CARE HOMES FOR OLDER PEOPLE
The Moorings Church Road Earsham Bungay Norfolk NR35 2TJ Lead Inspector
Mrs Judith Huggins Unannounced Inspection 8th December 2005 11:45 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 The Moorings DS0000027272.V270259.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. The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Moorings Address Church Road Earsham Bungay Norfolk NR35 2TJ 01986 892269 01986 892269 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) Mr Malcolm Paul Blackham Mr Robert James Blackham, Mrs Sally Crawford Mrs Frances Friday Care Home 39 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (39) of places The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Thirty-nine (39) Older People may be accommodated of which thirtyfour (34) may have dementia. Total number not to exceed thirty-nine (39). The home shall have one person on shift at all times who has received training in dementia awareness. 2nd June 2005 Date of last inspection Brief Description of the Service: The Moorings is an extended property situated in six acres of grounds in the village of Earsham, close to the town of Bungay. The home is registered to accommodate up to thirty-nine older people but due to recent conversion of double bedrooms to single rooms, the home currently accommodates thirtyfour service users in twenty-eight single and three double bedrooms. The three double bedrooms have an en-suite facility. Four single rooms do not but there are plans for en-suite facilities to be provided in two of these. Bedrooms are on the ground and first floor with the first floor accessed by passenger lift. There is car parking to the front and the side of the property. The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place unannounced and lasted just over four hours. A number of events during the day meant that staff were not interviewed in detail. However, both assistant managers, one of the partners, and one member of ancillary staff were spoken to. In addition, the inspector spent some time in three of the communal areas of the home, listening and observing interactions between staff and residents. Five residents were spoken to and, despite some confusion, able to express some views about the quality of the service they receive. Comment cards were left for relatives and visitors, but none was received before the report was drafted. What the service does well:
As at the last inspection, the environment of the home is being very well maintained. The work in progress at the last visit has been completed, and areas of the home were clean and tidy. Residents spoken to say that the “girls” are very good and very kind. Staff were noted as responding well and calmly to residents, including when one became distressed. They also took pains to explain what they were doing when they needed to use hoists to move people, recognising that this can otherwise be a very frightening process. Staff were respectful, kind and caring in the interactions seen or heard during the inspection. The findings of the home’s survey of relatives, notified since the last inspection, show that relatives feel the service is good quality, and that they consider this has improved. This includes factors such as the “atmosphere” of the home and the attitude of staff. One of the partners has recently completed one of the quarterly audits of service quality, looking at a good range of issues and identifying where there is a need for improvement. The thorough approach to monitoring the quality of the service means that “budding” problems can be picked up and remedied before residents are affected. Residents like the food that they are offered they say, and despite difficulties with short-term memory in many cases, choices are still offered and recorded so that residents can be given what they like for meals. Overall, the service is good quality and the varying needs of some very dependent and confused residents are dealt with calmly and in an organised manner.
The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 6 Given that staff were dealing with a death, which had occurred earlier in the day, needed to deal with one episode of difficult behaviour, and the fire alarm went off during the afternoon, the inspector commends the calm and professional manner the staff team carried on with their duties. What has improved since the last inspection? What they could do better:
Although reviewed regularly each month, care plans need to be updated when there are obvious changes, such as following discharge from hospital with a fracture. Such an injury would obviously affect the mobility of a resident, and also how they would be helped with personal care such as washing or bathing and dressing. The care plan needs to set out how these needs are to be met so that the person’s needs can be met during the time they take to recover, and to encourage this recovery. Similarly, changes in medication made by the GP need to be clarified and acted upon, so that people receive prompt treatment to help address individual problems.
The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 7 The scheduling of medicines needs to be looked at to make sure that people are not having doses of the same medicines too close together as this could result in people becoming affected too much by the medicines given. Also, to ensure that any medication needed early in the morning can be given at the time the GP considers necessary and without affecting residents adversely. This is particularly important where other does of the same medicine are given at lunchtime, or when it needs to be given before the resident has their breakfast. It would be helpful to make sure that there are clear indications in care plans, when weight loss (or gain) should trigger additional support or advice from the GP or dietician, to ensure that residents’ nutrition is maintained. Although, in discussion, the management team are aware of this, the supporting records do not “do justice” to their knowledge and practice. Although staff responded calmly and confidently when the fire alarm was activated (not a drill on this occasion), there was some delay in establishing whether there was a fire, so losing valuable time that would be needed if an evacuation was required, and putting another staff member at risk when the first one checking did not return promptly. Businesses are required by the fire brigade to have an evacuation plan, and advice should be taken from them to ensure that the plan balances the need to avoid calling the brigade unnecessarily, with the need to ensure that assistance is called promptly if this is needed. 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 Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The standard is not applicable. The home does not admit people for intermediate and rehabilitative care. EVIDENCE: The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 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 Residents’ health, personal and social care needs are set out in a plan of care. Residents’ health care needs are followed up with the GP but not fully met. Some work is needed to ensure that procedures for dealing with medicines fully address needs. EVIDENCE: Care plans for four people were checked. These provide evidence of regular review of both assessments and care plan goals, with dates entered monthly. One important risk assessment (for manual handling) seen has not been dated and signed by the person taking responsibility for its completion. There is evidence that health care issues are referred to the GP and discussed at regular visits. This is recorded in individual care plans, and also on a separate sheet recording who needs to see the GP (or where advice is needed), and what the issues of concern are. One person returning to the home with a broken ankle, following a period in hospital, did not have the care plan updated. It is evident from daily notes that the fracture was taken into account, and the care plan was updated at the
The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 11 normal review date. However, it did not show the person’s health care needs, and changes in practices for example for moving and handling and maintaining personal hygiene that were necessary from the point of return to the home. Residents weights are monitored to ensure that concerns can be addressed, although there is no clear guidance on nutrition assessments about trigger points for increased monitoring or referral for the dietician’s advice. For example, one person has lost 7 pounds in three months. There is no indication or assessment of whether this is desirable or concerning. However, discussion with the partner present and assistant manager showed that this area is monitored and discussed by care staff, and referred where there are concerns. The process of administration of medication observed, followed good practice. Dosages on medication packs and administration records were checked, and the person carrying out the activity secured the cooperation of residents, encouraging them to take the medication, encouraging drinks and making sure that the medication had been taken before signing the administration record. The trolley was locked each time it was left unattended for any reason. However, the GP visited one person and a change in medication is recorded on the GP visit file and in the person’s care plan. This has not, based on medication administration records, been clarified or acted upon. Records show when residents have refused to take medication. On some occasions this is recorded as given later in the day. This presents difficulties where another dose of the same medication is due later in the day. For example, one person refused a morning dose of one tablet, which was then recorded as administered at 2.15, with another dose administered at teatime. (This could contribute to over sedation, or increased risk of falls for example.) A large proportion of the medication is given in the morning, meaning that the round takes a considerable time to complete. This can, according to a staff member responsible, take from 7.30am to 10 or 10.30am. Less medication is due at lunchtime and the round was completed in a timely manner. Medication administration charts are annotated with the location of medicines that are not in blister packs, as a reminder for staff. This is good practice. The staff member responsible confirmed that training is provided. The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 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): 14, 15 Residents are enabled to make choices and exercise control, as far as they are able. Residents receive a wholesome, appealing and balanced diet in pleasant surroundings. EVIDENCE: All of the residents at the home have some degree of dementia and confusion. However, efforts are made to consult people about routine choices such as what to wear and what to eat. Residents’ rooms show that they are able to bring in personal items and records show that this is arranged for people in order to create a more homely and familiar environment. Residents are asked each day, what they would like to eat the following day, and this is recorded. Those spoken to were not sure what was on the menu having forgotten what they had been asked, but said that the food is good. The cook confirmed care staff check choices, and that she freezes portions of any food left over (dated) so that there is a range of options available for people who might like something different. She has a list of those people who are diabetic. There are, according to the cook, no residents who currently
The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 13 need food to be pureed. The main meal on the day of the inspection was beef stew, dumplings, mashed potato and fresh vegetables. It smelled appetising. There is a range of dining areas spread through the home so that residents can eat in small groups. Each was set with napkins and appropriate cutlery. One area does not have tablecloths, although these are used in the other areas. Training in “food for thought” for people with dementia has been provided for the cook. The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 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 Residents and relatives can be confident their concerns will be listened to and acted upon. EVIDENCE: There is a complaints procedure available. The record checked showed that none have been made, and the home has a good record of “customer satisfaction” from their own surveys. There are letters or cards complimenting the service and there have been no complaints made directly to the Commission, or concerns expressed in the last year. The practices of monitoring service quality by regular audits, help to identify and address issues which might present concerns so that these can be addressed proactively. The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 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, 26 Residents live in a safe, well-maintained environment. The home is clean, and hygienic, although with some odour in a very limited area. EVIDENCE: Redecoration and refurbishment on a large scale has been completed. Décor is generally in good condition, with minor damage for example where a resident has peeled a patch of wallpaper in the ground floor corridor. A first floor corridor to the rear of the home has been improved, with tiled flooring now carpeted. No concerns have been raised in relation to fire safety by the fire authority. Areas of the home looked clean, and in none of the communal areas was there any unpleasant odour – these being maintained to a good standard. However, there are difficulties in one area where problems within a room or rooms are resulting in odour detectable in the corridor. This aspect of hygiene measures
The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 16 is looked at when the quality audits take place, so that it is monitored and addressed. For this reason no requirement is made at present. The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 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 Residents’ needs are met by the numbers and skill mix of staff. EVIDENCE: Residents speak highly of the staff, saying that they are very good. Interaction between staff and residents was observed on a number of occasions and in different locations. Staff were able to move and handle residents competently and used persuasion and encouragement where residents were confused. Staff provided explanation to residents for each activity observed, when they were helping residents. The staffing complement during the afternoon has been increased by one, although unfortunately one person reported sick on the day of the inspection. There is a nucleus of staff with considerable experience working at the home. The Moorings DS0000027272.V270259.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): 31, 33, 35 and 38 Residents live in a home run and managed by a person fit to be in charge and able to discharge responsibilities, and who is working towards achieving the qualifications required in the standard. The home is run in the best interests of residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff is monitored and promoted. EVIDENCE: The manager has applied for, and been successful in obtaining, registration as a “fit person” with the Commission. She has extensive experience within the home, working her way up through the care team structure, and has a good understanding of the care needs of older people, as demonstrated in her
The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 19 interview and supporting paperwork. She is working towards the management qualification she needs so that the management of the home fully meets the standard. The partners support her closely. The partners continue to monitor the quality of the service via a range of means. This includes objective and regular audits, and provides for discussion with staff and residents (in so far as residents are able to express a view). There is an annual survey of relatives. The last quarterly audit was viewed. There are interim audits looking at smaller and more discrete areas of service delivery. Each audit results in a programme of action and identifies who will be responsible. Records of these are available in the home and the Commission is notified of the results of surveys of relatives. The manager and assistant managers have access to monies held for safekeeping. Residents’ relatives are invoiced for expenditure incurred, or monies held may be used. The partner auditing service quality does not at present, check the records kept. Health and safety issues are monitored via the regular audits, with different emphasis according to what issues have previously been focussed upon. Accidents are monitored and some analysis has been identified as desirable, also actions to minimise the risk of these happening again. Two residents have had high numbers of falls in the last month and the reasons are being looked into, according to the partner present. This is good practice. (Account needs to be taken of issued raised at standard 9.) The fire alarm went off unexpectedly during the inspection and automatic fire doors closed appropriately. Staff reported to the hall area to see which zone was affected and maintained a calm demeanour. However, the process of checking this zone took a considerable time and a second person then placed themselves at potential risk. This did ensure that the fire brigade was not summoned unnecessarily, but resulted in some delay should this have been necessary. The Moorings DS0000027272.V270259.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 x x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 4 x 3 x x 3 The Moorings DS0000027272.V270259.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 OP8 Regulation 14 and 15 Requirement The registered persons must ensure that assessments and care plans are reviewed promptly where there are significant changes (and not wait until the expected monthly review date), so that they reflect current needs and how these are to be met. The registered persons must ensure that changes in medication made by the GP, are clarified and acted upon promptly to ensure residents receive the medication they are prescribed. The registered persons must seek advice about intervals between doses of medication, where these are not given at the prescribed times for any reason, and clarify the actions required of staff to ensure therapeutic levels are not exceeded. Timescale for action 31/01/06 2 OP9 13(1) 31/01/06 3 OP9 13(2) 31/01/06 The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 22 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 OP7 Good Practice Recommendations The registered persons should ensure that all assessments are dated and signed by the person completing them as an aid to monitoring review frequency and maintaining accountability. The registered persons should ensure that nutrition assessments and eating and drinking care plans are clearly linked to show what weight range (and body mass index) is desirable in each case, and identify trigger points for action. The registered persons should review the morning medication round to ensure that residents receive their medication at prescribed times, and secure advice about rescheduling doses (see requirement 3 above). The registered persons should ensure that the partners’ quality audit provides for periodic inspection and check upon records of valuables/finances held on behalf of residents. The registered persons should review fire and evacuation procedures and seek advice of the fire officer about the evacuation plan to ensure that staff are not unnecessarily exposed to risk and that there is no unnecessary delay in summoning the fire brigade or initiating evacuation. 2 OP8 3 OP9 4 OP35 5 OP38 The Moorings DS0000027272.V270259.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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