Inspection on 01/07/08 for Himley Mill Nursing Home

This inspection was carried out on 1st July 2008.

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 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

Himley Mill Nursing Home 06/06/06

Himley Mill Nursing Home 09/11/05

Himley Mill Nursing Home 09/05/05

Himley Mill Nursing Home 13/12/04

Himley Mill Nursing Home 04/02/04

Himley Mill Nursing Home 20/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Himley Mill Nursing Home School Road Himley Dudley West Midlands DY3 4LG Lead Inspector Joanna Wooller Key Unannounced Inspection 1st July 2008 08:30 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 Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 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. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Himley Mill Nursing Home Address School Road Himley Dudley West Midlands DY3 4LG 01902 324021 01902 892396 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) www.bupa.com BUPA Care Homes (CFHCare) Ltd Miss Gillian Howarth Care Home 86 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30), Learning disability (10), Mental disorder, of places excluding learning disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (10), Physical disability (56), Physical disability over 65 years of age (30) Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Kingswood Unit - 26 PD, of which 10 may be LD Woodlands Unit - 10 OP, 30 PD(E), 30 PD - Minimum age 60 years on admission Beeches Unit - 30 DE(E), 30 DE - minimum age 60 years on admission of which 5 may MD(E) or 5 MD - minimum age 60 years on admission 6th June 2006 Date of last inspection Brief Description of the Service: BUPA Himley Mill Care Home (with Nursing) is located on the periphery of the villages of Wombourne and Himley and approximately five miles from the City of Wolverhampton. Gillian Howarth is the Registered Care Manager. Himley Mill Care Home was purpose built to provide care for people requiring nursing care. Over a period of time the concept of care has changed to now include three specialist need care categories placed within the three separate units. Beeches offer care to 30 service users with dementia. Woodlands offer nursing and personal care to 30 service users. Kingswood has been developed into a unit for 26 younger adults with complex nursing needs. Each unit has a Head of Care in charge that is supported by trained nurses and care staff. Accommodation is provided in single rooms with spacious communal areas, the units also contain a small kitchenette where the staff can prepare hot and cold drinks and a snack for service users. Outdoor space in the form of patios and lawn areas are available for the service users on each unit, these areas were evidenced as safe, accessible and secure. The managers office, the training school and the reception are located in the main building where the laundry and central kitchen are also sited. Fees - Beech Unit £496 to £712 Woodlands Unit £482 to £690 Kingswood Unit £904 The fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the service. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 1st July 2008 by the lead inspector. The Manager, Gill Howarth was at another of the groups’ homes and Elizabeth Bevan was managing Himley Mill. During the morning Mrs Howarth returned to Himley Mill to participate in the inspection. An Expert by experience and his carer assisted us to gain evidence for the report. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Another inspector carried out an observation called ‘Short Observational framework for Inspection’ (SOFI) on Beech Unit. The inspection included the following elements; A tour of the building, Observation and inspection of records relating to provision of care, Discussions with several service users through case tracking and SOFI. Case tracking is where we look at the service users records and experiences and SOFI is a form of observation. Discussions with several of 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, training, recruitment and health & safety. No complaints had been brought to the attention of the Commission For Social Care Inspection and no complaints were outstanding within the home. There had been one safeguarding incident reported and this had been dealt with appropriately and was now closed. The Inspector was made very welcome in the home and all assistance was given to gain the evidence required for the report. Service Users spoken to at the visit were complimentary about the home. Comments included “They always do their best for me” “The friendliness of staff is excellent” “The overall standard is very good” The home manager sent us their annual quality assurance assessment (AQAA) when we asked for it. This document was completed to a good standard and gave us all the information we asked for. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 6 The quality rating for this service is 2 star. This means that that people who use this service experience good quality outcomes. What the service does well: What has improved since the last inspection? What they could do better: Several issues were of note at this visit, which will require further discussion with the provider and the home manager. • Due to increasing dependency levels on the younger adults/Learning Disability unit it becomes increasingly difficult to match their experiences DS0000022340.V367027.R01.S.doc Version 5.2 Page 7 Himley Mill Nursing Home • • • with that of the National Minimum Standards. The Expert by Experience confirmed this as he felt the home was too large and the uniformed staff was too formal. The category may need re-evaluating. The satellite kitchens on each unit are in need of refurbishment. The equipment and surfaces is not ‘user friendly’ and some units are broken. The dishwasher system needs to be altered to avoid equipment being left on the floor and the storage system was not working. Some food was not stored correctly. Picture menus could be introduced to assist service users when they are choosing their meals – on all units The SOFI tool evidenced that meal times on Beech Unit People who use the service sometimes have to wait for their meals and staff interaction could be improved. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 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 Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users do have the information they need to make an informed choice about the home. All service users are assessed prior to admission to be assured that their needs can be met. EVIDENCE: The Statement of Purpose was available throughout the home. This was a corporate copy and prospective service users would benefit from a more personalised one about Himley Mill Multi site. The document does not promote the service and the differing facilities on each unit. The manager with the support of her operations manager should address this. The Service User Guide on each unit were personalised and explained the service that they offered. There was evidence through ‘Quest’ the care Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 10 planning system which has been introduced, that service users and their relatives are fully involved in planning the care that they will receive and signatures are gained at this point to sign that the package is agreed. One gentleman spoken to told us that he was delighted in the way his wife was admitted and cared for. He said, “It was like home from day one.” He was upset because he couldn’t look after her but he said, “ I am happy now knowing she was well cared for and safe. The staff are marvellous, so patient and friendly.” The admission documentation was evidenced as being fully completed and through case tracking it was found to include the service users choices and medical condition and needs. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users health, personal and social care needs are set out in a comprehensive individual plan of care. Service users health needs are fully met and they are treated with respect. Service users are protected by the homes medication policies and procedures, which have been reviewed by the company. EVIDENCE: The requirements for medication that were made at the last visit had been met corporately and policies and procedures were reviewed nationally. This was read and signed by the trained staff at the home. This medication policy now meets the criteria of the National Minimum Standards and the guidance from the Nursing & Midwifery Council and the Royal Pharmaceutical Society The compact nomad system had been purchased to assist with storage and safe administration on each unit. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 12 Printed administration sheets had been introduced which assisted the home to - monitor stock levels, allow precise ordering and disposal, and monitor those drugs refused. Stock levels had been monitored with the new regime and this was very much improved with this system, avoiding service users missing their medication. Consents were gained for administration of medication should the individual not have the capacity to respond. The staff was aware of being precise with administration times and dosage intervals. The company are monitoring staff competence in medication administration and would continue to do so through clinical supervision by the trainer. Each treatment room had been fitted with an air conditioning unit to maintain suitable temperature for storage of medicines and the individual clinical Refrigerator temperatures were recorded also. The home follows their own policies and procedures and the Royal Marsden Manual of Clinical Procedures. There is evidence of company specialists both regionally and nationally who can be consulted for advice and support at any time. Any pressure ulcers are recorded. The information is collated by the provider and the information is used to identify trends and inform the purchase of appropriate equipment. Two pressure sores were identified and these were being monitored by the tissue viability nurse. Records were seen with photographic evidence and progress`was being monitored and reviewed. All residents have a nutritional screen using the company nutritional screening tool. Every service user is registered with a General Practitioner of his or her choice (within the constraints of access to G.P.s). The company are re-introducing ‘personal best’ into the home. This system promotes good and thoughtful practice within the home by all their employees and recognition for such practice is celebrated. Beech Unit The care plans of two people were looked at in depth as part of the case tracking process. The use of quest has made person centred planning on this unit much more of priority. All care documentation was appropriately completed. Risk assessments were up to date and there was evidence to show the unit staff do review these as required. Both of the people who I looked at had displayed some challenging behaviour. The home has taken appropriate steps to manage this, care planning was descriptive and when I spoke to staff they understood the care plans contents and were able to give a good account of peoples needs. Because some of the people living on this unit were unable to discuss their care due to having dementia and cognitive Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 13 impairment a SOFI observation was also completed. Comments from relatives during inspection “I have complete and utter peace of mind here I never worry that P is not being looked after”. “the staff are excellent and I know they do their best to look after the people here”. Woodlands Unit The care plans of two service users were inspected through case tracking. Both care records reflected the current condition of the service users and they were completed comprehensively. Consents and signatures were noted along with designated named nurse and key worker names. Medication is thoroughly documented within the care plan stating the drug, dose, administration times and side effects. Full risk assessments for mobility were completed and a photograph of the individual was mounted in the care folder. Communication care plan was included in each record and completed appropriately and had been reviewed. One gentleman spoken to said “Its lovely here – and I like being in my own room. I do join in activities and chat to other service users.” Kingswood Unit The service users case tracked in this unit were very dependant and required high levels of nursing care in the clinical setting, which did not meet the National Minimum Standards set for Learning Disabilities. Their individual nursing needs outweighed their primary condition and this was well documented in their care records. Records were up to date and contained all relevant risk assessments and consents to meet their needs. One gentleman visiting the unit told us “The staff are very supportive and compassionate. They inform me of what’s happening with my wife and how she is. I visit to help with her lunch. She is settled here and its good that I can think of her as being safe and well looked after when I leave. “ One gentleman showed me his flowers and his room was personalised and comfortable. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users preferred lifestyles are documented and positive attempts are made to meet their expectations. A full and varied menu is available in the home. The BUPA Menu Master helps to ensure the menu meets the nutritional needs of the individuals. Service users are helped to make informed choices about their life in the home. EVIDENCE: Photographs of activities that have taken place within each unit are displayed on boards for service users and relatives to see. Bedrooms are personilised as desired by the service users themselves supported by their relatives and representatives. Activity records are available that evidence the activity programme on each unit. Activities range from group sessions to one-to-one time. A range of suitable activities are listed but the activity team are open to new ideas and suggestions. Pub lunches are planned to suit those who wish to go, and Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 15 recently one carer assisted a service user to choose an outfit for a family wedding and the carer was invited to escort the lady to the wedding as a sign of appreciation by the family. Unit newsletters are produced by the activity organisers to advertise future events, birthdays and any other news. Two of the activity organisers attended a company Activities Best conference. The home was given a selection of musical instruments and a selection of DVDs to enhance the activities programme within the home. One lady on Woodlands commented “I dont want to bother with activities but enjoy watching things going on and any entertainment.” She went on to say “ I find it better to sit quiet and just chat to people.” One lady and one gentleman sat outside under a large umbrella enjoying the warm weather and they were observed by the activity organiser, she was making flowers with some service users for their themed nights which were planned. The idea was to have evenings for different holiday destinations such as one would experience on a cruise but some service users had become confused thinking they were going on a cruise ship and leaving the home. This was discussed with the management and would be reviewed by the unit managers. Many of the service users were frail and required one to one contact with the activity organiser and this was documented and reviewed in the individuals care plan. Hand masaages are popular and reminisence is enjoyed by many. The personal best system can be used within this range of standards by acknowleding individual service users preferred activity and promoting their choice. Most of the staff were involved with the recent fete and relatives and service users joined in to assist also. The introduction of the BUPA Menu Master helps to ensure the menu meets the nutritional needs of the service users. The home have started the Night Bite system to ensure that food is available 24 hours a day. The Chef Manager attended BUPA Chefs Best conference which enabled him to keep up to date with ideas and initiatives. No issues were raised with regard to food preparation. Service users individual likes and dislikes were documented in the care plan and this information is received in the main kitchen. Tables were layed with cloths and service users were seen making choices about where they ate their meals. On Kingswood unit there was a sensory room that the Expert by Experience was shown but due the staff ratio to People who use the service he was concerned that people did not get that chance to use it very often. The lounge area in this unit was quiet noisey and busy. Staff were seen walking in front of the television when people were watching it. The Expert by Experience confirmed that he felt the main lounge seemed very noisy with staff constantly moving around and buzzer noises going off a lot of the time. We agreed that people’s personal needs were well looked after but their social needs were not given the same amount of input. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 16 Again on this unit also it was confirmed by the Expert by Experience that the “Cruise” was confusing and people could of thought they were going on a cruise ship, instead it was holiday themed evenings at the home which was then leading to disappointment for some people who use the service. SOFI observation was completed over an hour and half session and included a lunch time. We saw that there was little staff interaction with the four people being observed. However when it did happen it was generally good interaction. We noticed that meals took along time to get to people, fish and chips were served once this had been eaten a wait of over 35 minutes for desert and some people had not had a drink by the time the observation had ended. People said “if you ask for a drink you usually get one”. These findings and comments were discussed with the unit manager who said there are over 17 people on the unit who require some sort of assistance with meals, the staff find it a very busy period of time and do not want to rush the people they are helping. As a result some people do have to wait a long time for assistance and also between courses. This is often more of a problem during tea times when staffing levels are reduced but people on the unit tend to be more agitated and restless and need far more care and attention. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are confident that their complaints will be listened to and dealt with appropriately. Service users are protected from abuse. EVIDENCE: The home have a clearly defined company complaints policy with agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a three tier framework including the home, the regional management team and the national Quality and Compliance department. BUPA Care Homes has robust policies for dealing with allegations of abuse or neglect. Staff can not only raise concern within the home they have access to senior staff outside the home. There are well documented procedures for reporting under PoVA should the need arise. Staff interviewed were confidently able to discuss whistle blowing procedures, why it protects everyone and how thye would follow up their actions. One carer Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 18 said “ I am very confident that if I reported something the management would support me and deal with the issue immediately. We have all received training in this subject and we are knowledgeable about abuse and the signs to look for.” Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in safe and well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: The cleanliness on each of the units was good all but one bedroom on Beech unit. This area had an offensive malodour, which required urgent attention. Daily cleaning had not addressed the issue and an alternate floor covering was on order. The environment on all units was bright and airy, lots of natural light came into the communal areas and windows and French doors were open. The inspection took place on a warm day and the service users were able to sit outside under umbrellas if they wished. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 20 One visitor said “Its always really pleasant and clean, I never worry about walking into the unit. All the staff work hard to keep it looking nice.” The cleaning regime on the units is robust and the domestic cover is appropriate for the size of the home. One issue was raised in the satellite kitchen on woodlands – there was a lot of dishes/cups etc that were stacked in the sink in greasy water. The manager agreed that did not appear to be good working environment and other systems to deal with the issue would be discussed. The dishwasher system was bulky in such a small area and this also is to be reviewed. The kitchen areas were small and very over crowded with large equipment and cupboards. The manager agreed that this area did need to be refurbished for a better working environment for the staff using it. The manager told us “We use a specialist microfibre cleaning system that combined with effective cleaning regimes keeps the home clean and odour free. Our comprehensive policies and procedures include control of infection and handling clinical waste.” She went on to say “The home is supported in maintaining the environment by a central team of experts within BUPA Care Homes. We have a specialist property and estates department as well as a hotel services department.” Staff were well informed about the use of gloves and aprons and there were sufficient supplies in nthe home at all times. The manager and trainer are keen to set up an infection control group within the home consisting of staff from all departments and this is to be commenced with the help of the health protection manager in the health authority. There had not been any outbreaks of infectious conditions within the home and any minor infections had been contained through strict management by the well-trained staff. The Expert by Experience felt that Kingswood was more like a hospital than a home and we discussed that the people who use the service are unwell but still require good communication and strong interaction from the staff. We discussed that the unit was too large for a home that the Expert by Experience would expect to live in and that the staff had discussed splitting the unit in to two smaller areas that would be more personal and intimate. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 to 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of well-trained staff meet the service users needs in each unit. The homes recruitment policy protects the service users and keeps them in safe hands. EVIDENCE: The staffing levels on each unit were based on the number of service users in the unit. There were two trained nurses on each unit during the day and reduced to one on each unit during the evening and night shifts. 22 carers were on duty for the whole site. At busy times such as meal times these staffing numbers were well tested and staff appeared very busy and unable to chat to people who use the service due to their workload. This was discussed with the manager and will be looked at. Four activity organisers were employed for the units. Three domestics were employed for each unit and their hours fluctuated to give a longer daily cover. Satellite kitchen duties were covered between 5 and 7pm. There was one chef, two assistant cooks, one cook and four kitchen assistants that rotated to cover the main kitchen duties. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 22 Four staff was employed for the laundry duties and two were in daily. The manager confirmed the information included in the Annual Quality Assessment Audit – That there are comprehensive Human Resource policies to aid effective recruitment and staff management. They maintain the correct numbers of staff agreed with the inspectorate and taking account of the individual needs of the residents. They perform appropriate Criminal Record Checks ( crb) , PoVA checks (Protection of Vulnerable Adults) and NMC (Nursing and Midwifery Council) PIN checks for staff. Which were seen on the staff files inspected. There is a training matrix specific to the home that identifes the training requirements of the staff. The homes trainer is a competent person who is fully aware of her task to keep the staff appropriately trained and competent to work with the service user groups. The Quality Assurance audits confirm that the staff are well trained as the relatives and service users feedback that the staff are professional and well trained. The training is mapped on a matrix and monitored by head office to ensure that the staff training targets is maintained. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31, 33, 35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interest of the service users. Service users finances are safeguarded by the company’s robust procedures. The health safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager and her staff confirmed that regular Health & Safety meetings are held with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from these meetings go to the Regional Manager. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 24 There are regional and national experts available within the company for advice and guidance if required. There are dedicated Health & Safety staff within the Quality and Compliance directorate. BUPA Care Homes has a comprehensive suite of Policy and Procedure manuals that are regulalrly reviewed by experts and updated when required. BUPA Care Homes has an independent annual customer satisfaction survey carried out which is collated and returned to the company when the results are gathered. Comments from relatives included: Very caring to mothers problems, go beyond the call of duty The home manager is excellent leading to a happy environment for residents and good care staff who work well together. Have been very pleased with the care my mother has received at the home. Friendly staff seem to ‘own’ their patients. The home is very good they know the individual needs of my relative. The service is very good for quality care and cleanliness. There are friendly and caring staff. Comments from residents included: The staff try to do their best for me The service is very good the staff are very friendly. The service is very good because everyone is always happy. Sometimes if staff are off sick we have to be washed later in the day. Residents may handle their own finances should they wish to do so. Records of all financial transactions are kept in the home. The home has undergone a BUPA financial audit which indicates full compliance. The Health and Safety standard in the home is constantly monitored and audited through sytematic checks of equipment and supplies. Fire safety is paramount and the staff are trained professionally and in-house. Minutes of the Health & Safety meetings are available in the home. Accidents records were recorded and monitored for trends relating to type of accident, where it occurred, time and any injury. Notes are recorded in care records if such an incident occurred and staff was aware that they monitor the service users for any side effects of the accident. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 Regulation 16 (2i) Requirement Food stored in the satellite kitchens must be stored correctly. Some food was opened and not labelled or dated. The cupboards in these areas also must be kept clean. Timescale for action 01/09/08 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 OP1 Good Practice Recommendations A Statement of Purpose should be personalised to the home and have set out all the services the home has to offer to enable prospective people who may use the service to make an informed choice about where they live. Picture menus should be introduced to assist people who use the service to make a choice about their meals, snacks and drinks. The satellite kitchens are in need of refurbishment to allow staff to cater for the people who use the service in an organised manner. Curtaining at the windows on Beech Unit would make the unit feel more homely for the people who use the service DS0000022340.V367027.R01.S.doc Version 5.2 Page 27 2 3 4 OP15 OP19 OP19 Himley Mill Nursing Home 5 OP27 and give privacy and shade as certain times of the day. Dining room seating needs reviewing to allow all people who use the service to eat at the table if they so wish. Staffing numbers should be sufficient to allow for interaction with people who use the service during busy times and meal times to ensure their needs can be met. Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Himley Mill Nursing Home DS0000022340.V367027.R01.S.doc Version 5.2 Page 29 - 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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