CARE HOMES FOR OLDER PEOPLE
Moorleigh Villa 280 Gibson Lane Kippax Leeds LS25 7JN Lead Inspector
Mary Bentley Unannounced 28 June 2005, 10.00am
th 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 Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Moorleigh Villa Address 280 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 Care Home Only 4 Category(ies) of Old age (4) registration, with number of places Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 28/10/04 Brief Description of the Service: Moorleigh Villa is located in the village of Kippax on the outskirts of Leeds. It is a domestic style detached property set in the grounds of Moorleigh Care 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 4 older people with low to medium dependency, all the accommodation is in single rooms and there is a lounge/dining room on the ground floor. The home is cosy, well maintained and decorated and furnished in a domestic style. There is ramped access from outside and a stair lift provides access to the first floor. The home shares gardens and car parking with Moorleigh, the gardens are accessible to service users and are well maintained. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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 was carried out by one inspector who spent three and a half 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; the last inspection took place in October 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 the four residents, staff and management, examination of care records and 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: What has improved since the last inspection?
There were no requirements identified at the last inspection. The home continues to offer a high standard of care and the environment is maintained to a good standard. A new call bell system has been installed since the last visit, additional call points have been provided making it easier for residents to
Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 6 call for staff assistance. An alarm has been fitted to the front door, staff said this was an improvement as they are now alerted to people entering and leaving the building even when they are busy elsewhere in the home. 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 J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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 Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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. Standard 6 does not apply to this service. Prospective residents and/or their representatives are provided with information to enable them to make an informed choice about the home. EVIDENCE: The care records seen showed that the home had carried out pre-admission assessments for the two residents recently admitted and assessments undertaken by other social and health care professionals were available. Prospective residents and/or their representatives are encouraged to visit the home prior to making a decision about admission. A copy of the most recent CSCI inspection report is prominently displayed in the home. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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 & 10 Residents are treated with dignity and respect and their care needs are met despite the fact that this is not fully evidence in the care plans. EVIDENCE: The records of two residents recently admitted to the home were seen. One resident had come to the home a few days before the inspection and the assessment of needs was still being done, however an initial plan of care had been put in place based on the information obtained during the pre admission assessment. A falls risk assessment had not been completed for one resident with a history of falling. A risk assessment had not been completed for the use of bed rails. One resident was causing concern because of weight loss, the home was keeping a record of all food and drink taken and had referred to the matter to the General Practitioner. A new simplified version of the nutritional risk assessment is to be implemented; this should make it much easier for staff to record the monitoring of nutritional status. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 10 The records of another resident showed that although care plans had been put in place they had not been reviewed for two months. The manager said that the care plans had been discussed with the resident and her family but this was not recorded. There were no photographs of the recently admitted residents. Residents appeared well cared for and the records showed that they have access to a range of health and social care professionals. Residents were satisfied that their needs were met. Requirements and recommendations have been made in relation to these standards. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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 and in maintaining contact with family and friends; residents would benefit from the opportunity to take part in a more varied range of activities. EVIDENCE: Daily routines are flexible and take account of the preferences and capabilities of residents. All the residents receive visits from family and/or friends and some go out with their visitors, there are no restrictions on visiting. The home now has a cordless phone, which allows residents to receive phone calls in the privacy of their own rooms. Residents are offered the opportunity to join in social events at the nursing home but staff said that for the most part they choose not to. The activities records suggested an over reliance on the use of television and videos for entertainment. The lunchtime meal was nicely presented and enjoyed by residents. Residents’ dietary preferences are recorded and choices are offered. A recommendation has been made in relation to one of these standards. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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 Residents are protected and feel safe living in the home. EVIDENCE: The complaints procedure is accessible to residents and their representatives. The commission has not received any complaints about this service. Training on abuse and adult protection is provided during induction and NVQ training, staff are currently receiving training on the local authority adult protection procedures. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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, 23, 24 & 26 Residents live in a clean, comfortable and pleasant environment. Overall the environment is safe however a potential risk is created by the absence of window restrictors on the first floor windows. EVIDENCE: All areas of the home were clean and odour free and there is an ongoing programme of redecoration and refurbishment. The lounge/dining room on the ground floor is decorated and furnished in a comfortable, homely style and the gardens are safe and accessible to residents. In all the bedrooms residents had their personal possessions around them. A stair lift to the first floor is available for residents with mobility problems. The home had an inspection from an environmental health officer in February of this year and the recommendations made during that visit have been implemented. The windows on the first floor are not fitted with restrictors to limit how far they can be opened.
Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 14 A requirement has been made in relation to one of these standards. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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 The staffing arrangements are appropriate to the needs of residents. EVIDENCE: The home has one member of staff on duty during the day and at night one member of staff sleeps in the home. If additional support is needed this is provided by staff from the nursing home, which is next door and by the manager who is on call. Catering and laundry services are provided by the nursing home. Duty rosters are available for staff. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 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) 37 & 38 Staff should be made aware of the importance of maintaining accurate, up to date and non-judgemental records. EVIDENCE: Care records are stored safely in the home however some of the entries could possibly be distressing to or misinterpreted by residents or their representatives accessing the records. One the residents recently sustained an injury as a result of an accident, appropriate action was taken to ensure the resident received medical attention however the commission was not informed of the incident. Requirements and recommendations have been made in relation to these standards. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 17 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x 2 2 Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 18 No 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 7 Regulation 15 Requirement Care plans must be kept under review and provide evidence of involvement by service users and/or their representatives. A photograph of every service user must be available. A risk assessment must be carried out in relation to the use of bed rails and a written record must be maintained. Window restrictors must be fitted to the first floor windows. The CSCI must be informed of any incident in the home which adversely affects the well being of service users. Timescale for action 28 September 2005 31 August 2005 31 August 2005 28 September 2005 31 August 2005 2. 3. 7 7 17(1)(a) Schedule 3.2 17(1)(a) Schedule 3.3 (p) 13(4)(c) 37 4. 5. 19 38 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 12 Good Practice Recommendations A falls risk assessment should be carried out for service users with a history of falling. Service users should be offered the opportunity to take
J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 19 Moorleigh Villa 3. 37 part in a more varied programme of activities. Care staff should receive training on record keeping. Correction fluid should not be used in care records. Moorleigh Villa J52 J03 S1483 Moorleigh Villa V235545 280605 Stage 4.doc Version 1.40 Page 20 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
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