CARE HOMES FOR OLDER PEOPLE
Moors Park House Moors Park House Moors Park Bishopsteignton Teignmouth Devon TQ14 9RH Lead Inspector
Peter Wood Unannounced Inspection 31 May and 02 June 2006 10:00 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 Moors Park House DS0000067197.V296193.R05.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. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Moors Park House Address Moors Park House Moors Park Bishopsteignton Teignmouth Devon TQ14 9RH 01626 775465 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) Moors Park Bishopsteignton Ltd Mrs Nicole Haywood-Lloyd Care Home 37 Category(ies) of Dementia - over 65 years of age (37), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (37), Old age, not falling within any other category (37), Physical disability over 65 years of age (37) Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 09/08/06 Brief Description of the Service: Moors Park House is registered as a Care Home providing Personal Care for thirty-seven elderly frail service users who may have additionally a degree of physical or mental disability, in the categories of OP, PDE, MDE and DE. Most service users have single rooms (the two double rooms generally only used as doubles at the specific request of service users), and most have en-suite facilities. Moors Park House has been a successful residential care home for about two decades, and can cater for the full range of elderly people including those with associated mental and physical disorders such as dementias. The home is a superior detached property set in its own grounds, is well kept and managed and is well adapted and equipped to meet the needs of its service users. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two weekdays at the end of May and the beginning of June 2006. The focus of this inspection was to inspect all key standards and to seek the views of residents, staff, relatives and professional visitors to the home, the latter using comment cards and survey forms. Considerable time was spent with the registered manager examining documentation. A full tour of the building was undertaken. The “case tracking” methodology was used whereby four residents were selected to be consulted, along with their keyworker, relatives and professional visitors such a district nurses. Care planning and other documentation, particularly relating to the “case tracked” residents was examined. What the service does well: What has improved since the last inspection? What they could do better: Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 6 The home sufficiently meets all the key National Minimum Standards examined on this occasion. However, the fire safety risk assessment requires updating. In the light of the new ownership and the consequent shift in emphasis in management roles and responsibilities, it is recommended that the owner and manager agree and write down their respective roles and responsibilities to ensure all management aspects are covered. It is also recommended that the manager studies all the National Minimum Standards and Schedules (not just the key standards) and satisfies herself that the home fully complies. 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. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 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 Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 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): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems for admission are thorough and comprehensive and allow residents and their relatives to be confident that their needs can be met. EVIDENCE: The home produces a brochure, Statement of Purpose, Services Users’ Guide and other documentation which accurately describes the aims, objectives, values and facilities offered at Moors Park House. The registered manager undertakes a pre-assessment prior to a resident’s admission, followed by detailed assessments that generate comprehensive care plans. The home does not offer intermediate care. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are properly assessed and met and residents are treated respectfully. The home’s practices relating to medication administration protect the residents from risk. EVIDENCE: Detailed Care Plans were seen which were generated from comprehensive assessments. The Registered Manager reviews each care plan regularly. Risk assessments were seen with respect to safe handling. Night care needs, continence aids, and diabetes care were documented. The home has sufficient numbers of competent staff, with the backup of specialist equipment, to care for very dependent residents. This was recently commended by health staff at a case conference regarding a resident who was admitted to hospital. Residents can self medicate subject to a satisfactory risk assessment. The medication administration practice at lunchtime was observed. The home has good policies, procedures and practices for the proper administration of medication. Residents were observed to be, and reported that they were, treated with respect by staff.
Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 10 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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities provide daily interest for the residents. Contact is maintained with families, residents are encouraged to exercise choice and meals are nutritious and varied. EVIDENCE: The culture of this home is that residents are encouraged and enabled to do as much for themselves as possible. They have a range of activities, published in the newsletter (produced by a graphic artist trained member of staff), from which to choose whether or not to partake. Resident’s rooms reflected their personality, often containing items of their own furniture as well as smaller personal items. Residents told me that they were able to get up and go to bed at whatever time they wished. Those with relatives who lived locally enjoyed being visited and taken out by them. This home receives a great number of visitors: 31 people visited on the day between the two inspection visits. The lunchtime meals observed in the very pleasant dining room was attractive, with choice offered, and nutritious. Menu plans accompanied the PreInspection Questionnaire. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 11 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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are listened to and issues resolved promptly. Complaints and suggestions from residents, relatives or other visitors to the home, are treated seriously. EVIDENCE: The home has a complaints procedure, and follows the good practice promoted in the National Minimum Standards that issues are resolved before they escalate to become complaints. The home has good procedures and a training programme in place to protect residents from any form of abuse. A detailed and up to date policy an adult protection was available for staff. Staff interviewed knew how to respond appropriately should there be a suggestion of abuse. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 12 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a very pleasant, well-maintained home that is comfortable and which provides sufficient facilities to meet their needs. EVIDENCE: Moors Park House is a superior property, enhanced nearly two years ago with a new extension, which meets or exceeds all standards. Moors Park House has been a care home for many years, adapted to meet increased residents dependency over those years. The home is well maintained, decorated and furnished on a planned basis, and is set in its own attractive grounds. The facilities provided by the extension are exceptionally good. The new owner has plans to further enhance the facilities of the home. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by staff in sufficient numbers to meet their needs. Staff are competent by experience and training. Recruitment processes protect vulnerable residents. EVIDENCE: Staff are carefully recruited, inducted and trained, as evidenced by the documentation in the individual staff folders kept at the home and by the portfolio of experience and training files kept by individual staff members. Keyworkers of “case tracked” clients kindly brought in these portfolios for examination. Numbers and competence of staff, by reason of experience and training, is good at this home. The home uses a proper application form with a declaration of no convictions, undertakes CRB checks and undertakes proper references. References are generally verbally given to the manager, who writes down comments from the referee. The home provides training in health and safety topics as required, and enables and encourages staff to undertake NVQs. At the present time about half the staff have NVQ 2 or above, together with some who are currently undertaking the qualification at level 2 or 3. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well run home. The owner, manager and their staff team strive to provide a stimulating, safe environment that respects and protects residents’ rights. EVIDENCE: The home has very recently changed hands. The new owner already owns several successful care homes in another part of the country. The exceptionally well-qualified and experienced registered manager has remained as manager through four owners, each with their different styles and degree of hands-on approach, and is currently adjusting to an enhanced role. It is recommended that the owner and manager agree and write down their respective roles and responsibilities to ensure all management aspects are covered. All records inspected were in order, though the fire safety risk assessment requires updating. It is recommended that the manager studies all the National
Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 15 Minimum Standards and Schedules and satisfies herself that the home fully complies. Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 4 X X X X X X 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 3 X 3 X 3 X X 3 Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 17 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 OP38 Regulation 13 Requirement The fire safety risk assessment requires updating. Timescale for action 31/07/06 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 Refer to Standard OP31 Good Practice Recommendations It is recommended that the owner and manager agree and write down their respective roles and responsibilities to ensure all management aspects are covered. It is recommended that the manager studies all the National Minimum Standards and Schedules and satisfies herself that the home fully complies. 2 OP38 Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 18 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Moors Park House DS0000067197.V296193.R05.S.doc Version 5.2 Page 19 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
