Inspection on 02/11/05 for Moulsham Home

This inspection was carried out on 2nd November 2005.

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 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

Moulsham Home 24/07/07

Moulsham Home 25/07/06

Moulsham Home 30/06/05

Moulsham Home 27/01/05

Moulsham Home 23/09/04

Moulsham Home 03/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Moulsham Home 116/117 Moulsham Street Chelmsford Essex CM2 0JN Lead Inspector Alan Thompson Draft Report Unannounced Inspection 2nd November 2005 2:00 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 Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 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. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Moulsham Home Address 116/117 Moulsham Street Chelmsford Essex CM2 0JN 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) 01245 350043/350750 01245 350750 Miss Nicola Pedita Victoria Jason Gardener Miss Nicola Pedita Victoria Jason Gardener Care Home 18 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (18) of places Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 18 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 8 persons) The total number of service users accommodated in the home must not exceed 18 persons 30th June 2005 Date of last inspection Brief Description of the Service: Moulsham Home is an adapted detached domestic style property situated close to the centre of Chelmsford and all local amenities. The home is currently registered to accommodate 18 elderly people (over 65 years), including 8 places for people diagnosed as suffering with dementia. There are twelve single and three shared bedrooms on two floors. A shaft passenger lift is available to provide access between levels. Communal space comprises an L shaped lounge and dining room on the ground floor, as well as a fully separate quiet/visitors room at the rear of the dining area. The home has a rear garden with an accessible patio area. Off street parking is available at the front and rear of the property. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 1400 hours on Wednesday 2nd November 2005. This was the second inspection of this home in the inspection year 2005/6. The content of this report reflects the inspector’s findings on the day of the inspection, and from taking account of relevant findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Residents and staff were spoken with. There were no relatives available to speak with, but questionnaires were left at the home so that they had the opportunity to make their views on the service known to the Commission. Random samples of records, policies and procedures were inspected and a tour of parts of the premises took place. All residents spoken to, who were able to express an opinion, said they were satisfied with the care they received, and with the quality of the food and accommodation offered. Staff confirmed they received good support from management. They also confirmed that they received training appropriate to their role. What the service does well: What has improved since the last inspection? Foot pressure mats have been installed in all bedrooms to aid staff in supporting residents at night. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 6 What they could do better: The home needs to fully comply with the Criminal Records Bureau guidance when recruiting new staff Staff training is needed on POVA (protection of vulnerable adults) procedures. ----------------------- 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. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 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 Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 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): 3 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission of new residents. EVIDENCE: Prior to admission the manager either visits prospective new residents to carry out an initial assessment of need or the service user is invited to spend a day in the home to meet residents, staff have a meal and view the premises. This allows for the assessment to be carried out over the day. The format headings covered included self care, memory, orientation, challenging behaviour, sensory abilities, mobility, continence. On the day of admission this is updated to include needs assessment of: diet, weight, medical history/background, history of falls, manual handling, personal care, mental state, social hobbies and interests. A personal risk assessment is completed as a separate document. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 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): 8&9 The health care needs of residents were generally assured. The home’s medication procedures, practices and staff training appeared to provide adequate guidance for dealing with medicines. EVIDENCE: Residents health care needs are included in the homes assessment format and care planning document. At the time of this inspection no residents were suffering from pressure sores, but when needed, district nurses will visit the home to provide treatment and appropriate aids and pressure relieving equipment. Continence advice is sought via the Community Continence Advisor. An optician and chiropodist visit the home to provide treatment and services to residents. Some residents continue to visit their own optician in Chelmsford. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 10 A local dentist is available for residents to use, but again some have continued to use their own dentist, with staff or relatives support. Hearing tests are requested through the GP and will usually be carried out at local hospitals. Nutrition advice is sought directly via the Nutritionalist at Broomfield hospital or through the GP. There were no residents self administering their own medication. However the home has a risk assessment policy in place covering this subject should it be needed in the future. The homes policy on the ordering, supply, administering, storage, security and disposal of medicines was presented for inspection and provided clear instructions to staff on the required procedures. A random sample of medication records were inspected and were found to be appropriately maintained at the time of this inspection. The care manager advised that there are always two staff (including one senior) responsible for giving out medication. Records are kept of returned stocks. The homes pharmacist provides annual ‘refresher’ training to staff on medication issues. Accredited training is also accessed through a local college. This course is entitled ‘Safe Handling of Medicines’. Evidence of staff training under this subject was on display in the main entrance hallway. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 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): 12, 14, 15 Regular opportunities are provided to residents to meet their recreational, social and religious interests and needs. Residents were supported in exercising choice regarding day to day routines in the home. Meals provided would appear to ensure a wholesome, varied and nutritious diet for residents. EVIDENCE: Notices were displayed regarding planned activities, residents meetings, information about Age Concern and a copy of the Charter of Rights. Activity records had been maintained. Regular activities are offered mornings and afternoons by staff to residents. These include: bingo, indoor games, board games, cards, nail care, singing, quizzes and discussions. Entertainers also visit regularly. There are monthly church visits to the home and several residents attend a local chapel once a month for tea. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 12 Local school children visit the home to meet with residents and one attends a local school weekly for lunch. A college student also visits to talk with residents. Community trips include shopping, pub and seasonal outings. The church mini bus is loaned for some of these. A pantomime group are staging a show at the home in December and this event will combine with the home’s Christmas party. A new service soon to be available is a visiting ‘storyteller’. Residents spoken with said they were satisfied with the range of opportunities and activities available, they also confirmed that they are provided choices regarding meals and daily routines. One resident continues to manage her own finances, relatives provide this support to others. Regular monthly residents meetings are held, minutes of discussions are kept. Evidence was seen that residents may bring personal possessions into the home, records had been kept of these. Information was displayed on how to access independent advocacy services. The home’s menus were seen and evidenced a good choice of food was available. Nutrition records had been kept. The main meal of the day is lunch with three choices. There was also a choice of hot or cold teatime meal. Residents are asked their preferred choice the day before. The manager confirmed that supper of crisps, biscuits or sandwiches were always available. The home kept good stocks of food. The community dietician is accessed through the GP practice. Special diets eg diabetic, are catered for. Monthly meetings in the home include asking residents views on the food. Residents spoken with confirmed their full satisfaction with the food provided. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 13 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 Procedures and polices in place were aimed at protecting residents from abuse, however further staff training was needed on this subject. EVIDENCE: The home’s adult protection guidance booklet and written policy statement on this subject included definitions on types of abuse and on how to react and record suspicions or allegations of abuse. In addition the home also had a copy of the Essex County Council guidance on the protection of vulnerable adults and the Dept of Health POVA guidelines, along with the Essex Vulnerable Adults Protection Committee handbook. It would be good practice for all of this information to be collated into one pack for staff to refer to. Staff training on adult protection and abuse had taken place but was now in need of being updated to take account of the 2004 POVA procedures. There is a requirement in this report on this issue. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 14 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): 19,20,21,23,24,25,26 The home was comfortable, bright and well maintained. Residents’ outdoor space was accessible and well kept. The premises appeared safe, were accessible, and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was very clean and considered to be hygienic. EVIDENCE: General maintenance in and around the home is provided by a designated staff member. Renewal of the fabric and redecoration of the premises takes place on an ongoing rolling programme. In the inspectors view the premises were well maintained, furnished and equipped in a comfortable and homely way. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 15 Communal bathing facilities are provided for with two ‘assisted’ bathrooms and one ‘walk-in’ shower. Communal toilet facilities were seen to be located close to the lounge areas. The homes sluice facility was located on the first floor. The laundry is on the ground floor. This was small for the size of the home, but was well organised and the equipment installed was adequate. A call bell system was seen fitted in private and communal rooms. Bedrooms inspected were varied in shape and size. All were well decorated, equipped and furnished to a comfortable and homely standard and met recommended size standards. Residents spoken with confirmed that they were satisfied with the accommodation provided them. They also said that they had been permitted to bring into the home with them items of personal possessions. Records of these had been kept. All rooms were centrally heated with thermostats fitted to bedroom radiators, as were radiator guards. Hot water is regulated for delivery at or close to 43 degrees Celsius (not tested). Since the last inspection foot pressure mats had been installed in all bedrooms. This was to alert staff when residents got out of bed during the night, thus ensuring staff were quickly on hand to support night time needs. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 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): 27 & 30 Staffing levels and skills appeared to meet the needs of residents. Staff were generally provided the training to equip them with the skills for their role, but update training on adult protection procedures was due. Recruitment procedures aimed at safeguarding the protection of residents had not always been followed. EVIDENCE: Staffing rotas were inspected. Minimum staffing levels remain three carers on daytime shifts except sometimes between 1500–1600 hours when very occasionally (as reported by the care manager), there are only two carers on duty. Two waking carers work night time shifts. There is an overlap of night staff and day staff shifts between 0700 & 0800 each morning, to provide additional support to residents’ at this busy time. Separate and additional rostered staff were employed to undertake cooking, cleaning and maintenance duties. The manager’s hours were supernumery. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 17 Staff recruitment records were not fully inspected but it was noted that CRB (criminal record bureau) procedures had not been adequately followed for all new staff recently employed. CRB checks had been actioned for new staff but some had commenced employment before a check against the DOH POVA list had been received. The manager undertook to address this situation immediately. There is a requirement on this issue. Training provided to staff included: falls management & prevention, catheter care, leg ulcers, manual handling (care manager provides this in-house), food hygiene, first aid (update on this due in December 2005), diabetes, dementia awareness, fire safety, medication, care practice. Other planned training included: contamination and infection control and funeral procedures. New staff received structured and recorded induction training. The pack includes areas of: premises, H & S, COSHH, fire, worker role, records, aiding residents, manual handling, personal care, nutrition, care of equipment, medical needs, hygiene and accidents. All but two staff have received NVQ level 2 training. One was on NVQ level 3. The registered manager and the care manager have both completed their NVQ level 4 awards. A discussion took place with the care manager regarding the benefit of improving records kept of training provided to staff. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 18 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): 33 & 37 Procedures for gaining the views of residents and relatives were in place. Records required by regulation were in place and up to date. EVIDENCE: The care manager confirmed that the home’s quality assurance process was scheduled for implementation in December 2005. This involves a questionnaire being completed by residents and a separate form being sent to relatives. Topics covered are views on care provided, facilities in the home, menus, support offered and the consultation process. Comments received are acted on and records maintained of actions taken. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 19 Random samples of records required to be kept were inspected. These included: staff rotas, accident records, visitors book, fire drills, regulation 37 notices, nutrition records, furniture brought in by residents, medication and fire procedures All seen were considered appropriately maintained at the time of this inspection. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 20 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 3 X Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 21 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 18 Regulation 13, 18 Requirement The registered manager must ensure that staff training includes POVA (protection of vulnerable adults) procedures and guidance. The registered manager must ensure that full criminal record check procedures are followed for all new staff employed. Timescale for action 28/02/06 2 29 13, 17 30/11/05 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 18 Good Practice Recommendations The homes written adult protection polices, procedures and guidance should be kept together in a format which is readily available for staff reference and use. Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Moulsham Home DS0000017892.V263040.R01.S.doc Version 5.0 Page 23 - 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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