Please wait

Inspection on 16/03/09 for Moundsley Hall Nursing and Residential Home

Also see our care home review for Moundsley Hall Nursing and Residential Home for more information

This is the latest available inspection report for this service, carried out on 16th March 2009.

CSCI found this care home to be providing an Excellent service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This home provides a comfortable, clean and very well mantained environment which is provides people with plenty of choice about where to spend their time. People are consulted so that their needs and preferences are known and plans provide staff with relevant information so that they can provide the right support to each person. People are supported to receive appropriate health care and to follow a healthy lifestyle. They are protected by the home`s arrangments for the storage and administration of medication. People choose how they spend their days. There is a very wide range of suitable activities and there are constant efforts to find new experiences for people. When people choose to spend time alone, this is respected. Visitors are welcomed to the home. There is a good variety of food and menus suit the people in the home. There are good arrangements for handling complaints and comments and for protecting people who live in the home. The staff team is made up of people who receive ongoing training so that they are competent. The manager is committed to maintaining high standards and making improvements where possible. There is a robust system for assuring the quality of the care which takes account of people`s comments about the service they receive.

What has improved since the last inspection?

The range of activities has improved so that people have a better choice of what to do. There have been improvements to the physical environment, such as decoration, new furniture, the furnishing of the sensory room and library and the creation of an additional lounge. The home has purchased more pressure relieving mattresses and cushions. There has been more training for staff so that they are better prepared to provide support to people. There have been improvements in the systems for the storage and administration of medication.

What the care home could do better:

The manager told us that she has identified areas for improvement including an even wider range of activities to include pottery classes, computer skills and games and more adventurous trips. Plans for the environment include enlarging the laundry so that there is better separation between soiled and clean laundry, building a smoking shelter, providing more pots for people to plant flowers. Ongoing decoration and refurbishment is planned as well as the purchase of more pressure relieving equipment. More staff training is planned and the handover process will be developed further to make better use of the computer.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Moundsley Hall Nursing and Residential Home Walkers Heath Road Kings Norton Birmingham West Midlands B38 0BL     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Christine Lancashire     Date: 1 6 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Moundsley Hall Nursing and Residential Home Walkers Heath Road Kings Norton Birmingham West Midlands B38 0BL 01214333388 01214334774 info@moundsleyhall.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Moundsley Hall Nursing Home Limited care home 69 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The home may accommodate one named person in the category of EMI (nursing) The home may also accommodate two named persons with a learning disability, one of whom is over 65 years. Date of last inspection Brief description of the care home Moundsley Hall Care Home is registered to accommodate 69 residents requiring both nursing and residential care. The home is registered to accept residents from 55 years of age. The home is purpose built and was first registered in 1996. The new extension Care Homes for Older People Page 4 of 26 Over 65 16 69 69 0 0 69 Brief description of the care home for an additional 15 residents was opened in June 2006. The home is located on the outskirts of Kings Norton near Birmingham. It is conveniently located for local amenities. Accommodation is provided in two units on three floors and offers 57 single and 6 double bedrooms. All bedrooms benefit from having en-suite facilities. The home stands in spacious well maintained grounds. When the weather permits, residents can access the grounds with ease and garden furniture is provided for them to use. The fees are available on application to the home. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited this home on a weekday without telling anyone that we would be arriving. The purpose of the visit was to see how the home is meeting key National Minimum Standards. Before the visit we had received information from the manager about the running of the home and the plans for development. At the inspection we spoke to the registered manager, nurse manager, residential manager, some members of the staff team, some people who live at the home, some relatives and the owners. We looked round the building and into several bedrooms. We looked at the records which the home is required to keep and these include records about the peoples and preferences, safety, menus, staff rotas, medication, staff recruitment and training, complaints and minutes of meetings. We looked at the systems which the home has for monitoring its performance and at the results of questionnaires completed by people who live there. We used this information to write this report. Care Homes for Older People Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: The manager told us that she has identified areas for improvement including an even wider range of activities to include pottery classes, computer skills and games and more adventurous trips. Care Homes for Older People Page 7 of 26 Plans for the environment include enlarging the laundry so that there is better separation between soiled and clean laundry, building a smoking shelter, providing more pots for people to plant flowers. Ongoing decoration and refurbishment is planned as well as the purchase of more pressure relieving equipment. More staff training is planned and the handover process will be developed further to make better use of the computer. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering moving into this home are provided with the necessary information in formats which suit them, in order to make an informed choice. Assessments and visits to the home ensure people know, before they move in, that their needs can be met by the home. Evidence: The manager told us that there is a website which provides information about the home for people considering moving in, their relatives and representatives. There is also a brochure and Statement of Purpose. The most recent CSCI report is on the website and the home keeps copies of this available for people who do not have access to the internet, in a variety of formats including large print and audio. There is a specially designated room where people and their families can sit and read the homes quality assurance minutes of meetings, view the menus and see the photo album of trips and activities. Care Homes for Older People Page 10 of 26 Evidence: The manager told us that people are welcome to visit with their representatives or families at any time. No appointment is needed. People are also invited to spend time experiencing the atmosphere of the home and meeting people who live there and the staff. They may ask any questions which they may have and sample the food. Prior to admission the manager carries out a full pre-admission assessment which is conducted where the person is living. This could be their own home, another care home or hospital. We sampled peoples files and found that the pre-admission form is very comprehensive and forms the basis of the initial care plans. Any assessments carried out by other professionals are also taken into account. At the viewing and assessment stages before admission when the person is making their choice, the home also provides listening forms and getting to know you where the client can detail their needs and wishes and the manager can explain how the home proposes to meet them. People who live in the home and relatives who were visiting on the inspection day told us that they were provided with good information and made welcome when they first came into contact with the home. These processes make sure that people can be assured that the home will be able to meet their needs. Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health, personal and social needs are set out in a care plan so that they can be met by staff. People are treated with respect and their privacy and dignity are maintained. They are protected by the homes practices in relation to the storage and administration of medication. Evidence: We sampled six peoples files and found that they provided detailed information about each persons needs and clear instructions for staff about how to meet these. The care plans aim to be holistic and to cover all areas of the persons life. The care plans are developed using the information in the assessments carried out at the time of admission. They contain well organised and relevant information to make sure that staff know how to deliver care to each person which meets their needs and preferences. There are additional instructions for night staff about the attention people need on their shift. There are monthly evaluations for each section. Peoples health needs are recorded. These include those which are to be met by staff and those requiring the involvement of a variety of health professionals. There are Care Homes for Older People Page 12 of 26 Evidence: records of contact with other professionals and the outcome of the consultation or treatment. There are forms with basic details in case people need to be admitted to hospital. There are suitable arrangements for the storage and administration of medication. Staff who administer medication are trained to do so. We saw that the home had recently been inspected by the PCT pharmacist and the arrangements were found to be satisfactory. The home has a homely remedies policy with the agreement of the homes General Practitioner. Residents spoken with confirmed that all the staff treat them with dignity and respect. One resident stated, They are too good to us. Staff were observed during the inspection being respectful to the residents. The files which we sampled contained peoples preferences about the actions which people would like staff to take around the time of their death and after. The home has implemented the national gold standards framework guidelines. Care Homes for Older People Page 13 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples lifestyles in the home match their preferences and they are offered a wide range of activities. They are encouraged to maintain significant relationships with people in the community and they receive a choice of nutritious meals which meet their needs and take account of their preferences. Evidence: The manager told us about a wide range of activities which are provided for people. There is an activities coordinator who arranges monthly and weekly activities which include crafts, visiting entertainers, flower arranging, games, trips to the supermarket, pubs and garden centres, theatres and concert venues and fitness exercises. In addition to the lounge areas there is a sensory room with a fish tank and relaxing light shows. There are several areas where people can watch television and a quiet library room. We saw photos of people enjoying parties and outings. On the day of the inspection there was a visiting singer in the main home and people in Clarence House were enjoying a word game with staff. During the Summer, people took part in the Moundsley Hall Olympics, with a variety of events, including welly wanging, skittles, art challenge and basket ball. People showed us their certificates for winning events such as croquet. On the outside of the building there are shelves at a convenient height for seated people to undertake gardening. These have boxes where people Care Homes for Older People Page 14 of 26 Evidence: have planted bulbs. The flowers will be visible from the covered conservatory seating area. Visitors told us that they are always made welcome and kept informed of the planned events. They may go to communal areas, into peoples rooms or walk in the extensive grounds. Visitors are welcomed to take part in activities in and outside the home. We saw many examples of how people are involved in making decisions about their lives and provided with choice. People are asked about their preferences at the time when the care plan is written. These include surveys of peoples views, listening forms, residents meetings and informal contact with staff on a daily basis. The manager told us that as a result of listen to peoples views, changes have been made to the times at which the newspapers are delivered, cheese and crackers as a third option after tea, more pub trips and a change in the day the hairdresser comes. There have also been many changes and improvements to the activities. The menus show a variety of meals which are rotated on a seasonal basis. These include a cooked breakfast if people would like one. People are provided with choice at each meal time. Their needs and preferences are known and recorded. We saw nutritional assessments and evidence that action is taken to try to make sure that people retain a healthy weight. People told us that they enjoy the food and have plenty of choice. Feedback forms are used to gather peoples views on the meals and the minutes of residents meetings also show that food is a regular topic for discussion. Care Homes for Older People Page 15 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good arrangements to ensure that people are protected, including the arrangements for handling complaints. Evidence: We saw that there is information about how to make a complaint on display in the home as well as in the information provided to people who live there and their families. The people who we spoke to told us that they would complain to the owner or manager if they were not happy. The manager told us that all complaints are taken seriously and investigated. A timescale for resolution is agreed by all parties and once the issue is sorted out, a date if set for review to make sure that the person is still satisfied with the outcome. We looked at the record and found that action taken has been recorded and the reponses to the people making the complaints are shown clearly. Since the last inspection the CSCI has received no complaints about the home. The manager showed us the records relating to an investigation which took place following an allegation realting to pressure area care. This was not upheld and the investigation has now concluded. The home provides protection of vulnerable adults training as part of their induction training. The manager told us that this is backed up by additional training. The manager is confident that all staff would report any concerns to her if they had any. The contact details of the CSCI are clearly displayed. The homes quality audit shows that people feel safe in this home. People told us that they feel safe and they would Care Homes for Older People Page 16 of 26 Evidence: tell the manager if they were not happy. Peoples relatives told us that they feel that staff keep people safe. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, clean and safe environment which is well maintained and meets their needs. Evidence: The main building is large and purpose built so that people have en-suite facilities. There are five shared rooms to provide accommodation for couples and people who wish to share. All bedrooms have views over the grounds. The annexe to the home, which is known as Clarence House, accommodates 15 people in single rooms, all with en-suite bathrooms. We looked at several rooms and found that people had chosen to pesonalise them with items brought from home. People told us that they are pleased with the accommodation and they feel comfortable in their rooms. There are several seating areas, including a library room and a sensory room, a large room where visiting entertainers perform and a conservatory area. There are assisted bathing facilities, providing the choice of a bath or shower. When changes are made to the building, the needs of the people who live there are considered. For example, the newest lift is housed in a shaft which is accessed by means of a short glass sided corridor. This provides people with excellent views of the extensive and well maintained gardens. Care Homes for Older People Page 18 of 26 Evidence: Since the last inspection, there have been ongoing improvements to the physical environment. These include the completion of the second shower room, the library room and the extended paved area. The communal areas have been refurbished and new curtains have been fitted in the main conservatory lounge and the library room. Shower rooms and WCs have been decorated to make them more homely. There are new displays of plants throughout the home. The sensory room has been developed by the addition of a fish tank, slide projector and large bean bag. There are good systems to make sure that the building is well maintained and kept clean and free from infection. These include daily cleaning checklists, weekly hygiene audits and a system for making sure that all requests are responded to by the homes own maintenance worker or supporting contractors. There are good arrangements for controlling the spread of infection. These include clear procedures for infection control and the disposal of clinical waste, four sluice rooms and supplies of gloves and aprons for staff undertaking personal care tasks. There is a purpose built laundry which has a well organised work flow. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in this home are cared for by sufficient numbers of staff who are well trained and competent to do their jobs. They are protected by the homes recruitment practices. Evidence: The rotas show that there is a good level of staff cover to meet peoples needs. We spoke with managers and staff in the home and they had a good level of knowledge about the people who live there. People in the home and visiting relatives told us that the staff are helpful and approachable. We looked at the training records and found that staff have the opportunity to attend training in areas relevant to their roles. Induction training is followed by NVQ training. Refresher training is provided when necessary. The manager told us that all care staff have a planned time scale to achieve their NVQ Level 2 and there are four in-house assessors who assist them to achieve this. Over 80 per cent are qualified with the remainder of staff signed up for training. Staff are recruited through a standard procedure which includes taking up references and making checks through the Criminal Records Bureau. We examined the files of recently employed staff and found that the home keeps to their policy and ensures that the appropriate checks are carried out. We discussed with the manager the Care Homes for Older People Page 20 of 26 Evidence: advisability of making telephone calls to verify professional references. She told us that she would add this to the checklist. Staff are supervised on a regular basis and their performance is appraised. There are handover periods and staff meetings to make sure that information is communicated in a useful way and to improve consistency. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well managed home which is run in their best interests and where there are good systems for maintaining the quality of care. Their financial interests are safeguarded and their health, safety and welfare is promoted and protected. Evidence: The registered manager is well qualified and experienced to undertake her role. She is supported in management by a nurse manager and residential manager who help to develop systems and supervise staff. We saw that there are good systems for making sure that the high standards are maintained and that peoples views are taken into account when assessing the quality of the service and making plans. The National Minimum Standards are displayed on the noticeboard and we saw a notice in the lift, informing people which three standards were being looked at closely that month. We saw feedback forms in peoples files and survey responses from people in the home and their relatives. Care Homes for Older People Page 22 of 26 Evidence: We saw the well organised system for making sure that peoples personal money is accounted for. All additional services, such as chiropody, hairdressing, taxis etc are clearly listed in sheets for each person. The records clearly show the initial deposit and balance counting down. The contact details for the person who is in control of the money is clearly shown. The manager provided us with details of the dates for the servicing and checks on equipment in the home. We checked a sample of these against records in the home. We looked at the arrangements for storing and recording materials which may be hazardous to health. We saw risk assessments in relation to people in the home, various tasks and the environment. These help to keep people safe. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!