Inspection on 06/06/06 for Himley Mill Nursing Home

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Himley Mill Nursing Home 01/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Himley Mill Nursing Home School Road Himley Dudley West Midlands DY3 4LG Lead Inspector Mrs Joanna Wooller Key Unannounced Inspection 6 June 2006 09:15 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.V297284.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.V297284.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 (CFH Care) Limited 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.V297284.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 9th November 2005 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. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three inspectors attended the home unannounced for this key inspection. Gill Howarth the Manager was away form the home on a study day. Jane Willis, Head of Care for Kingswood Unit assisted the inspectors. However Gill returned to the home to be involved with the visit. The management of the home has much improved now the team of staff are settled and being well supported by Gill. The feedback from service users and relatives has all been positive and very complimentary about the service. Service users told the inspector that they considered it home very soon after moving in and the staff are very friendly and supportive. A varying age range of service users is cared for at the home and there was strong evidence that each person is considered and assessed as an individual with care plans demonstrating this. The inspectors were very impressed by the standard of cleanliness at the home and the activity schedules for all units. The special needs of younger adults and older people are all considered when management look to introduce new processes or ideas into the units. What the service does well: Each unit offers a home for life. Many service users and relatives said they had total confidence in the home and the staff who worked there. Several service users told the inspector that it felt like home straight away. The staff are all appropriately trained to deal with the diverse range of care needs that the individuals present with and all the individual preferences. Good quality meals are served and a varied diet is catered for considering the individuals’ needs and preferences. The teams of staff on each unit are welcoming and open. Due to the varying age range and diverse categories of the service users at the home the task of meeting individual needs is far greater, however the teams of nurses and care staff are working very well towards an excellent service for all. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 6 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. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 7 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.V297284.R01.S.doc Version 5.2 Page 8 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): 1-6 The quality outcome of this outcome group is good. This judgement has been made using available evidence including a visit to this service. The individual health, personal and social cares needs of residents had been established and these were being met by the staff, which were evidenced to have the necessary skills and experience to carry out their role. EVIDENCE: The Statement of Purpose and Service user Guide was available. Staff continued to complete full assessments of individuals prior to admission. Prospective service users details were recorded on appropriate documentation. A trial period as part of the contract/ terms and conditions was offered to new residents. The resident or their relative receives written confirmation to ensure that the home can meet their individually assessed needs. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 9 Again relatives spoken to at the inspection had felt very comfortable about their loved ones entering the home as they were reassured and supported by the staff. They felt the home was well managed and that the staff was able to offer friendship to the service users and be supportive to those with any diverse needs. They felt the quality of the home was good and that the home offered suitable therapies and activities for the age range of users in the home. The relatives commented that they were always made welcome and offered a drink, which was very kind when staff were so busy. One gentleman said he felt the staff were his friends too. He tried to attend all the functions to support the home. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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 - 11 The quality outcome for this group is good. This judgement has been made using available evidence including a visit to this service. Individual health, personal and social care needs had been established. Some care records were incomplete but generally staff that possessed sound knowledge and skills was meeting individual service users needs. EVIDENCE: On each unit care records were recorded to a very high standard. Care documentation was well recorded however the need to insert space to sign for some tasks was noted. This was to be amended by the Manger. The care records were individualised and well written. Communication was included for some service users and a suggestion was made that all individuals should have one along with personal hygiene and individual needs. The GP was in the home at the time of the inspection and a lengthy discussion took place with regard to his absolute trust and admiration for the professional team that worked at the home. He was confident that the staff looked after his patients very well. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 11 Through quality audits, privacy and dignity were continually monitored as being delivered to the service users by the staff. Service users agreed that the staff were polite and respected their dignity in some quite embarrassing situations, one lady said. She said it was comforting to know that compassionate staff could assist her and not make her feel as though she was a problem. The pharmacist recorded medication audits 4 times a year, and in house audits were also completed. The GP commented that he reviews medication regularly but the staff assists him with their good observations. The senior staff spoken to confirmed that compassionate consideration is given to service users and their relatives at the time of the individuals’ death. Training has been received to refresh staff on the procedure and expected outcomes of care relating to a death. One gentleman spoken to said his mother was very ill and thought she might die but the staff were remarkable and she is now well again but he felt reassured that should she pass away he would be well supported. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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 - 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was providing residents with a good quality of life. Residents were provided with a varied lifestyle, which took consideration of individual’s wishes and previous interests. Meals were of a good standard and provided residents with choice. EVIDENCE: As part of the assessment of this area all units were visited and a number of residents spoken to, files examined and discussions held with staff and the hobby therapists. Each unit provided residents with a range of activities based on their choices and in the case of The Beeches on previous interests and following discussion with relatives. All the hobby therapists were aware of residents’ likes and dislikes and were highly committed to provide residents with a good service. As part of the resident documentation all residents had a support plan based on their social needs and the home had completed life maps and life histories. The home had a hairdresser that visited the home and residents had the opportunity to have their spiritual needs met. The home was alert to the Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 13 diverse needs of the residents and considered residents’ heritage and background. On The Beeches unit residents had the opportunity to take part in small group activities and the hobby therapists provided some individual time to residents. This may have been doing manicures or sitting talking to residents. Some residents had been out on day trips and to the pub. The home was in the process of developing a sensory garden. Unfortunately the secure outdoor area could not be used by the residents due to the unevenness of some of the flagstones. This does need to be repaired as soon as possible as many of the residents enjoyed spending time outside. Whilst the hobby therapists were doing a good job and providing a range of activities for residents there was scope for more time to be given to this aspect of the care. Residents on Kingswood were being provided with a range of activities based on their wishes. Activities took place in small groups and every resident had individual time with the hobby therapists. Residents had individualised programmes that involved activities such as going to the pub, out for walks, regular trips out, along with a range of activities within the home. This included listening to music, using the sensory room, watching TV and a range of art and craft activities. The hobby therapists were aware of the individual preferences of each resident and tailored a programme to meet each person’s wishes. Residents were encouraged to make choices over their lives. Residents on Woodlands were provided with a range of activities including flower arranging, trips out- on the following day a number was visiting the Black Country museum. Previously some had been to the theatre. All units were observed to be relaxed and there was a friendly atmosphere throughout. Visitors were welcomed at any time. The home’s routines were quite flexible with residents able to take breakfast when they got up. A resident in Kingswood stated that she chose how she spent her time and could do things when she wanted. It was also noted that on Woodlands a number of residents had chosen to have their lunch outside and several were having a can of beer before lunch. All residents spoken to stated that they liked the meals and confirmed that there was always a choice. In addition a resident could always have something that was not on the menu if they wanted and discussions with the cook on duty confirmed that they did make specific meals for some residents that requested it. The catering staff, in consultation with care staff, also provided meals that residents on EMI unit, would find easier to eat and provided some finger foods. The catering staff was extremely flexible and would go out of their way to meet the food requests of residents. The home provided a diabetic menu and provided food for residents that needed a soft or pureed diet. Observation showed that these meals were well presented and looked appetising. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 14 The home provided a range of snacks and there was always food in the units for residents to eat between meals and during the night. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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 the following standard(s): 16 - 18 This quality outcome is good. This judgement has been made using available evidence including a visit to this service. The home provided a complaints procedure made available to any person wishing to raise a concern. Staff training records ensured that the staff are provided with the appropriate training to protect the residents. EVIDENCE: There had been no complaints made about this home to the Commission since the last inspection. Nine had been made to the management of the home and one had been substantiated relating to the heating on one unit. The home had a robust complaints process, which could be accessed by relatives and residents. Staff confirmed that they were involved in ongoing training via various courses. Records evidenced that across the complex 23 staff had completed NVQ level II in Care; and 10 more were involved in the process. External training for Abuse have been carried out along with Whistle Blowing procedure training and Challenging Behaviour training which will protect the service user and staff should the need arise. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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 the following standard(s): 19 - 26 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the home; a tour of the premises and discussions with the head of cares on the units. Residents were provided with a warm comfortable home where they can continue their life style assisted by the staff team. There were some minor areas that required attention but they were cosmetic. EVIDENCE: Located off the A449 the home stands in its own grounds; consisting of three separate units each one providing care for the diverse needs of individuals. BEECHES This unit had a pleasant comfortable atmosphere, the recently decorated lounge had yet to have the pictures returned to the walls. Individual bedrooms were evidenced to have personal possessions displayed. The unit had a good standard of hygiene the staff work hard to maintain this standard. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 17 Bedrooms were located near to bathrooms, toilets and the shower room. There was a requirement to “box” in the hot water pipes within the bathrooms, protecting the residents in the event of a fall. The slabs on the large patio had been uneven for a short time this problem excluded the residents from going outside. During the inspection the slabs were raised and made safe. KINGSWOOD The main corridors within the unit would benefit from decorating further enhancing the environment where areas were looking tired and beginning to show signs of age/marks. There was a need to review bathroom number three water temperature which, was a little under the required temperature. The fragile portable ramp from the dining room was unstable; there needed to be a more substantial ramp to safely cater for the wheelchair manoeuvres. Discussions with the head of care on the unit identified that the bathroom proposed to become a wet room had a number of articles stored within it including a chair that should be disposed of. The unit was maintained to a first-rate standard of hygiene, the staff worked as a team to maintain this level. WOODLANDS The unit was well maintained; lounge carpets referred to in previous inspection reports was being replaced, however this had been shampooed twice weekly in the interim and this teamwork had made an immense difference to the overall state of the carpet. The inspectors were informed that it was planned to commence replacing the carpets in Woodlands on the 3 July 2006. This will include the carpet in bedroom No 22 which was particularly badly stained. It was noted that a small ramp should be created at one resident’s patio doors to enhance his independence. There was a need for the hot water pipes in the bathrooms to be “boxed” in, to prevent an accident to any older person. There was written evidence from the well-maintained records to identify that the equipment in the units were serviced and visually checked on a regular basis. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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 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 - 30 Quality in this outcome is good. This judgement has been made using available evidence including discussions with staff in each unit, records and the training facilitator. The training programme continued to meet the development needs of all the staff employed at the home. Training included specialist people to meet the diverse health needs of residents. EVIDENCE: From the written evidence provided by the training facilitator it was apparent to the inspector that training for all the staff was a high priority. Staff spoken to and from the records seen at the time of the inspection this was confirmed. Staffing levels were satisfactory to meet the diverse health needs of the residents in each unit. At any one time there was always trained qualified nursing staff on duty; supported by committed care and housekeeping staff. Recruitment of staff was in line with the guidelines of the National Minimum Standards. The required checks were evidenced from the records. No staff would be employed prior to a POVA check being returned. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 19 The training facilitator confirmed initial staff training; this was a combined training package. Two of the head of care staff had completed a POVA course. Raising awareness and promoting positive practices. Staff confirmed that specialist trainers provided any awareness of a specific health care. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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 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 - 38 This quality outcome is good. This judgement has been made using available evidence including a visit to this service. The residents were benefiting from a home that reviewed its practices through quality audits. The home’s system for the safeguarding and recording of residents’ money was robust and provided residents with protection. The home’s health and safety procedures were improved with regular training of staff and good management of the estates ensuring the safety of staff and service users. EVIDENCE: The home continues to have systems in place to ensure that appropriate check are made and security provided to all service users and staff. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 21 The home system for staff training was good and the staff do receive the necessary mandatory training of fire, food hygiene, health and safety and moving and handling. The home had risk assessments in place for safe working practices. This training is organised by the Training coordinator based at the home. A training room is available for all staff to use and for training days and lectures. The maintenance man was undertaking the necessary servicing of equipment including hoists and wheelchairs and fire prevention equipment. The maintenance man was also undertaking the testing of water temperature both for the control of the legionella bacteria and for the safety of residents. Generally the water temperatures were satisfactory. The home had procedures in place for the testing of fire prevention systems and the fire alarm and the emergency lighting was being tested appropriately. There were regular fire drills taking place to ensure staff are alert to procedures so protecting the service users. The home had procedures in place for the safe storage and use of hazardous substances. Radiators were at a suitable heat not to cause a hazard. Risk assessments were in place however outdoor garden furniture was not assessed and this was to be instigated asap. The home maintained records of accidents and these were monitored for particular trends such as time of accident etc. The home was not the appointee for any of the residents but did have small amounts of money for some of the residents. The home had a robust system to safeguard residents’ money keeping accounts of money left with the home and over expenditure. Any expenditure was backed up. The home maintained a separate bank account for residents’ money and individual records were being kept. Although residents’ money was kept in the bank if cash was needed, for example for a resident to go shopping, the home would draw the money from the bank to give to the resident. The care staff were now receiving formal supervision but were receiving daily oversight from senior care staff and nursing staff. The home had a policy on supervision. The home did have an appraisal system that looked at career development and it is combined with the appraisal and the supervision procedures. Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 3 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 3 3 3 3 3 3 3 3 Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP25 Regulation 13(4)(a) Requirement The registered person shall ensure that all parts of the home to which residents had access are so far as reasonably practicable free from hazards to their safety. The pipe work within the bathrooms should be guarded A programme of routine renewal of the carpets in the premises is to be implemented. Timescale for action 06/07/06 2. OP19 16(j) 01/08/06 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 2 Refer to Standard OP8 OP38 Good Practice Recommendations All service users to be assessed to have a communication care plan as standard. Risk assessments for outdoor furniture to be updated Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 Page 24 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 Himley Mill Nursing Home DS0000022340.V297284.R01.S.doc Version 5.2 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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