Inspection on 17/03/06 for Moorside Hall

This inspection was carried out on 17th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Moorside Hall 14/12/06

Moorside Hall 16/06/05

Moorside Hall 29/03/05

Moorside Hall 30/07/04

Moorside Hall 05/02/04

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

CARE HOMES FOR OLDER PEOPLE Moorside Hall Wyresdale Road Lancaster Lancashire LA1 3DY Lead Inspector Mrs Jennifer Dunkeld Unannounced Inspection 17th March 2006 12:00 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 Moorside Hall DS0000009681.V270513.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. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Moorside Hall Address Wyresdale Road Lancaster Lancashire LA1 3DY 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) 01524 69901 Mrs Kathryn Lesley Regan Mr Robert John Murray Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (6) of places Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service is registered to accommodate a maximum of 22 service users in the category DE (Dementia). The service may accommodate 6 named service users in the category of OP (older persons 65 and over) within the overall maximum number of 22 16th June 2005 Date of last inspection Brief Description of the Service: Moorside Hall is a care home registered with the Commission for Social Care Inspection to accommodate up to 22 people with a dementia, it can also 6 named people who are aged over 65 years within the overall total of 22. Set in its own grounds, and close to Lancaster City Centre, the home offers accommodation on either a single or shared room basis. The home has recently had major building alterations, which now enables the majority of residents to have a single bedroom with en-suite facilities with a toilet and a hand-wash basin. There is a large conservatory with a dining room and a lounge adjacent to it. There is also a small lounge on the first floor. The first floor is accessible by a passenger lift. Mr Murray is the proprietor of Moorside Hall and also employs a care manager, this post is currently vacant and has been advertised. Pior to admission, service users care needs are assessed and individual care plans are implemented. Access to health care services such as General Practitioners or District Nurses is arranged as required, as is the services of visiting professional such as Dentists, and Chiropodists. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has been inspected against the National Minimum Standards for older people introduced in April 2002. This year, all registered Care Homes are to be inspected at least twice this year and both visits can be unannounced. This inspection was over 2 days, the first day of which was unannounced. The inspection lasted for a total of 5.5-hour during the day on 17/3/06 and 24/3/06. The inspection looked at various aspects of care. In the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small group of residents. All records relating to these individuals are examined, along with the rooms they occupy in the home. The residents are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other residents who contributed in many ways. This inspection included discussion with residents, staff and a senior carer, in addition to viewing the home’s required written information such as policies and procedures about various issues for instance ‘Health and Safety’. The residents written plans of care were also viewed for 3 people. The plan of care is a document outlining the needs of the individual resident and how these are to be met. The plans of care cover all aspects of the individual’s life including health, personal care and social activities. A new type of plan of care being used at Moorside Hall is a very comprehensive document and clearly identifies people’s needs. Thereby ensuring people are content in the care they receive. The residents the inspectors spoke with happy with life at Moorside Hall. One resident said, ‘It is very good here you can’t fault it, the staff are lovely’ The 6 comment cards received from the relatives of residents reflected their general satisfaction in the care offered. However 2 people expressed some concern about the heat in the conservatory, which is the main sitting area. Heat is due to the sun through the windows. As there are already blinds to the windows, one relative wondered if an awning would be beneficial, allowing people to look out of the windows but would offer shading from the sun. This seems a suggestion worth considering. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There is a need to appoint a new care manager and consider applying to register the individual, as the person in this role sees to the day to day Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 7 management of care within the home, whilst acknowledging that one of the management team are always available. 2 relatives felt that there could be more activities to offer the people who live there, a more fulfilling life style. The complaints procedure held on the resident’s files needs updating as these refer to the NCSC (the previous registration authority) There is a need to ensure that the Service Users Guide is accurately worded as it currently states “ The main aim of Moorside Hall is to enable our elderly residents to leave an ‘ordinary life’”. Presumably this should state, “The main aim of Moorside hall is to enable the residents to lead an ordinary life.” 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. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 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 Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed as they Key Standards were fully met during the previous visit. EVIDENCE: Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 10 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 Arrangements to meet the health, personal and social care needs of the residents are outlined in the individual’s care plan. This results in people feeling content in the home. EVIDENCE: The management has recently developed a new system for recording information about the individual and their needs. This includes health care, personal and social care. The care plans for three people were viewed as part of the tracking process. Each file contained the following; -Social Services “Core Assessment” in addition to a full assessment by the home prior to the persons admission to Moorside Hall. -An in-depth care plan reflecting all needs and how these are to be met. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 11 - Risk assessments as appropriate to the individual. -A record of residents meetings and issues raised. -Moving and handling needs -Dietary needs -Record of activities that the person has participated in Each resident has a Key worker who co-ordinates the care plan. Each resident also has a “My life story” book that the resident and their relatives have contributed to, this tells of the persons life, past and present. -On file is a document “when I die” this is a diverse document that outlines the persons wishes upon death and is appropriate for all cultures, sexes and religions. It ensures the person’s wishes are known and are then carried out according to their religious needs and wishes. - a Progress record is held on their file (diary note of events) The residents said they are ‘Well looked after’ ‘my needs are met’ and ‘The staff are good’. The staff spoken with were aware of the individual care plans and of people’s needs. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 12 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 & 15 The life style of people at Moorside Hall is in many circumstances a continuation of their preferences prior to living at the home, depending on their individual capability. The residents’ benefit from a healthy balanced diet. EVIDENCE: Some residents spoke about the social side of life at Moorside Hall. Activities such as knitting, tai chi, visiting entertainers and sing-along are regularly provided. Indeed on one of the days during this inspection an entertainer visited the home to play his keyboard and encourage people to join in a sing-a-long. This was popular with many of the residents. Dominoes were being played on the 2nd day of this inspection and 5 residents were participating with support from the care staff. Each service users activities programme is recorded on their file. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 13 However of the 3 files examined as part of the ‘tracking process’ one persons activity record reflected no activities since 7/5/05 some 10 months previous. Where an individual is asked to participate but refuses this should be recorded as evidence of the endeavours that are made to ensure people have a fulfilling lifestyle. Residents said that they like to be taken around the lovely park opposite the home but a number said they can’t walk it now’ but occasionally staff take them in a wheelchair. Comment cards received from 2 relatives questioned whether there were enough activities in the home to keep people from becoming bored. 1 relative spoken with during the visit said ‘they do have activities but my mum wouldn’t join in no matter what they did’. He added that he was pleased with the home and the care given. The dietary needs of each resident are recorded on their file. The menus reflect choice and a healthy balanced diet was on offer. All meals are home made with cakes and puddings being popular, the smell of these baking adds to the homely atmosphere. The residents stated that the food was good. 2 Comment cards received from relatives of the residents reflected that the food is good. There is a need to increase the 2 weekly menus to perhaps 3 or 4 weekly, to reduce repartition. New information about the dietary needs of elderly people has recently been published and a copy of this is being sent to the home in order they can ensure peoples dietary needs are fully met. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 14 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): 18 The home provides a safe environment where the people are well protected from abuse. EVIDENCE: The homes recruitment procedure is robust to ensure the right calibre of person is appointed. Criminal Records Bureau clearances are taken up before anyone commences work in the home to protect people from unscrupulous people. The homes policies and procedures in relation to abuse are in line with the Department of Health document ‘No Secrets’. Staff stated that abuse is discussed as part of their induction training. This should be expanded upon and offer additional training to ensure that all staff fully understand the various types of abuse and how to recognise them. The home has a ‘Whistle Blowing ‘ policy. Whereby staff are encouraged to report if they suspect abuse may be taking place. The staff spoken with said they would have no hesitation in reporting anyone they suspected to be abusing. The outer doors of the home have appropriate locks to them to prevent intruders. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 15 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): None of these standards were assessed during this inspection but the recommendation made during the previous visit was followed up. EVIDENCE: During the previous visit it was recommended that residents should be provided with a key to their bedroom door unless a risk assessment indicates this is not practical for an individual. The type of lock is one that allows for access in an emergency but offers greater privacy to the resident. The management have taken this on board and some people have a key to their room while others have stated they don’t want one and signed a declaration to this effect. Others have a risk assessment on their file indicating that a lock would not be good for the individual concerned. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 16 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): 29 The residents’ benefit from a well recruited staff team. EVIDENCE: The information provided in staff files confirmed the registered provider of Moorside Hall operates a thorough recruitment procedure so as to ensure the safety and well being of service users accommodated there. In all staff files viewed, a full employment history had been obtained and in discussion, the registered provider confirmed that any gaps in a candidate’s employment history would be investigated. In addition, two written references and a satisfactory Criminal Records Bureau clearance were available on the files examined. The 6 comment cards received stated the following; ‘The staff at Moorside Hall are always attentive to the residents needs’ ‘ There are not always sufficient staff on duty especially at weekends’ ‘The home is impressive in terms of its flexibility and the obvious care taken to accommodate the individual needs of residents.’ ‘The staff are wonderful at Moorside Hall ‘ Moorside Hall DS0000009681.V270513.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): 32 & 35 The management at Moorside Hall demonstrate they are open and honest. They ensure people’s finances are safe guarded. EVIDENCE: The service provider and the staff ensure that the home keeps the residents and their families informed at all times about the running of the home and the services on offer and welcome comments as to how they can improve the service. The Care Manager post within the home was vacant at the time of this visit and Senior care staff were endeavouring to ensure the smooth day to day running of the home. The senior carer on duty, Sharon Stone, was very informative and helpful. She demonstrated her ability to work as part of a team while taking responsibility for the home during her shift. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 18 The management team according to the residents and staff are approachable and listen to concerns. Comments such as ‘Bob (home owner) is good he’s always pleasant’ ‘nothing is too much trouble for him’ ‘He’s not always here but we can contact him or one of the other members of the management team’ were made during the visit. Residents are supported to manage their own financial affairs for as long at they are able or wish to do so. When this is not possible, third party advice such as from a relative or advocate is sought. Where the home has to be involved in handling any resident’s money, this is recorded in detail e.g. the amount credited/debited, the reason for the debit, the balance and this record is signed and witnessed at each transaction. Only one resident currently requires this support, the record of this was viewed as part of this inspection. The record was accurate and appropriately signed. Moorside Hall DS0000009681.V270513.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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x x x x 3 x x x STAFFING Standard No Score 27 x 28 x 29 4 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x 4 x x x Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 OP27 OP12 Good Practice Recommendations The service provider should ensure that the relatives of the residents are content that there are adequate staff on duty at all times to meet the needs of the residents. The service provider should ensure people have activities they wish to participate in and record when people refuse. Moorside Hall DS0000009681.V270513.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Moorside Hall DS0000009681.V270513.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. 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. 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