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Inspection carried out on 1 March 2017

During a routine inspection

We carried out this unannounced comprehensive inspection on 01 and 02 March 2017. This inspection was undertaken to ensure improvements that were required to meet legal requirements had been implemented by the service following our last inspection on 03 June 2016.

At the previous inspection improvements were required to ensure medicines were managed safely and this was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, with regards to safe care and treatment. At this comprehensive inspection on 01 and 02 March 2017 we found improvements had been made to meet the relevant requirements previously identified at the inspection on 03 June 2016.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People who used the service and their relatives told us they felt the service was safe. There were appropriate risk assessments in place with guidance on how to minimise risk.

We observed good interactions between staff and people who used the service during the day. People felt staff were kind and considerate.

Recruitment of staff was robust and there were sufficient staff to attend to people’s needs.

Medication policies were appropriate, comprehensive and medicines were administered, stored, ordered and disposed of safely. Safeguarding policies were in place and staff had an understanding of the issues and procedures.

People’s nutrition and hydration needs were met appropriately and they were given choices with regard to food and drinks. Staff responded and supported people with dementia care needs appropriately. Care plans included appropriate personal and health information and were up to date.

People’s health needs were responded to promptly and professionals contacted appropriately. Records included information about people’s likes and dislikes and we observed that people had choices, for example, about when to get up, what to do and when and where to eat.

Staff were caring and kind with the people they supported. Throughout the inspection we observed staff members to be kind, patient and caring whilst delivering care.

People and relatives told us they were involved in making decisions about their care and were listened to by the service.

We saw people being treated with kindness and respect and when support was provided, such as supporting people eating their lunch time meal.

We found the service aimed to embed equality and human rights through well-developed person-centred care planning which ensured that each person had a person-centred plan in their care files.

People were involved in developing their care plan and sensitive information was being handled carefully.

The service had a service user’s handbook called Moorfield House Service User Guide which was given to each person who used the service in addition to the Statement of Purpose.

The service followed the Six Steps programme in end of life care and were supported by relevant community professionals.

People who used the service and their relatives spoke positively about how the service was managed.

Staff told us they felt there was an open, transparent and supportive culture within the home and would have no hesitation in approaching the manager about any concerns.

The service undertook a range of audits of the service to ensure different aspects of the service were meeting the required standards.

There was a business continuity plan in place that identified actions to be taken in the event of an unforeseen event.

Throughout the course of the inspection we saw the registered manager walking around and observing and supporting staff.

Residents and relatives meetings were undertaken approximately every three months and comments from people who used the service were positive.

The service worked alongside other professionals and agencies in order to meet people’s care requirements where required.

Inspection carried out on 3 June 2016

During an inspection to make sure that the improvements required had been made

This was an unannounced inspection carried out on the 03 June 2015. At our previous inspection undertaken on 09 October 2015 and 18 February 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the safe management of medication. As a result, we took enforcement action in relation to these concerns and the home was served with a warning notice. As part of this unannounced focused inspection we checked to see that improvements had been implemented by the service in order to meet legal requirements.

This report only covers our findings in relation to those requirements. You can read previous inspection reports, by selecting the 'all reports' link for Moorfield House on our website at www.cqc.org.uk.

Moorfield House is registered to provide accommodation and personal care to up to 33 people. The home is located in Irlam, on the corner of Moorfield Road and Liverpool Road, close to local shops and bus routes.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

During this inspection, we found that although improvements had been made in the safe handling of medicines within the home, improvements still needed to be made. At the previous visit, we found that some people had ran out of stocks of medicine and that medication was not always given as prescribed. Medicine Administration Record Sheets (MARS) were not always completed fully.

On the day of this inspection there were 33 people living in the home and we checked the medicines and records for five people living at the home. The five people had a full supply of medicines in the home at the time of the inspection.

Although clear improvements had been made we found that medicines were not always given as prescribed by the doctor. One person who was prescribed a shampoo from their doctor to be used twice a week had their MARS signed daily. A second person was not given their blood pressure tablet for seven days out of 19 as it had been declined by the person, or they were sleeping. The same person regularly refused most of their medicines; however there was no record of staff asking for the doctor to review.

We saw one night time medication had been incorrectly signed as given on the day of our inspection, because the dose was not due until that evening.

This is a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, because the provider did not have appropriate arrangements in place to manage medicines safely. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 18 February 2016

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 09 October 2015. During that inspection we found three breaches of Regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Moorfield House is registered to provide accommodation and personal care to up to 33 people. The home is located in Irlam, on the corner of Moorfield Road and Liverpool Road, close to local shops and bus routes.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

As part of this unannounced focused inspection we checked to see that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Moorfield House on our website at www.cqc.org.uk.

During this inspection, we found that the registered person had not protected people against the risk of associated with the safe management of medication. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

The assistant manager confirmed that all staff had now received medication training, which we verified from training records. This enabled the home to administer medication at any time within a 24 hour period, such as in circumstances were people required pain relief.

We found that the home had introduced body maps to assist staff when applying prescribed creams, however not all records where creams had been prescribed had body maps attached. A number of records we looked at showed people were prescribed at least one medicine to be taken ‘when required.’ We still found that not all medicines prescribed in that way had adequate information available to guide staff on to how to give them. We found there was no information recorded to guide staff on which dose to give when a variable dose was prescribed.

We found some medicines were not always given as prescribed by the doctor. We found that five people who had been prescribed certain medicines had ran out of stock for a period of between two to four days. One person who had been prescribed a medicine, had ran out of stocks on the 13 February 2016 and the medicine was still not available on the day out our inspection. We spoke with the registered person about these concerns, who told us that the failure to receive replacement stocks were due to either the GP failing to sign the prescription or the chemist not delivering stocks on time. The registered person assured us that they would contact the GP and pharmacy to ensure that medicines were provided when people needed them.

In one record we looked at where a person had been prescribed food suppliments, there were no records on the MAR to demonstrate that the medication had been given to the person who used the service. In another record we looked at, where a person had been prescribed a medicated shampoo, no records existed to demonstrate that it had been administered. In both instances, the assistant manager told us that the medication had been administered, but staff had failed to maintain appropriate records.

This is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, because the registered person had not protected people against the risk of associated with the safe management of medication.

At our last inspection we found that the registered person had failed to provide person centred care that reflected personal preferences. This was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, person centred care. This specifically related to choices around meal times and included the absence of choice for people on pureed diets.

During this inspection, we found the provider was now meeting the requirements of the regulation. We looked at a menu board outside the dining rooms, which indicated two choices of main meals and deserts were provided. During our visit we watched staff and the cook ask people what they wanted for their lunch, which included the options available. The cook also explained to us that if people were not happy with choices available, they would provide other options and people could have what they wanted.

For pureed diets, we saw that people has chosen chicken, mashed potatoes and mixed vegetables. These meals were presented in an appetising manner on individual plates. People on pureed diets were individually asked by the cook what they wanted. We also looked at a four weekly menu that the service used, which had involved input from people who lived at the home.

During our last inspection we found that the provider had failed to assess and monitor the quality of service provision. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to good governance.

During this inspection we found that the service was able to demonstrate that they were meeting the requirements of regulations. The service had implemented a system audits including environments and food hygiene. Other audits included cleaning, mattresses, pressure cushions and other equipment such as hoists and wheel chairs.

The home had introduced a system of monitoring accidents and incidents including falls, which were reviewed by the clinical lead on a monthly basis. This ensured appropriate action had been taken to address increased risks to people following incidents or falls. The home had also introduced checks to ensure that written consent had been obtained from people who used the service in order to ensure that care files accurately reflected people’s written consent or that of their representatives.

We looked at minutes from resident meetings, which included families. Issues debated included fundraising for the benefit of the home, activities and establishment of a ‘tuck shop’ for people who used the service. We were told that resident meetings would be scheduled for the remainder of the year, with the next meeting arranged for April 2016. The home had introduced a suggestion box in the reception area and had distributed questionnaires to people and families. We looked at some responses that had already been received, which spoke favourably of the services provided.

Inspection carried out on 09 October 2015

During a routine inspection

This was an unannounced inspection carried out on the 09 October 2015.

Moorfield House is registered to provide accommodation and personal care to up to 33 people. The home is located in Irlam, on the corner of Moorfield Road and Liverpool Road, close to local shops and bus routes.

At the time of our visit there was a registered manager in place, though they were not present during the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection carried out in April 2014, we did not identify concerns with the care provided to people who lived at the home.

During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During the inspection we checked to see how the service managed and administered medication safely. We found people were not always protected against the risks associated with medicines, because the provider did not have appropriate arrangements in place to manage medicines safely.

We were told that night staff did not administer medicines. During our inspection we identified a number of people who required the administration of PRN medication, this is medication given as and when required such as Paracetamol to relieve pain. This meant no member of staff was able to administer any PRN medication during the night-time if it was required.

We found that a number of records we looked at were prescribed at least one medicine to be taken ‘when required.’ We found that all medicines prescribed in that way did not have adequate information available to guide staff on to how to give them. We found there was no information recorded to guide staff on which dose to give when a variable dose was prescribed. It was important this information was recorded to ensure people were given their medicines safely and consistently at all times. We also found there was no information recorded to guide staff as to where to apply creams to ensure people were given the correct treatment.

We found one medicine, which was dated the 12 August 2015, where manufacturer’s instructions clearly stated that the medication once opened should be thrown away after 28 days. We spoke to a senior member of care staff who confirmed that the medication had been opened on the 12 August 2015. We found that contrary to manufacturer’s instructions the medication had not been disposed of as instructed and was in fact still being used by the service. We were told by the member of staff that the medication would be disposed of immediately.

We found that the registered person had not protected people against the risk of associated with the safe management of medication. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

We found people on pureed diets received the leftovers from the previous day’s lunch, which was stored in the fridge. We asked how people on a pureed diet were given a choice. The cook told us they were not offered a choice.

The cook also explained that when the drinks trolley was taken around in the morning, it was at that time other people were asked what they wanted for lunch. We were also told there was no choice on Fridays as people just wanted fish and chips. However, according to the menu there should have been the choice of battered fish or cottage pie, plus two desserts. What was offered was a fish cake, chips and mushy peas and no cottage pie.

When we asked about this we were told that all the residents had asked for fish, however, when we spoke to one person just before lunch about what they wanted for lunch, after explaining the options available, they told us they wanted cottage pie. There was no alternative potato or vegetable available. In addition, there was only weak squash available to drink in plastic cups. One person complained that their squash was warm. Though they received an apology, no attempt was made by staff to replace it, or to add an ice cube. The meal experience was very task orientated.

This was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, person centred care, because the provider had failed to provide person centred care that reflected personal preferences.

We found the service undertook a limited number of audits including environmental, medication and food safety. A medication audit had also been undertaken by an external pharmacist. We were provided with no evidence of how the service monitored falls as a means of identifying any trends and how the service learnt from complaints or concerns raised by people. We spoke to the clinical manager about the effectiveness of auditing by the service, especially in light of the concerns we identified in respect of medication, dementia friendly environments, the meal time experience, activities and stimulation.

The service was also unable to demonstrate how they regularly sought the views of people who used the service and took regard of any complaints, comments and views made. Though questionnaires had been devised, these had not been circulated. The last residents meeting was in April 2015, with no other evidence available of other resident or family meetings. There was no suggestion box available for people to suggest improvements in the quality of the service.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance, because the service failed to assess, monitor the quality of service provision effectively.

You can see what action we told the provider to take at the back of the full version of the report.

People who lived at Moorfield House and their relatives told us that they or their loved ones were safe living at the home.

We found the home had suitable safeguarding procedures in place, which were designed to protect vulnerable people from abuse and the risk of abuse. We looked at the service’s safeguarding adult’s policy and procedure, which described the procedure staff could follow if they suspected abuse had taken place.

We found people were protected against the risks of abuse, because the home had appropriate recruitment procedures in place. Appropriate checks were carried out before staff began work at the home to ensure they were fit to work with vulnerable adults.

On the whole, we found there were sufficient numbers of staff on duty during the day to support people who used the service. However, several members of staff raised concerns that they did not always feel there were enough staff on duty to meet people’s needs, especially during the night shift.

Senior staff confirmed they received formal training in subjects such as safeguarding, first aid and the Mental Capacity Act, which we confirmed by viewing the training matrix. Most staff were either in the process of undertaking a National Vocational Qualification (NVQ) in care or had completed the programme.

We looked at the service supervision policy, which stated that supervision would be undertaken at least six times each year and more often if a performance problem was under discussion. Though we saw evidence of supervision having been undertaken, it was not consistent with the service policy.

We were told by the clinical manager that apart from three people who used the service, most people were either living with memory issues or dementia. We found the home did not have adequate signage features that would help to orientate people with this type of need. We saw no evidence of dementia friendly resources or adaptations in any of the communal lounges, dining room or bedrooms. This resulted in lost opportunities to stimulate people as well as aiding individuals to orientate themselves within the building.

We have made a recommendation in relation to environments.

People and relatives consistently told us that staff were kind and caring. Throughout our inspection, where we observed interaction between staff and people who used the service, it was kind and respectful.

During the inspection we saw several examples of where staff at the home had been responsive to people’s needs. For example where people were required to be weighed weekly or monthly, there were records to suggest this had taken place.

Care plans were comprehensive and of a good standard. All care plans provided clear instructions to staff of the level of care and support required for each person. We found that care plans were reviewed on a monthly basis.

During our inspection, we checked to see how people were supported with interests and social activities. On the day of our inspection we did not observe any activities being undertaken with people. We were told by staff that the service did not have an activities coordinator.

Staff told us the management were approachable and supportive.

The home had policies and procedures in place, which covered all aspects of the service. The policies and procedures included; safeguarding, whistleblowing, consent and medication.

Inspection carried out on 14 April 2014

During a routine inspection

Moorfield House is a residential care home providing personal care without nursing. At the time of our visit there were 25 people who were resident at the home. Our inspection was co-ordinated and carried out by two inspectors, who addressed our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We spoke to six people who used the service who told us they felt safe and were treated with respect and dignity by the staff. Following recent concerns, we found safeguarding procedures were in place and staff were able to demonstrate how they would safeguard the people they supported.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints and concerns. This reduced the risks to people and helped the service to continually improve.

The home had policies in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs) although no applications have been submitted. We spoke to staff about their knowledge of the Mental Capacity Act and DoLs which was vague and inconsistent. We confirmed that senior managers had all received training. The clinical manager told us they were about to deliver training to all staff.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.

Managers set staff rotas, they took people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. Staff told us they had no concerns about staffing levels. This helped to ensure people’s needs were always met.

Recruitment practices were safe and thorough. A range of policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

People’s health and care needs were assessed with people who used the services or their relatives and health care professional. Specialist dietary, mobility and equipment needs had been identified in care plans where required. Overall, people and their relatives said that their care needs were being met.

Visitors confirmed they were able to visit their loved ones at any time and speak in private. They felt welcomed by friendly and cheerful staff.

Is the service caring?

People were supported by kind, friendly and attentive staff. Staff showed patience and gave encouragement when supporting people. People commented, “ I feel safe definitely." "I think its very good, staff are very nice." "No concerns about how things are done here." "I'm quite happy here."

Relatives completed quality assurance questionnaires. Where shortfalls or concerns were raised these were addressed.

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People completed a range of activities inside the service regularly. The home had a dedicated activities coordinator who organised daily activities and events and was assisted by a volunteer who attended on several occasions each week.

People we spoke to were aware of the complaints procedure but had never had cause to complain. There were no formal complaints recorded at the time of our visit. People can therefore be assured that complaints would be investigated and action is taken as necessary.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. This was confirmed by a visiting health care professional.

The service had some quality assurance systems in place. Records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. They felt supported by the manager. One member of staff told us; "I feel supported, any problems I know where to go for help and assistance." This helped to ensure that people received a good quality service at all times.

Inspection carried out on 28 May 2013

During a routine inspection

We looked at a sample of care plans and found they contained information about people’s likes and dislikes.

We walked around the home and saw that all areas were clean and tidy. People’s bedrooms were personalised with photographs and ornaments.

We looked at how staff at the home managed and responded to complaints and monitored the quality of the service they provided.

We spoke with people living at the home and their relatives. Comments included: “I like it here.” “They are brilliant with X and with me.” “It is excellent.” “Very nice and friendly.” “It’s nice here I like it.”

Inspection carried out on 11 September 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC (Care Quality Commission) inspector joined by an

Expert by Experience – a person who has experience of using this type of service and who

can provide that perspective.

We spoke with people living at the home who told us: "They’re very efficient and extraordinarily kind, I’d recommend it to anybody." People told us that they were offered a choice of meals and could chose to eat in the privacy of their rooms if they wished to do so.

Reports under our old system of regulation (including those from before CQC was created)