Inspection on 25/07/06 for Moulsham Home

This inspection was carried out on 25th July 2006.

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 24/07/07

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 Key Unannounced Inspection 25th July 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 Moulsham Home DS0000017892.V297921.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.V297921.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 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.V297921.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 5th May 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 £540.00 to £570.00 and there are additional charges for hairdressing, chiropodist, newspapers, toiletries 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.V297921.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 five hours and five minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff, and some visiting relatives. As part of this inspection surveys were sent to eight residents, three relatives’ two General Practitioners, two district nurses and the social worker to obtain their views on the service the home provides. Five residents surveys were returned, four were positive in their comments, the fifth stated that the home could offer more activities and could do with more staff. All relatives surveys returned stated that the home provided an excellent service and that they were always welcomed in to the home at any time. General Practitioners surveys were returned and both were positive in their comments, one saying that the surgery has a good working relationship with the home and that it provides an excellent service and that people are well cared for. All other survey forms returned were positive. Twenty-nine of the thirty-eight standards were inspected. What the service does well: What has improved since the last inspection? Residents have been assessed for a stand-up hoist, which has been purchased by the home recently. This has improved the quality of life for those using it. New windows have been fitted around the home. Many areas of the home have new carpet fitted. Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 6 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. Moulsham Home DS0000017892.V297921.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.V297921.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the 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 terms and conditions with the home. EVIDENCE: The homes Statement of Purpose is combined with their Service User Guide and the homes complaint procedure is attached and this is supplied to prospective residents prior to any visits. The Statement of Purpose and Service User Guide are in the process of being updated to include recent changes to staff qualifications. Each resident is provided with a contract of his or her terms and conditions with the home. Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 9 A pre-admission assessment is carried out initially both in their own home and at Moulsham, where prospective residents are invited to spend the day, have a meal and meet the staff and other residents. On admission the assessment is updated to include any further information gained and the assessment then informs the care plan. Moulsham Home does not provide intermediate care. Moulsham Home DS0000017892.V297921.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 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 judgment has been made using available evidence including a visit to the 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. There are no protocols in place for administering as and when required medication. Residents are treated with respect and their dignity and privacy is upheld. EVIDENCE: Care plans examined evidenced that the care provided is regularly reviewed and that any changes in residents’ health, personal or social needs are met. The home keeps clear records of all health professionals visits. The district nurse visits weekly or more often when required and provides treatment and any appropriate aids that are needed. Medication is administered by senior staff that are trained in administering medication. The homes policy on ordering, supply, storage, administering and Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 11 disposal of medication provides clear instructions to staff. As and when (PRN) medication did not have clear guidelines of why, how, when, what dose and how often it should be administered. To ensure residents safety PRN protocols must be in place for all PRN medication that is prescribed. The home does not have a copy of the Royal Pharmaceutical Society of Great Britain guidelines for the Administration of Medication in Care Homes, the owner/manager said that a copy would be obtained from the Internet and that it would be shared with the staff team. Residents spoken with said that they felt that staff treated them well and with respect, staff interaction with residents on the day of the inspection was observed to confirm this. Staff were sensitive when addressing residents and care was taken when assisting them in various situations. Moulsham Home DS0000017892.V297921.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 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 judgment has been made using available evidence including a visit to the 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: The home offers a range of activities that include, bingo, indoor games, quizzes, sing-a-longs, manicures, board games and cards. An entertainer visits the home regularly and residents confirmed that they enjoyed this. Regular outings in the community include shopping trips, church, pub and seasonal activities. Residents spoken with confirmed that they were able to have visitors whenever they wished and that the home often offers relatives the opportunity to share a meal with them. Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 13 Regular residents meetings are held in addition to daily consultation with residents on their requirements. Information on advocacy services, planned activities and residents rights is displayed around the home. Residents and their relatives spoken with commented on how good the food was and that there was always plenty of choice and other options available should they change their mind. The planned menu shows a choice of three different options each lunchtime and nutrition records confirmed that further choices of meals were available if required. The dining area was spacious and the tables were attractively laid out. The home had a good stock of food and beverages in its clean and tidy storeroom. Moulsham Home DS0000017892.V297921.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 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 adequate. This judgment has been made using available evidence including a visit to the service. Complaints are acted upon swiftly and all issues are taken seriously by the home. No up to date training on the Protection of Vulnerable Adults has taken place. EVIDENCE: The home has a complaints policy and each resident receives a copy prior to their admission; the policy is in the process of being updated by the owner/manager, who will then provide residents with an updated version. Residents and their relatives spoken with knew who to take their concerns to if they needed to and were confident they would be acted upon. The homes policy and procedure on the Protection of Vulnerable Adults is in the process of being reviewed. Each staff member has been supplied with the Essex County Council guidelines for staff booklet. There has been no recent staff training provided on the Protection of Vulnerable Adults. All staff must have up to date training on the Protection of Vulnerable Adults. Moulsham Home DS0000017892.V297921.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 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents live in a safe well-maintained comfortable environment that meets their needs and has sufficient communal facilities that are clean, pleasant and hygienic. EVIDENCE: The home is well furnished, well maintained and safe for its residents. New windows have just been fitted to the front of the premises. The manager/owner said that re-decoration takes place on a rolling programme. The garden area contains chairs, benches and tables with umbrellas and has steps leading into the car park at the rear of the building. One resident spoken with said that they enjoyed sitting in this quite area to read their book. Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 16 The lounge area is L shaped and spacious and residents spoken with said they enjoyed the opportunity to get together and have singsongs with others, they also commented on enjoying their music. The home has two assisted baths and a walk in shower, there are sufficient communal toilets located close to the lounge area. All the bedrooms are very individual and have many personal possessions in them. Residents confirmed that they were able to bring smaller items with them. All radiators were covered and have thermostats fitted and the new windows all have restrictors on them. Hot water taps are fitted with regulators and those tested were within the required range. All bedrooms have foot pressure mats in them to alert night staff when residents require support. The home was clean, pleasant and hygienic and a relative who visits the home regularly at varying times of day confirmed that the home is always clean and pleasant. Moulsham Home DS0000017892.V297921.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 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 adequate. This judgment has been made using available evidence including a visit to the service. Staff are well trained, competent and supplied in sufficient quantities to meet residents needs. The homes recruitment practice does not meet all the requirements to support and protect the residents. EVIDENCE: The homes duty rota evidenced that sufficient staff were rotered for each shift; the owner/managers hours are supernumery. There are three carers on shift during the daytime and two carers awake throughout the night. Shifts overlap to ensure that adequate handovers take place. The home employs a cleaner and a cook in addition to care staff; existing staff or the owner/manager covers any vacant shifts. The home rarely uses agency staff but has done so occasionally on a night shift. All but the newest staff have achieved NVQ training at a minimum of level 2; the owner/manager and the deputy manager have both achieved the Registered Managers Award recently. The benefits of collating training records to assist in identifying training needs were discussed with the owner/manager. Three staff files were inspected and all but the newest staff recruited contained all the required documentation. One file contained only one reference that had declined to comment, as the employee had not been employed for long. Two Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 18 written references must be obtained before appointing a member of staff. The same file did not contain a Criminal Records Bureau or POVA First check. A satisfactory CRB check and a satisfactory check against the POVA First list must be carried out before staff are confirmed in their post. The owner/manager had applied for the CRB and was waiting for more evidence from the employee to complete the form. A POVA First check was applied for in the inspectors presence by the owner/manager and a copy of the results will be forwarded to the CSCI. The owner/manager said that she had undertaken a risk assessment for this employee and they do not work unsupervised until the appropriate checks have been received. There is evidence of staff training that includes service specific training in addition to the mandatory requirements. Moulsham Home DS0000017892.V297921.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home is well managed and run in the best interests of the residents and their financial interests are safeguarded. The health, safety and welfare of the residents is promoted and protected. EVIDENCE: The manager has completed NVQ Level 3 in care and the Registered Managers Award and updates herself with regular training. The home holds residents personal spending money that is requested from the relatives when needed. Three residents financial files were inspected and all were correct; two of the residents owed money to the home, which the Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 20 owner/manager said were paid back when fees were invoiced if relatives did not respond to requests for more spending money. All safety certificates were in place. Policies and procedures are all in the process of being updated. Accident and fire records were appropriately maintained. The home has recently changed its supplier of cleaning products and is awaiting safety data sheets. Moulsham Home DS0000017892.V297921.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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X 3 3 3 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 X X 3 X X 3 Moulsham Home DS0000017892.V297921.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 OP9 Regulation 13 (2) Timescale for action The registered person shall make 31/10/06 arrangements for the safe administration of medicines in the care home. This refers to the protocols for PRN (as and when) medication. The registered person shall make 31/10/06 arrangements for staff to be trained in the Protection of Vulnerable Adults. This is a repeat requirement. The registered person shall not employee a person to work in the care home unless they have a satisfactory Criminal Records Bureau check and have been checked against the POVA First list. This is a repeat requirement. 31/10/06 Requirement 2. OP18 13 (6) 3. OP29 19 (1) (i) Schedule 2 Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Moulsham Home DS0000017892.V297921.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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.V297921.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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