CARE HOMES FOR OLDER PEOPLE
Moorleigh Villa 280 Gibson Lane Kippax Leeds West Yorkshire LS25 7JN Lead Inspector
Sue Dunn Key Unannounced Inspection 13th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Moorleigh Villa DS0000001483.V329822.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 Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Moorleigh Villa Address 280 Gibson Lane Kippax Leeds West 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 *** Post Vacant *** Mrs Beverley McHale Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Moorleigh Villa is located in the village of Kippax on the outskirts of Leeds. It is a domestic style property set in the grounds of Moorleigh Nursing Home. Catering and laundry services are provided by the nursing home. It is within easy walking distance of the Health Centre, local shops and amenities. The village has bus route links with Leeds, Castleford and Wakefield. The home provides care for a maximum of four older people with low to medium care needs. The home has four single bedrooms, fitted with washbasins. There are two communal toilets, one of each floor and there is an assisted bathroom on the ground floor. There is a lounge/dining room on the ground floor and a small kitchen that is used to prepare snacks and drinks. The home is cosy, well maintained and decorated and furnished in a domestic style. A ramp provides wheelchair access from outside and a stair lift is fitted in the home. The home shares gardens and car parking with the nursing home, the gardens are well kept and are suitable for use by residents. Moorleigh Villa DS0000001483.V329822.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 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, (none had been given out) and social care professionals. However the home was in the process of conducting its own customer satisfaction survey and one of the CSCI survey forms has been returned since the visit. One inspector carried out the inspection visit which started at 11.00 am and finished at 16.45 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. There were 4 ladies in the home cared for by one care worker. The fees for care ranged from £380 - £420 per week. Personal toiletries and clothing, chiropody, hairdressing and newspapers were not included in the fees. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
Restrictors had been fitted to the windows on the first floor to limit their opening and reduce the risk of accidents. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request.
Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 (6 NA) 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 pre admission assessments could be improved by including information about peoples’ emotional, social, cultural, intellectual and spiritual needs, as these must also be taken into account when assessing if the home can meet needs. EVIDENCE: One person had chosen the home to be closer to her family. She and a relative said they had visited the home before moving in.
Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 10 An assessment carried out by social services gave some background information about the person’s recent history and events leading up to a hospital admission. A pre- admission assessment was done by the nursing home to ensure they would be able to meet the assessed needs. This showed that a visit had been arranged and established that physical care needs could be met. A further assessment was done before making a move to the care home when a vacancy arose. The assessments in all the files could have been improved by taking account of social, emotional, cultural, intellectual and spiritual needs. The manager said this information was gathered once people were in the home but although staff clearly had relevant background information about the service users little of this was recorded in the care plans to provide direction for staff giving the care. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using all the 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. The information about individual needs was more detailed in some care files than others and this is an area that could be improved. The principles of dignity and privacy were put into practice. EVIDENCE: Three care files were examined. Each had a front index and was sectioned out for consistency of recording. One file did not have a photograph to identify the service user. Care plans had been pre typed under headings such as communication, grooming, and nutrition. All were the same with the basic generalised guidance on care one would expect for anyone. Staff had however added additional hand written information to some of the care plans.
Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 12 All the care plans could be improved by more detailed recording to show each person’s personal preferences and what staff should do to work effectively with them. The staff spoken with clearly carried this information in their heads but did not record it to personalise the care plans. Risk assessments had been done. One showed the person had moved into the high risk category for nutrition and the standardised care plan stated she was to be weighed regularly. There was nothing however recorded on the weight chart in the file. A falls risk assessment had not been completed though earlier information indicated the person had several falls. There was evidence to show that GP’s were contacted when required. One person had just returned to the home from hospital without any warning. This referral could be tracked back to the daily notes The care worker commented on the lack of care and dignity afforded to the service user during her discharge from hospital. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to this service, examination of documentation, discussion with service users, staff, the manager and a relative and observation. Staff had a good understanding of how each person liked to pass their day and the routines of the day were organised around the preferences, choices and abilities of each service user. More could be done to reflect social, cultural and spiritual needs in the written documentation in each of the care plans. Overall activities suited the domestic setting and the present group of ladies living in the home. The home provided a varied and nutritious diet. EVIDENCE: The manager said that some relatives felt there were not enough activities. She explained how difficult it was to introduce activities for the sake of it when people were quite content to sit in the lounge knitting or watching TV. The weekly activity programme however does not do justice to the low-key activities and interactions that take place during the course of each day.
Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 14 Because of the small nature of the home everyone benefited from the visits of relatives and all looked forward to a relative who had been a regular weekly visitor for several years. This day was described as the ‘grooming day.’ Some files included a social activity plan. The content of this and the weekly activity programme was quite limited however and did not give a picture of how each person liked to spend their day. For example one person’s file said ‘likes watching TV’, but nothing to say which programmes were favourites. On closer examination a care worker was able to give a good description of how people liked to be occupied. She said that some ladies liked to be settled in front of the TV for ‘Countdown’, another liked to complete her a bath in time to watch her favourite soap. She said that staff would read the headlines from the daily newspapers, which prompted interest and comments and would do the ironing in the lounge and chat about a range of topics. The ladies were given the opportunity to go across to the nursing home when there was entertainment and occasional trips to garden centres were enjoyed. Table games such as dominoes were played for short periods but said to create anxiety in people who had a short concentration span. There was evidence of attempts at plastic basket weaving. One person gave the impression this had been done more to humour staff than from any real enthusiasm. Overall activities suited the domestic setting and the small group living in the home. The ladies said they liked the food, which was made in the nursing home, and chosen the day before. The meal served on the day of the visit was freshly cooked and well presented and eaten with enjoyment. There was fresh baking and the small kitchen was equipped to make light snacks. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area was good. This judgement has been made using all the available evidence including a visit to this service, discussion with service users, staff and the manager and examination of documentation. Service users were protected from abuse by the home’s policies, procedures and staff training programme. However more should be done to make the complaints procedure more effective. EVIDENCE: There had been no complaints since the last inspection. The ladies said they felt they could speak freely to staff if they were not happy about anything. However one person said that sometimes they had to speak to several staff and still didn’t get a satisfactory solution or answer. A member of staff said the adult protection training was in the form of a video. All staff had signed to say they had received the training. The manager was advised to contact the local authority adult protection unit to see if there had been any amendments to the procedures. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 16 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, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to this service, discussion with service users, staff and the manager, examination of documentation and observation. The design and layout of the home provided a clean, safe and homely environment in which service users could follow their chosen relaxed lifestyle. There must be systems in place for staff to make sure everything in the home is working correctly so that repairs can be carried out speedily. EVIDENCE: The home was well furnished and decorated in a domestic style. All areas were clean, warm and comfortable. Bedrooms were of a good size with some signs of personal possessions. There was one assisted bath on the ground floor. The company who service the hoist gave assurances over the telephone that the equipment had recently
Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 17 been serviced. The manager agreed to forward a copy of the test certificate as soon as she received it. The water from the hand washbasin on the first floor was running cold and the soap dispenser was not working. The maintenance man repaired this during the visit; however, it was disappointing to note that the staff had not picked up the problem. A rusting clotheshorse in the first floor bathroom should be taken out of use. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 18 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 all the available evidence including a visit to this service, examination of documentation, discussion with staff, the manager, a visitor and service users and observation. Staff in the home were trained and well informed enough to meet the needs of the service users. EVIDENCE: There was one senior care worker caring for the four ladies who were at the home, which included one person who had unexpectedly returned from hospital. She and the care worker who relieved her in the afternoon were familiar with the ladies preferences and were seen to offer choices. There was a friendly and respectful relationship observed between staff and service users. The home employs a trainer and all staff undertake the statutory three days paid training each year. The training records showed all staff started with induction training in the main nursing home before starting work. The manager said the training may stretch over several days depending on family commitments and would be followed by a period of shadowing with an experienced member of staff. A training record for 2006 showed the care worker had covered basic care, manual handling, a fire awareness update, first aid, abuse and continence.
Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 19 A member of staff spoken with said she had achieved NVQ and had a medication update training in 2005. There were leaflets advertising forthcoming training events on the office wall. She said staff could link into any of these events as long as they were not on duty at the time. In house satisfaction surveys showed that service users were very satisfied with the service they received from staff. A staff file was examined to determine the quality of recruitment and selection of new staff. The file did not include a photograph of the employee. The candidate had received a copy of the job description and completed an application form giving two referees. Written references were included from both. The returned Criminal Record Bureau (CRB) check was received during the induction period. The manager said staff did not work unattended during this time and their appointment was subject to a satisfactory CRB check. There was an interview checklist, which gave some insight into the interview process. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 20 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 was good. This judgement has been made using available evidence including a visit to this service, discussion with the manager and staff, examination of documentation and discussion with service users. 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. However there was a shortfall on safety checks and the written records would benefit from more detailed information. EVIDENCE: The manager was experienced in running a home but had two remaining units of the NVQ4 in Management to complete to achieve an approved qualification.
Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 21 It was agreed that she could reasonably be expected to complete these by the end of August 2007. The manager described the difficulties of trying to arrange staff meetings which staff could attend outside their working hours. She said she overcame this difficulty by speaking to staff on a one to one basis. A care worker confirmed that the manager was always available to discuss any matters relating to care and the day-to-day management of the home. The manager said that she and the trainer gave staff supervision and was surprised to find that a care worker spoken with was not clear if she had supervision. Written notes from supervision were seen in the file examined. There was evidence that staff could express their views through the homes quality assurance questionnaires and that service users and their families had been made aware of their care plans. The latter could be improved by more detailed written information to guide staff rather than relying on verbal information, which could lead to care, needs being overlooked. The maintenance man said the staff in the home carried out routine safety checks. The following records were up to date: Fire safety certificate Water temperature checks Fire alarm checks PAT electrical tests, to check the safety of personal electrical equipment. It was brought to the manager’s attention that the Landlords Gas safety certificate had expired on 9.01.07 and was due for renewal. Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 2 2 Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 31/03/07 2. OP19 3. OP21 4. 5. OP31 OP37 6. OP38 All care plans must include information which is detailed enough to reflect the diversity of each person’s needs and show how those needs are to be met. 23 (2) b Staff must do regular routine checks of the building to make sure everything in the home is working correctly so that repairs can be carried out speedily. 23 (2)( c ) Hand washing facilities must be (j) in working order to reduce the risk of cross infection. Completed 9 (2) (b) The manager must complete the (i) 10 (3) NVQ4 award in management. 17 Written records must be up to (1)(a)(3)( date and sufficiently detailed for a) the care and protection of service users. There must be a photograph on record of each member of staff and each service user. 17(3)(a) The home must have a landlord’s gas safety certificate which shows that checks have taken place annually. 31/03/07 20/02/07 31/08/07 31/03/07 31/03/07 Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 24 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 OP4 Good Practice Recommendations The pre admission assessments could be improved by including information about peoples’ emotional, social, cultural, intellectual and spiritual needs, as these must also be taken into account when assessing if the home can meet needs. The manager should ensure that the complaints/comments procedures are effective and matters raised by service users receive a speedy response. The manager should organise staff team meetings periodically and keep an agenda and minutes of the meetings for the benefit of those who are unable to attend. 2. 3. OP16 OP32 Moorleigh Villa DS0000001483.V329822.R01.S.doc Version 5.2 Page 25 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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