Inspection on 30/06/05 for Moulsham Home

This inspection was carried out on 30th June 2005.

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 25/07/06

Moulsham Home 02/11/05

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 OJN Lead Inspector Alan Thompson Final report Unannounced 30th June 2005 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 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 I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Moulsham Home Address 116-117 Moulsham Street, Chelmsford, CM2 0JN Telephone number Fax number Email 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 I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 Date of last inspection 27th January 2005 Brief Description of the Service: Moulsham Home is an adapted large 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 were 12 single and 3 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 I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 1045 hours and ended at 1530 hours on Thursday 30th June 2005. This was the first 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 the findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Six residents and three staff were spoken with. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All residents spoken to confirmed that they were satisfied with the care they received and with the accommodation and food offered. Staff confirmed they had been offered NVQ award level 2 training. What the service does well: 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. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 7 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 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 I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 8 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 standard(s) 7 & 10 Care plans in place set out the residents daily needs to provide staff with the actions required to meet these. Staff pay attention to ensuring that residents privacy and dignity is respected. EVIDENCE: Care plans were inspected. The format was unchanged since the last inspection and met the standard. Information included residents’ personal and background history, next of kin details and name of GP. A daily plan of care is documented under headings of eating, drinking, breathing, mobility, behaviour, mental state, sleep, personal cleansing, dressing, elimination, work & play, daily likes/dislikes, memory, social & leisure, personality, family contact, medical, orientation, teeth, hearing. Residents are weighed every month, records of this were included in care plans. All care plans inspected had been regularly reviewed by staff. Also seen in care plan files were personal risk, risk of falls and manual handling assessments. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 9 The care manager confirmed that residents’ rights were covered at the induction of new staff. Residents spoken with confirmed that they were always treated with respect and courtesy by staff and said they had no complaints about staff attitudes. Consultations with health care professionals takes place in private rooms, screens were provided in shared rooms. Residents also said that staff providing personal care always closed doors to ensure privacy. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 The home had maintained good contact with, and encouraged involvement from relatives. Involvement had also been welcomed from community contacts. EVIDENCE: Visitors are welcome at all reasonable times. This was confirmed by residents spoken with. Staff offer refreshments to visitors. Shared rooms had privacy curtains and there was also a designated ‘visitors lounge’ on the lower ground floor. Written information on this subject was included in the statement of purpose and service users guide. On-going community contact included a volunteer singing group visiting once a month, a student from a nearby college visiting regularly, and local clergy visiting weekly and monthly to offer services in the home. One resident visits a school each week for lunch, and several residents attend a local chapel once a month for tea. Residents said in they wish to go shopping staff will take them into Chelmsford town centre. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. EVIDENCE: The homes complaints policy was inspected, this was seen to include information to the prospective complainant on who to complain to, with timescales for a response from the home. Also included were contact details of the local CSCI office and of the local Citizens Advice Bureau and Community Health Council. Written guidance is provided to staff on recording complaints. Records are kept in the home of all complaints received and of actions taken, none had been recorded since the last inspection. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Furnishings in the home looked comfortable and the premises were well maintained. Private accommodation was comfortable and suited to needs and preferences. The premises appeared safe, were accessible, and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was 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. 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. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 13 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 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. All rooms were centrally heated with thermostats fitted to bedroom radiators, as were radiator guards. The manager confirmed that hot water was regulated for delivery at or close to 43 degrees Celsius (not tested). The inspector asked residents if the lighting in their rooms was adequate for them, those who expressed an opinion said it was. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staffing levels and skills appeared to meet the needs of residents. Staff recruitment procedures aimed at the protection of residents had not always been followed. This could result in there being a risk to residents. EVIDENCE: Staffing rotas were inspected. Minimum staffing levels remain three carers on daytime shifts except between 1500 – 1600 hours when 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. The care manager confirmed that care staff were a minimum 18 years of age and that staff left in charge were at least 21 years of age. Staff files were inspected and those seen contained application forms, a record of training, contracts of employment, copies of proof of identity with a photograph, and induction records. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 15 Criminal Records checks had been applied for, however one member of staff employed since May 2005 only had a copy of a CRB disclosure dating back to 2002. This did not comply with the Criminal Records Bureau’s current guidance and requirements. Advice was therefore provided to the care manager relating to the minimum expected level of checks to be undertaken before new staff commence employment in the home. There is a requirement in this report on this matter. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 37, 38 Residents monies held in the home had been managed competently. Records required by regulation were up to date but until staff recruitment records held in the home include evidence that CRB disclosure checks are in place this standard cannot be fully judged. The health and safety of residents and staff was generally assured. EVIDENCE: One resident continued to fully manage his own finances The remaining residents’ personal allowance monies were held for safe keeping in the home in a locked safe. No benefit books were held. All personal allowance monies are provided by relatives, transactions were recorded. A sample of these records were inspected and were considered to be appropriately maintained. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 17 Random samples of other records inspected included: care plans, staff rota, records of monies held for safe keeping, regulation 37 notices, details of next of kin and background information, accident records, visitors book, fire drills, fire procedures, nutrition records and staff recruitment records. All were considered appropriately maintained except staff recruitment records which is explained by the requirement made under standard 29. Staff are trained in manual handling, infection control, first aid, fire safety, food safety, medication practices and health & safety. Certificates of evidence were displayed in the entrance hallway. Information was available for staff on the control of substances hazardous to health regulations (COSHH). Certificates/records seen evidenced that the homes fire alarms, fire equipment, gas equipment, electrical systems, emergency lights, passenger lift, portable electrical appliances, stair lift and portable & fixed hoists had all been tested/serviced by appropriate contractors. The homes’ in-house induction training package includes topics covering health and safety and safe working practices. There was a premises risk assessment in place. Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x 3 x 2 3 Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? 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 29 Regulation 19 Requirement The registered provider must ensure that criminal records bureau checks are in place on all new staff employed. Timescale for action 31/7/05 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 None Good Practice Recommendations Moulsham Home I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Fairfax House Causton Road Colchester, Essex COl lRJ 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 I56 I05 S17892 Moulsham Home V23256 UI 30.6.05 Stage 4.doc Version 1.30 Page 21 - 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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