Inspection on 24/07/07 for Moulsham Home

This inspection was carried out on 24th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 25/07/06

Moulsham Home 02/11/05

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 Pauline Marshall Unannounced Inspection 24th July 2007 09:50 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.V346483.R01.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. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 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 350750 F/P 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.V346483.R01.S.doc Version 5.2 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 25th July 2006 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. All prospective residents are provided with a combined Statement of Purpose and Service User Guide that gives them up to date information on the home. Fees range from £560.00 to £600.00 per week and there are additional charges for hairdressing, chiropodist, newspapers and dry cleaning. 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.V346483.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for four hours and fortyfive minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff, and a visiting relative. As part of this inspection surveys were sent to six residents, six relatives’ six health and social care professionals and ten care workers to obtain their views on the service that the home provides. Two residents surveys were returned and both were positive in their comments. Three relatives surveys were returned and comments included that “the home had excellent standards and provided superb individual care and it is a real home”. One health and social care professionals survey was returned and commented on the homes response to residents health care needs saying “the home calls the appropriate services when needed”. Seven care workers surveys were returned and included comments that “the staff work together as a team” and “the way it works is perfect”. “We are continually learning and have many training opportunities and would not change anything” Twenty-five of the thirty-eight standards were inspected. What the service does well: The home carries out a thorough needs assessment before residents move in and provides them with plenty of information on the home and how it runs. The care plans are thorough and assist staff in providing residents with the right level of care for them. The home offers a good range of both indoor and outdoor activities that are increased on special occasions such as birthdays, Christmas and Easter. The home is well looked after and decorated nicely, the furniture is in good condition and replaced when necessary. The home is clean and tidy and has no odorous smells. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 6 Residents are offered plenty of choice and are consulted regularly on what they want to do and eat. The food is of excellent quality. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Moulsham Home DS0000017892.V346483.R01.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 Moulsham Home DS0000017892.V346483.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carries out a thorough pre-admission assessment of needs and provides prospective residents with sufficient information to enable them to make an informed choice. Each resident is provided with a statement of his or her terms and conditions with the home. EVIDENCE: The Statement of Purpose and Service User Guide are together in one document and the owner/manager provides prospective residents with a copy of this document together with copies of the homes complaints procedure and fire notice. The offer letter includes full details of the fees and what is and is not included within them and after an initial day visit residents are offered a four-week trial period. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 9 A contract is provided for each resident and was in place for each of the three residents care files that were inspected. Residents spoken with confirmed that they had signed a contract and were aware of their terms and conditions with the home. The pre-admission assessment process begins on the prospective residents initial day visit and continues with the owner/manager visiting them in their own home wherever possible. Once the assessment is complete the home confirms that it can meet the prospective residents needs and sends them an offer letter that sets out all of the relevant details. This pre-admission assessment informs the initial care plan. Moulsham Home does not provide intermediate care. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 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. 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. The homes care plans contain the information required to meet the residents’ needs. Health care needs are fully met and there is a clear medication policy that is followed by all staff. Residents are treated with respect and their dignity and privacy is upheld. EVIDENCE: Three care files were examined and all contained full details of the level of staff intervention required. All care files contained a completed BASOLL (The Behavioural Assessment Scale of Later Life) and the information gathered on this was fed into the care plans. The care plans inspected were regularly reviewed at monthly intervals. The daily notes were informative and made reference to any health related issues. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 11 The district nurse visits the home weekly or more often when required. If residents are unable to remain with their own GP on admission they have five local surgeries they can choose from. The care files inspected showed clear recordings of health care professionals’ input (nurses, GP’s, social workers) including any staff intervention and any required follow up actions. Medication policy and practice is good and the records on administration were appropriately completed and the senior staff carries out regular checks to ensure any errors are dealt with immediately. The home has a copy of the Royal Pharmaceutical Society of Great Britain guidelines for the Administration of Medication in Care Homes and staff are encouraged to read it and it is stored with the medication administration sheets for easy reference. Residents spoken with commented on how nice staff was and how well they were treated and that staff respected their privacy and were always courteous and polite. Staff interaction with residents was observed and confirmed that they were respectful and polite when assisting residents with their daily activities. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents experience a lifestyle that matches their needs, they are encouraged to maintain contact with family and friends and have as much choice and control over their lives as possible. Residents receive a wholesome appealing balanced diet in spacious pleasing surroundings. EVIDENCE: Moulsham Home offers a good range of activities that includes visits to the local shops and parks. Residents spoken with said how they enjoyed the entertainers’ visits and liked the trips to Tesco’s. Indoor activities included board games, quizzes, sing-a-longs, manicures, cards, and bingo; details of when activities will take place are displayed on the homes notice board. Residents spoke of the activities arranged for special occasions such as birthdays, Christmas and Easter and said that a visit to the theatre to see Cinderella was most enjoyable. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 13 Visitors are welcome at the home and residents and a visitor spoken with confirmed that they were able to visit whenever they wished. The home offers visitors the opportunity to share a meal with their relative should they wish to do so. The home holds regular six weekly residents meetings in addition to consulting them on a daily basis. Residents spoken with confirmed that they enjoyed participating in meetings and were happy to be able to make their own choices. The home displays information on residents’ rights and advocacy services in a conspicuous place on their notice boards. The home operates a 28-day rolling menu that is adjusted to meet individual residents requirements. There is a choice of three different main meals at lunchtime and nutrition records evidenced that further choices are available if required. Residents spoken with said that meals are home cooked, plentiful and that there are alternatives available if wanted. The home receives regular deliveries of fresh meat, vegetables and milk and purchases any other food from the local Tesco’s. A relative spoken with said that they had visited other homes and the food at Moulsham Home is by far the best. The dining room was spacious and all of the tables had condiments, tablecloths and nicely laid out cutlery. There was fresh fruit and sweets available in bowls in the dining area. The home had a good stock of food and the storage area was clean and tidy. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 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. 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. Complaints are acted upon swiftly and all issues are taken seriously by the home. Residents are protected by the homes policy and practice. EVIDENCE: The homes complaints procedure was last reviewed in July 2007. The home provides residents with a copy of the procedure on admission and when any changes are made to it. The last complaint received by the home was in 2003 and this was appropriately dealt with. Residents and a relative spoken with confirmed that they knew how to complain if they wished to do so. All staff has received POVA (the Protection of Vulnerable Adults) training and has been provided with a copy of Essex County Council guidelines for staff booklet. The homes policy and procedure on the Protection of Vulnerable Adults is in the process of being reviewed. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 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. 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. Residents live in a safe well-maintained comfortable environment that meets their needs and it is clean, pleasant and hygienic. EVIDENCE: The home is well furnished and decorated and the owner/manager has in place a rolling programme for redecoration. The lounge carpet has recently been replaced and the fireplace removed due to risk to residents being unsteady on their feet. A new larger television set is due to be delivered shortly. There is a new cooker and a new fridge (lockable with temperature display for medicines) and the home has recently purchased a new medication trolley. Inside and outside space is comfortable and safe and residents spoken with Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 16 said how warm and homely the house is. A relative spoken with said that Moulsham Home is an excellent home and that they offer residents the best possible care. The home was clean, pleasant and hygienic and residents and relatives spoken with confirmed that the home was always clean and tidy and there were never any odorous smells. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 17 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. 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. Staff are competent, well trained and supplied in sufficient quantities to meet residents needs. The homes recruitment practice protects the residents. EVIDENCE: The homes rota demonstrated that there was sufficient staff on duty to meet the needs of the current residents. In addition to care staff the home employs a cleaner and a cook. The manager said that agency staff is only used occasionally when there is no alternative. The home has encouraged staff to undertake NVQ training and 90 of their staff has completed it. The manager and deputy manager has completed NVQ training in care at level 4. The senior carers that are left in charge of the home in the owner/managers absence are all qualified to NVQ level 3 in care. Three staff files were examined and contained evidence of good recruitment practice, however the newest employee did not have a cleared CRB (Criminal Records Bureau) check. There was evidence of this having been applied for Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 18 and a risk assessment had been carried out. This employee does not work directly with residents and always works under staff supervision. The home has recently had a student nurse working with residents on a voluntary basis and all recruitment checks had been carried out and were on the staff file. There was no evidence of fitness on the staff files. The home offers its staff a good range of training and includes service specific subjects as required by the current resident group. Training certificates are displayed in the homes entrance hall and copies are kept on the staff files. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the residents and their financial interests are safeguarded. The home is run in the best interests of its residents. The health, safety and welfare of the residents is promoted and protected. EVIDENCE: The owner/manager has completed NVQ level 4 in care and the Registered Managers Award and has recently had updates in moving and handling and food hygiene. The owner/manager said that she regularly updates her practice Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 20 and attends training with the staff team. The deputy manager has completed NVQ level 4 in care and is competent to manage the home in the owner/managers absence. The home carries out annual audits for its own quality assurance system and compiles a report of the findings. The owner/manager is currently carrying out the process for this year. The home holds small amounts of residents’ cash that is requested from the relatives when required. Three residents cash transaction records were inspected and all were correct. The owner/manager said that she generally paid out small expenses for residents if they had no cash available and needed to purchase items and then she invoiced the relatives for the amount due when requesting the monthly fees. Staff spoken with confirmed that supervision does take place and the staff files supported this, however this does not take place as often as required in the National Minimum Standards. The homes Annual Quality Assurance Assessment states that supervision is carried out on a three monthly basis. The homes policies and procedures are all in the process of being updated. All safety certificates were in place with the exception of the gas. The owner/manager said that the gas safety check has been carried out on 21/6/07 but had not yet received the certificate. Accident and fire records were checked and were all satisfactory. Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 21 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 3 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 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Moulsham Home DS0000017892.V346483.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 19 (1) (i) Schedule 2 Requirement The registered person shall not employ a person to work at the care home unless he holds all of the documents and information as specified in Schedule 2. This refers to the evidence of workers fitness. Timescale for action 30/10/07 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 OP36 Good Practice Recommendations Supervision should be held at least six times a year. 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