Inspection on 19/10/05 for Hammerwich Hall Nursing Home

This inspection was carried out on 19th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hammerwich Hall Nursing Home 11/08/08

Hammerwich Hall Nursing Home 11/09/06

Hammerwich Hall Nursing Home 11/05/05

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 OJL Lead Inspector Mrs Joanna Wooller Unannounced Inspection 09:30 19 October 2005 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hammerwich Hall Nursing Home Address 105 Burntwood Road Hammerwich Nr Lichfield Staffordshire WS7 OJL 01543 686376 01543 677240 Evansviupa.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Mrs Victoria Louise Evans Care Home 51 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Old age, of places not falling within any other category (45), Physical disability (10), Physical disability over 65 years of age (10) Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. OP Minimum age 2 MD Minimum age 45 years 10 PD Minimum age 60 years 8 may be nursing 8 PD (Physical Disability) - Minimum age 45 years on admission Date of last inspection 11th May 2005 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 DS0000022330.V259765.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on 19th October 2005 @ 09.30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 8hrs. The registered care manager was in the home for most of the visit accompanied by her Deputy, and one other registered nurse. Seven care assistants were on duty along with the regular ancillary staff. These staff included the administrator, the cook and a catering assistant, three domestics, one laundry person, and a maintenance person. These staffing levels were evidenced as adequate to meet the needs of current 46 residents in the home. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with seven residents, discussions with all the staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 11th Mat 2005 there had been no changes to the management of the home, no complaints had been received and no additional visits had been necessitated. There was strong evidence that all aspects of care were being well addressed, with residents being able to choose the home following a preadmission assessment and taking up an invitation to visit the home. Residents’ plans had been well written; some were based on the community care plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for residents were being upheld. No complaints, incidents or reports of abuse of any kind had been received since the last inspection, and policies and procedures seen covered these issues. The home was evidenced as fit for its purpose and was seen to provide a safe environment for the residents and staff. A homely atmosphere had been created in lounges and bedrooms, and the premises were very clean and tidy. Adequate spacious areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were inspected and found to be in working order. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 6 Health and safety aspects had been given a high priority and no shortfalls were noted. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were good with little staff turnover. Staff training had been given a high priority, with induction training being followed by NVQ training, and staff had received regular supervision. The manager monitors the training requirements on a matrix to ensure no shortfalls are made. The home appeared to be well managed by Ms Evans who is a qualified, registered and competent care manager. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting and business procedures are followed. The home is waiting for a major upgrade, which has been back and forth to planners and BUPA for some time now. The manager is fully aware of the need to improve the tired environment and she is to inform the inspector as soon as plans are complete. Summary comments “ We had a really fantastic time at ‘Butlins’ the staff were wonderful and could not do enough for us.” “ I am aware of the activities planned and will be part of them when Pam returns” “ I cannot wait to go on holiday again it was so good with smashing staff” “ Mother has settled well the staff and food were excellent” “I am always welcomed by the staff “ What the service does well: The home is now settled again with the new manager demonstrating strong leadership skills and staff support. The home is warm and inviting which is staffed with a team of staff that are caring and devoted to the residents. The environment, although due for upgrade, is homely and comfortable. Care is delivered with compassion to the residents and their privacy and dignity upheld. Staff were seen to be friendly and happy with the residents and the residents spoke very highly of them. Documentation supports the standard Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 7 of care being delivered. Records were individualised, up to date and reflected the current condition of the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents are admitted to the home following completion of a full BUPA pre admission assessment procedure, ensuring all the individuals needs can be met at the home. EVIDENCE: Residents confirmed when asked that they with the support of their relatives or social worker had been part of a pre admission assessment process prior to moving into the home. Documentation available to the inspector evidenced that the care plans are based on the information gained in this important process. A registered nurse completes all assessments and discussions take place with the team of management prior to admission. No changes have been made to the documentation since the last visit and the inspector raised no issues. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 11 The assessed health and personal care needs of individual residents had been well documented and were being met, with good standards of care being delivered. There was a safe system for the receipt, storage, administration and disposal of medicines. Residents were treated with respect, privacy and dignity, during the caring and dying process. EVIDENCE: Many residents and a few relatives spoken to all commented positively about the care being provided, the friendly staff and management. The residents’ individual plans and associated documentation was well written, meaningful and reflected the current condition of residents. The documentation seen and a discussion with both residents and staff members evidenced that health and personal care needs were being well met. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. When asked residents told the inspector that they were treated with respect, and that the staff were very good. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 11 NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. A local GP practice and a local pharmacist service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. The medicines within the home were administered with a safe system following medicines policy documentation. No resident was ‘self medicating’, but locked facilities were available. The pharmacist had completed an audit in September and the systems were found in order. The Deputy manager completes monthly audits with regard to administration and documentation of medication. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 The full social programme was made available; resident’s views were sought and acted upon. There was a relaxed atmosphere with residents continuing with their daily routine. Qualified cooks, offering choice and a balanced diet, prepared the meals at the home. EVIDENCE: The activity co-ordinator was on annual leave, despite this the residents openly told the inspector how much they had enjoyed the recent holiday to Butlins; accompanied by staff who in their opinion were “fantastic”. Residents were made aware of the full social programme from the displayed notices in the entrance hall. Planned for November was a fireworks celebration and Cheese & Wine party. Visitors were made welcome by the staff and management; no restrictions were made for the times of visiting. Links with the community are good. Residents were aware of the daily menu and told the inspector their choice. The inspector was impressed with the commitment by the management. Since Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 13 the previous inspection the home had invested in a special compartmented dish for the pureed foods served. Menus were well balanced and offered choice. The required temperatures were current and maintained daily. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home follows a robust BUPA complaints procedure and this was followed at all times. Residents’ rights were protected and staff were trained to ensure that residents were protected form abuse. EVIDENCE: An examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints were listened to and dealt with in the correct manner. Since the last inspection no complaints had been recorded or brought to the attention of this commission. Many ‘thank you’ and complimentary cards were seen from appreciative relatives. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 A routine sample of the home identified a well maintained environment providing the residents with a homely place to live. Residents had the opportunity to personalise their personal space. The management recognised that certain carpets need replacing. This will be part of the general refurbishment. EVIDENCE: The home was generally well maintained and suited for its intended purpose. Future plans to upgrade the home will eliminate the carpets identified in previous reports that were in need of replacement. A random sample of the bedrooms evidenced that they were personalised to suit individuals taste. One resident had arranged some of her Christmas decorations. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 16 Bathing and toilet facilities were located throughout the home. The laundry staff recognised and confirmed their training for infection control and COSHH the systems in place were satisfactory. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30. The assessed needs of service users had been met by an adequate number of suitably trained staff. Recruitment followed the BUPA procedures and had been correctly addressed which had contributed to the protection of service users. Staff training had been given a high priority. EVIDENCE: The duty rosters seen, and a discussion with the care manager and the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing service users. Staffing levels were being maintained to meet the individual residents needs. Staffing rosters were checked and were in order. In addition to the Deputy manager there was a trained nurse and seven carers on the morning shift, two nurses and six care assistants on each evening shift, and two nurses and three care staff on each night shift. Adequate ancillary staff had been provided each week. Residents when asked stated that staff were available when they wanted them, and that the staff were caring and friendly. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 18 Training had been given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training which had covered the needs of the registered client group. Staff told the inspector that they were encouraged to study. Training had been provided for staff in the awareness and management of dementia related conditions, and staff outlined this to the inspector. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The home appeared to be well managed and quality assurance was in place. Financial aspects were correctly addressed and recorded with safeguards to residents. Health and safety issues had been given a high priority and managed well. EVIDENCE: From observations made, discussion with service users, and discussions with the manager and staff, it was evident that the home was being run in the interests of service users. BUPA Quality Assurance, including feedback from residents and their representatives, was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 20 A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Day to day monies of residents were checked and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The manager and staff spoken to confirmed that health and safety issues are given a high priority. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 4 18 4 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 4 Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP15 Good Practice Recommendations Food is to be presented in a manner that is attractive and appealing for service users with special dietary needs. Hammerwich Hall Nursing Home DS0000022330.V259765.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Stafford Office 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 DS0000022330.V259765.R01.S.doc Version 5.0 Page 24 - 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. 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