Inspection on 11/05/05 for Hammerwich Hall Nursing Home

This inspection was carried out on 11th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hammerwich Hall Nursing Home 11/08/08

Hammerwich Hall Nursing Home 11/09/06

Hammerwich Hall Nursing Home 19/10/05

Hammerwich Hall Nursing Home 06/10/04

Hammerwich Hall Nursing Home 26/04/04

Hammerwich Hall Nursing Home 09/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Hammerwich Hall Nursing Home 105 Burntwood Road Hammerwich Nr Lichfield Staffordshire WS7 0JL Lead Inspector Joanna Wooller Announced 11 May 2005 09:15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hammerwich Hall Nursing Home Address 105 Burntwood Road Hammerwich Nr Lichfield Staffordshire WS7 0JL 01543 686376 01543 677240 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Mrs Vicky Evans Care Home 51 Category(ies) of 10 PD registration, with number 45 OP of places 2 MD(E) 10 PD(E) Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: OP Minimum age 60 years 2 MD Minimum age 45 years 10 PD Minimum age 60 years 8 may be nursing Date of last inspection 06 October 2004 Brief Description of the Service: Hammerwich Hall is a 51 bedded Care Home. The registered manager Vicky Evans has been in post since November 2004. She along with her deputy and a team of experienced nurses and care staff deliver 24 hour nursing care. Currently the home is being run by BUPA Care Homes and was first registered in 1988. The home is situated in the rural location of Hammerwich village. It comprises of one building, built in 1870. Presently the home is registered to take those service users identified on the page two of this report. There are four separate lounges and one spacious, airy dining room. Other facilities include a hairdressing salon, extensive gardens with gazebos and a sun lounge. All areas of the home have access by stairs, ramps and or a passenger lift. There are 10 Physically Disabled service user beds available. (Minimum age 60 Years). Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this announced inspection on Wednesday 11th May which commenced at 09.15hrs. The National Minimum Standards for Older People was used as guidance to assess the standards within the home. The total amount of time spent on this inspection was 12 hours, which included pre –inspection and fieldwork prior to the visit. Vicky Evans the Manager was in the home supported by her mentor Mrs Jane Melling. The Deputy manager. Joy was on duty and one other trained nurse. Ancillary staff in the home included the Cook who had two kitchen assistants with her, one person in the laundry, there were four domestics on duty and two administrators were in the office. The full time activity coordinator was also in the home. The maintenance man present in the home carried out maintenance. There were 49 service users in the home The inspection included: • A full tour of the building including service users bedrooms • Reading of care records and care plans • Talking to some service users • Management records • Discussion with the staff on duty BUPA Pre admission assessments had been completed for all new admissions and service users had received an acceptance letter to ensure their individual needs could be met at the home. Service users had individual care records, which included their individual health; personal and social care needs including specific choices. Service users spoken to say they enjoyed the activities, and their families’ involvement at some of the events. The inspector observed a balanced menu record. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 6 The environment was found to be clean, pleasant, hygienic and well maintained. Staffing levels were observed and duty rosters were seen. The inspectors observed the staff to be delivering a high standard of care and attention to the service users. The provider operations manager visits the home and forwards Regulation 26 report to the Commission For Social Care Inspection on a monthly basis. No issues were raised relating to service users finances. Medication systems were checked and found to be in good order. The health, safety and welfare of the service users and staff are monitored through the homes policies and procedures. What the service does well: What has improved since the last inspection? All the requirements had been met which were identified at the last visit. The recommendations were met or being considered. The standard of reporting in the care records was excellent. Each individual file was well organised and fully completed. Named and associate nurses were identified along with service users personal key worker. Staffing issues were almost rectified and recruitment of staff was ongoing. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 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 standard(s) 1-5 Information included in the statement of purpose was as required by the standard. A service user guide has been introduced into the home. Service users and representatives were encouraged to visit the home prior to admission. EVIDENCE: Relatives spoken to express their continued satisfaction with the home and the lovely care staff, that was caring and attentive. Each service users is issued with a BUPA Terms and Conditions of Residence that is signed on admission by the service users, this document includes all relevant information required by the service user to be aware of their rights. Personal care, mobility and medication were documented along with mental state, social interests and carer/family involvement; service users relatives/representatives are also included in this procedure. Each service user and their relatives are fully informed prior to admission that the home has the capacity to meet their needs. All necessary specialists needs were arranged as required. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 10 The care staff are trained and updated by the Nursing Staff in the home to ensure that they are skilled and experienced to care for the service users, and identify and meet their daily needs. In house and external training takes place. A confirmation letter is given to the service user or a representative prior to admission or at the time of admission to confirm that the home can meet the individual service users needs. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-10 There was evidence that service users individual health, personal and social care needs were documented and monitored as being met. Service users confirmed that they retained their dignity whilst in the home and they felt respected by the staff. EVIDENCE: Each service user had an individual plan of care, which includes health, personal, and social care needs. The care plans seen at the visit reflected the care that the tracked service users were receiving and these are updated at least monthly. Each plan of care was reviewed monthly, and these were found to be up to date on those inspected. Named nurses, associate nurses and key workers were identified on the records. There was evidence that the service users were involved in the plan of care as far as is possible. Relatives had been shown the individual plan of care and asked to sign the relevant risk assessments. Carers assist where necessary with personal care needs; key workers ensured that service users toiletries were available. Service users spoken to said that they continued to feel that Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 12 they were treated with dignity and respect. them to be as independent as possible. They said the carers encourage Health care services were made available to each individual. These services were delivered in the home environment if possible. Visits from these specialists are arranged if required and documented in the individuals care records. Personal assessments were carried out as required and up dated monthly. Pressure sore risks assessments were documented for each service user and evaluated monthly. The tissue viability nurse is contacted as necessary. Necessary equipment was available for the prevention of pressure sores, and the staff were trained in moving and handling. The care staff continue to observe each service users individual psychological health, report any deterioration. Nutritional assessments were recorded in the care records and monitored and seen as an important part of general health. No issues were raised relating to medication. BUPA policies and procedures were complied with. Skills workbooks continue to be completed by the staff in the home to ensure they were competent to carry bout their role. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 It was obvious from the comments and observations that the home had a relaxed welcoming atmosphere where individuals were encouraged to continue with their daily life style. Staff were observed to assist residents from the knowledge of individuals needs, visitors were recognised and welcomed. The meals prepared by the qualified competent catering staff offered both choice and a well balanced diet. Specialist dietary needs were catered for if necessary. EVIDENCE: The home had a very robust activity programme, arranged over the week to meet the needs and capabilities of the residents. A quarterly and monthly newsletter provided information of events proposed. The activity organiser is very committed to her role; she involves and encourages individuals less able. One of the projects at the time of the inspection was a life book. Residents spoken with confirmed that they were enjoying this form of reminiscence. From the recent resident meeting various outings were in the process of being arranged. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 14 The numerous photographs displayed in the Hall confirmed evidence of the activities arranged. Visitors were welcomed at the Hall at any time. One visitor confirmed that he was especially pleased with the care his wife received. Each individual resident was encouraged to exercise daily control in respect of his or her life style. The menus for the week were displayed at the reception area, for any person to observe. The records offered choice, variety and a well balanced diet. The meal for the day was observed being prepared in a clean well-maintained kitchen. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16-18 The inspectors were satisfied that the complaints process and investigation methods were robust and followed the required guidelines. Residents would be protected from abuse via the in-house formal and informal training of the staff. EVIDENCE: The inspector observed the complaints process displayed, information contained in the document would enable any person to raise an issue with the staff. Each of the residents had been provided with a copy of the homes procedure in the event of a complaint. It was discussed with the management that the Commissions address should be included in this particular document. Residents’ civic and legal rights were protected via a network of persons involved in the well being of individuals. The staff received formal training via the National Occupational Standards Awards in Care (TOPPS) this would be followed by the foundation course. This training method was evidenced from the documents provided. Training and general awareness of how to recognise and report any form of abuse was included. Staff spoken with confirmed they had received training for COSHH awareness. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 Hammerwich Hall registered some years ago to provide personal care for vulnerable people. The Hall proved a well-maintained environment with numerous homely touches in the decoration. Externally the home had mature gardens where residents can sit and enjoy. The Hall was exceptional in its hygiene, and standards provided. EVIDENCE: Hammerwich Hall provided a clean, warm, well-maintained environment for residents located on two floors. Many of the bedrooms overlooked the mature garden and trees. The home had a sensory garden area, where residents can sit by. Accommodation was personalised to suit individuals. Lounges were located throughout the ground floor. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 17 Bathrooms and toilets were sited around the home. One bathroom had been taken out of use at the time of this inspection due to a problem with the assisted bath seat. There are plans to refurbish and to construct bedrooms with an ensuite facility. Residents lived in a comfortable safe environment where all the necessary checks and risk assessments were in place. The laundry located out side the home operated over seven days, clean laundry was delivered to the residents’ rooms within the twenty-four hour period. The staff responsible for the hygiene of the home should be congratulated. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-30 Staff skill mix and numbers was found to be in line with the previously issued notice of staffing, however this was occasionally exceeded. Service users were evidenced to be receiving high quality of care and support. All staff were evidenced as being suitably trained to carry out their duties and the homes recruitment practices were in line with the National Minimum Standards. EVIDENCE: Staffing levels were suitable for the dependencies of the service users. The management were aware of the need to increase staffing should this rise. The care manager is able to advertise for the trained staff locally. Interviews were performed with the care manager and one other senior member of staff depending which service is to be provided. Two written references were obtained for each employee. No volunteers were employed. Induction includes lifting and handling training; fire - knowledge and instruction, meeting the service users and the aims and objectives of Hammerwich Hall. The new employee worked with a mentor from day one. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 19 The management provides training facilities and time; staff were paid for attending training courses. The new training package is to runs in conjunction with TOPPS requirements and the staff completes a Foundation programme following the induction programme. Over 50 of the care staff were NVQ trained. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-38 The health, safety and welfare of the service users and staff were promoted and protected as far as reasonably practicable. EVIDENCE: BUPA Quality assurance systems were in place and met with the National Minimum Standards. This system is used at intervals throughout the year to monitor quality and consistency. BUPA Head Office then reviewed the results. Service users informed the inspector that the staff in the home increased their quality of life. The service users’ financial interests were safeguarded by the BUPA systems in place. Service users were encouraged to look after their own financial affairs with the support of their families or representative. However if the service user requires some assistance this will be offered and the procedure for dealing with monies will be operated. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 21 Each bedroom is fitted with a lockable drawer and the home has a safe. Receipts were issued for all transactions and a ledger was kept. The registered manager continues to ensure safe working practices within the home including; moving and handling training and fire safety training, first aid training, food hygiene training and basic food hygiene qualification. Training on infection control is also undertaken in house. BUPA Policies and procedures were evidenced as working documents in the home. The health and safety of service users and staff were promoted with safe storage of hazardous substances, regular servicing of electrical and gas appliances, and regulation of the water system. Vigilant staff employed in the home assist with the security of the home, along with the security policy and procedure. The accident book was seen and found to be in order. Health and Safety notices could be seen throughout the home and a Health and Safety manual was available. Following the one to one induction of a new member of staff in the fire procedure; by a senior member of the staff. The staff confirmed that she felt that she could be part of the staff team in the event of a fire breaking out. The trainer used visual and written aids to provide an in depth training session. Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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 15 Good Practice Recommendations Food is to be presented in a manner that is attractive and appealing for service users with specail dietary needs . Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hammerwich Hall Nursing Home E51-E09 S22330 Hammerwich Hall V220697 110505 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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