provider without revealing the identity of the respondents. What the service does well: The home provides a clean, comfortable and homely environment for residents. The atmosphere is friendly and relaxed, residents said that staff are kind and caring and one resident described them as “marvellous”. The staffing levels are appropriate to the needs of the residents and residents spoken with said that they were satisfied that their needs are met. The home is managed in a way that promotes the privacy, dignity and independence of residents and contact with family and friends is encouraged by an open visiting policy. The activities offered reflect the preferences and capabilities of the resident group. The home offers a varied and nutritious menu and residents said they enjoyed the food. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 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 standard(s) 3 & 5 The home supports prospective residents and/or their representatives in making an informed choice by offering clear information about the range of services and facilities offered and by offering the opportunity for pre-admission visits. EVIDENCE: All the files seen contained a comprehensive pre-admission assessment. Two of the residents spoken with said their relatives had chosen the home for them. The home offers the opportunity to visit prior to admission but their experience is that this visit is usually made by relatives rather than by the prospective resident. The local authority contracting arrangements are such that the home has a short time in which to carry out the pre-admission assessment and arrange admission and this potentially restricts the choices available to prospective residents and does not always allow sufficient time for all parties involved to make a fully informed decision. CSCI inspection reports are made available in the home. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 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 standard(s) 7 & 8 The personal and health care needs of residents are met. In order to ensure that the home continues to deliver a consistently good standard of care the manager should carry out regular audits of the care records. EVIDENCE: The individual care plans of four residents were seen and all provided information on how health, personal and social care needs would be met. While most of the plans provided sufficiently detailed information some were missing important information such as the type of pressure relief equipment in use. The plans seen had been reviewed monthly and two provided evidence of involvement by residents and/or their representatives. In most cases the needs identified in the pre-admission assessment were addressed in the care plans, however one resident recently admitted was identified as being nutritionally at risk and at risk of falling and the appropriate risk assessments had not been carried out. The records showed that residents have access to a range of health and social care professionals and residents spoken with were satisfied that their care needs were being met. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 10 Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Residents are supported in exercising choices about their lifestyle and in maintaining contact with family, friends and the local community. The home provides a good, varied and nutritious diet, which takes account of individual choices. EVIDENCE: Residents were seen to spend time either in their own rooms or in the communal areas. Residents spoken with were satisfied that they could choose how and where to spend their time and that they could receive visitors in private. Residents’ personal interests and preferences are recorded and these records are kept in their rooms. The home produces an excellent newsletter, which includes photographs of recent social events in the home and information on forthcoming events. The meals looked and smelled appetising and were nicely presented. Residents said they enjoyed the food and confirmed that they are offered a choice. Staff were seen to provide assistance and encouragement with eating and drinking in a discreet manner and aids such as plate guards were provided where needed. Residents’ dietary requirements and preferences are recorded and where necessary the dietary intake of residents is monitored. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16 & 18 Concerns and complaints are taken seriously and acted upon despite the fact that the homes procedures for recording complaints fall short of the statutory requirements. EVIDENCE: The complaints procedure is available in the home and residents spoken with were aware of how to raise any concerns they might have. The home has had two complaints since the last inspection, one is currently being investigated and the other has been resolved. Neither has been recorded in the complaints log. The abuse/adult protection policy has been updated as recommended at the last inspection. Training on adult protection/abuse is included in the induction and NVQ training however this does not contain specific reference to multiagency approach to dealing with suspicions and/or allegations of abuse. A requirement relating to one standard has been made. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 21, 24, 25 and 26 The home provides a clean and comfortable environment however the safety of residents is compromised by the practice of propping doors open with wedges. The absence of radiator guards on four radiators places the residents in these rooms at risk of sustaining burns. EVIDENCE: Bedrooms and communal areas are decorated to a good standard and furnishings are comfortable and homely. Many of the bedrooms seen had been decorated recently and one resident was particularly pleased that she had been consulted about the choice of colour scheme. In all the bedrooms seen residents had personal possessions, which they had brought with them to the home. A number of bedroom doors are propped open using wedges; this creates a fire hazard, as the doors will not automatically close when the fire alarm is activated. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 14 Four radiators have not been fitted with radiator guards. The first floor shower was not working; it had been repaired following the last inspection but was once again out of use due to a problem with leaks. The home was having new laundry equipment installed, some residents commented on the noise but were aware of what was going on and they felt they would benefit from an improved laundry service. A number of requirements have been made relating to these standards. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 The numbers and skill mix of staff are appropriate to the needs of residents. Recruitment procedures are not consistently followed and therefore residents are not fully protected. EVIDENCE: Residents did not raise any concerns about the availability of staff and spoke very highly of staff describing them as kind and caring. Staff spoken with said there were enough staff on duty on the various shifts to meet residents’ needs. Additional staff are provided between 5.00pm and 10.00pm to assist with the evening meal and with residents evening/bedtime routines. The files of two recently appointed staff members were seen, in both cases the required pre-employment checks had not been completed before staff commenced work in the home. A requirement relating to one standard has been made. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 & 38 Residents’ benefit from the management approach of the home, which creates an open, positive and inclusive atmosphere. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are compromised by some practices. EVIDENCE: The manager is a first level nurse whose skills and experience are relevant to her role; she continues to work towards achieving an NVQ level 4 in management. The manager is well supported in her role by the provider and deputy manager. The home does not become involved in the management of residents’ finances, if necessary residents are supported in finding appropriate external support to assist with the management of their personal finances. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 17 The maintenance records seen indicated that regular maintenance checks are carried out on equipment in use in the home and on the fire safety systems. The issues that present a risk to the health and safety of residents and staff are detailed in the environment section of this report. Requirements have been made in respect of the safety concerns identified. Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 x x 2 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 x x x 3 x x 2 Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 16 Regulation 17(2) Schedule 4 23(4) Requirement A record must be maintained of all complaints including the action taken by the registered persons in respect of such complaints. Doors must not be propped open with wedges, where doors need to be held open an appropriate door closing device, which is activited by the fire alarm system, must be fitted. Timescale for action 31 August 2005 2. 19 31 August 2005 3. 21 23(2)(j) Timescales of 30/7/04 and 25/02/05 not met. The registered persons must 3 August make whatever arrangements 2005 are necessary to ensure that the first floor shower is returned to and maintained in working order. Previous timescales of 30/7/04 and 25/02/05 not met. The remaining four radiators must be fitted with suitable guards or replaced with low surface temperature radiators. Previous timescales of 30/09/04 and 25/02/05 not met. The registered persons must ensure that two written 4. 25 13(4) 31 August 2005 5. 29 19 11 July 2005 Page 20 Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 references and a satisfactory CRB check are obtained before new staff commence work in the home. 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. Refer to Standard 7 8 Good Practice Recommendations The manager should carry out a regular audit of the care records. Continence assessment should be carried out for all residents with an identified need in this area. Nutritional assessments should be carried out for all residents. Training on abuse and adult protection should include specific information on the multi-agency strategy. Records of residents meetings should be maintained. This is carried forward from the previous inspection. Consideration should be given to the implementation of a family contact sheet. This is carried forward from the previous inspection. 3. 4. 5. 18 32 33 Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 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. Extracts may not be used or reproduced without the express permission of CSCI Moorleigh J52 J03 S1358 Moorleigh V226618 250505 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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