Inspection on 17/01/06 for Moorleigh Villa

This inspection was carried out on 17th January 2006.

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

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

Other inspections for this house

Moorleigh Villa 12/02/09

Moorleigh Villa 13/02/07

Moorleigh Villa 28/06/05

Moorleigh Villa 28/10/04

Moorleigh Villa 02/06/04

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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 Villa 280 Gibson Lane Kippax Leeds West Yorkshire LS25 7JN Lead Inspector Mary Bentley Unannounced Inspection 17th January 2006 10:30 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.V277355.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 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 Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 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.V277355.R01.S.doc Version 5.1 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 inspection of this home and it was unannounced; the first inspection was also unannounced and took place in June 2005. The inspection was carried out between 10.30am and 2.00pm by one inspector. This inspection was focused mainly on management and staffing issues and during the inspection I looked at various records and spoke to the manager and staff. Residents were seen and spoken to briefly and parts of the home were looked at. The home prefers the term “resident” to “service user” therefore that is the term that will be used throughout this report. 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 discussed with the provider without revealing the identity of those completing them. What the service does well: What has improved since the last inspection? Most of requirements from the last inspection have been death with. Temporary window restrictors were fitted but the manager recognised that they were not suitable and arrangements have now been made for more secure restrictors to be fitted. The quality of record keeping has improved and photographs of all the residents are available. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 6 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 Villa DS0000001483.V277355.R01.S.doc Version 5.1 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 Villa DS0000001483.V277355.R01.S.doc Version 5.1 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): These standards were not inspected on this visit, for details please refer to the report dated 28 June 2005. EVIDENCE: Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 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): 7, 8, 9, 10 & 11 Residents’ personal and health care needs are met in a way that respects their privacy and dignity. Residents are protected by the homes systems for managing medication. EVIDENCE: The care plans set out in detail how the personal, health and social care needs of residents will be met. The plans are reviewed monthly and there was evidence of involvement by residents and/or their representatives. Photographs were available for all residents. The plans show that residents’ health care needs are met. Residents can see a GP either in the home or can visit the surgery, which is within a five-minute walk. Residents have access to community-based health and social care professionals as needed. Residents’ weights are recorded monthly and showed that all the residents had gained weight since admission. Should residents need continence assessments these are carried out by the District Nurses. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 10 The bed rails referred to at the last inspection are no longer in use. All the staff involved in assisting residents with their medicines have received appropriate training. None of the residents in the home at the time of the visit were self-medicating. The medicine charts were up to date. The information provided by the home makes it clear to residents and/or their representatives that residents may have to move if their care needs increase significantly. However this is not a step that is taken lightly and whenever possible the home enlists the help of community health care staff to support them in meeting residents needs until the time of death. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 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 the following standard(s): These standards were not inspected on this visit, for details please refer to the report dated 28 June 2005. EVIDENCE: Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 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 the following standard(s): These standards were not inspected on this visit, for details please refer to the report dated 28 June 2005. EVIDENCE: Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21,24 & 26 Residents live in clean, comfortable and homely environment. Overall the environment is safe however a potential risk is created by the absence of window restrictors on the first floor windows. EVIDENCE: The home was clean and well maintained. Residents’ bedrooms are decorated to a good standard, comfortable and well equipped. Door locks are fitted and call bells are available. Residents are encouraged to have their personal belongings with them. The home has 2 communal toilets. There is one assisted bathroom for four residents; this exceeds the National Minimum Standards, which recommend a ratio of 1 to 8. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 14 Temporary restrictors have been fitted to the windows on the first floor, the manager had already identified that they were not suitable. The home has had some difficulty getting the appropriate fittings however the manager said a supplier has now been identified and they have been ordered. Some concerns were identified about the laundry, these referred to clothing being damaged or returned to the wrong people despite the fact that the clothing was named, the manager said these issues were being dealt with. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 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 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 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: There has been no change to staffing since the last inspection, the home has one member of staff on duty during the day and a member of staff sleeps in the home overnight. The manager is contactable by phone and staff from the nursing home, next door, provide additional support if needed. The staff of the Villa and the nursing home are essentially one staff team with the majority of staff working in both homes. All the recruitment and training is organised by the nursing home and the records are kept there. Staff files were looked at in November 2005 and showed that all the required checks are done before new staff start work. The National Minimum Standards recommend that 50 of care are qualified to NVQ (National Vocational Qualification) level 2, at Moorleigh 57 of care staff have achieved an NVQ at level 2 or above, staff working in the Villa are included in this. The NVQ programme is ongoing Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 16 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. Records are kept of all training, including induction, done by staff. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 17 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, 35 & 38 The home is well managed, the interests of the residents are seen as very important to the manager and staff and they work hard to make sure they are safeguarded at all times. EVIDENCE: The manager has many years experience in the care of older people, she is working towards achieving an NVQ level 4 in management. The home issued quality assurance surveys to residents’ relatives in December 2005, the manager had examined the responses and was taking action to deal with any issues identified. The quality assurance systems now need to be developed further so that the findings are made available to service users. 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 Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 18 Some concerns about health and safety were identified, these included the matter of the window restrictors referred to in the environment section of the report and a safety gate fitted outside one of the bedroom doors on the first floor. The manager said this gate was no longer in use. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 19 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 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 3 4 X X 3 X 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 3 X X 2 Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 20 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 OP19 Regulation 13(4)(c) Timescale for action Window restrictors must be fitted 31/03/06 to the first floor windows. Previous timescale of 28/09/05 not met. The findings of the quality assurance surveys must be made available to service users. Requirement 2. OP33 24 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. 2. 3. Refer to Standard OP12 OP26 OP38 Good Practice Recommendations Service users should be offered the opportunity to take part in a more varied programme of activities. Carried forward from the last inspection. More care should be taken when dealing with residents’ personal clothing. The safety gate on the first floor should be removed. Moorleigh Villa DS0000001483.V277355.R01.S.doc Version 5.1 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 Villa DS0000001483.V277355.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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