Inspection on 09/05/05 for Himley Mill Nursing Home

This inspection was carried out on 9th May 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

Himley Mill Nursing Home 01/07/08

Himley Mill Nursing Home 06/06/06

Himley Mill Nursing Home 09/11/05

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 Joanna Wooller Announced 09 May 2005 09:15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 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 Care Home 86 Category(ies) of 5 MD(E) registration, with number 30 DE(E) of places 10 OP 30 PD(E) 10 LD 56 PD 30 DE 5 MD Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 be MD(E) or 5 MD - minimum age 60 years on admission Date of last inspection 13 Decmber 2005 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. 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 offers care to 30 service users with dementia care needs. 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 manager’s office, the training school and the reception are located in the main building where the laundry and central kitchen are also sited.Kalmit Jagpal, the newly appointed manager, has been in post for 12 months. She is to become the registered manager and an interview date has been arranged for June. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on Monday 9th May 2005 took place during one day and undertaken by two inspectors. The National Minimum Standards for Older People and Younger adults were used as guidance to assess the standards within the units. The total amount of time spent on this inspection was 10.5 hours, which included pre –inspection and fieldwork prior to the visit. The manager, Kalmit Jagpal was available for the inspection and an interim deputy manager Ms Howarth supported her. Heads of Care managed each of the three units. The management had received no complaints since the last visit and no additional visits had been made. The inspection included: • A full tour of the units, kitchen and laundry, including service users bedrooms • Reading of care records and care plans • Talking to residents • Observation of management records • Discussion with the staff on duty Pre admission assessments had been completed for all new admissions and service users were in receipt of an acceptance letter to ensure their individual needs could be met at the home. Service users had individual care records, which included their individual health, personal and social care needs. The inspector observed a balanced menu record; and that day’s menu was displayed in the dining rooms. The environment was found to be showing signs of the need for a deep clean and redecoration in all units. Staffing levels were observed and duty rosters were seen. The Responsible Individual Mrs McGarry-Wall is currently based at the home and she forwards Regulation 26 reports to the Commission For Social Care Inspection on a monthly basis. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 6 Service users finances were maintained by strict BUPA policy and procedure. The health, safety and welfare of the service users and staff are monitored through the homes policies and procedures. What the service does well: What has improved since the last inspection? The requirements were all met from the last visit and had been generally maintained. (See what can be done better) The manager is soon to be registered by the Commission For Social Care Inspection, which will give the home stability. Since the last inspection staff morale is higher due to recruitment of more staff. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 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: 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 Statement of Purpose and Service user Guide was available. The resident or their relative receives written confirmation to ensure that the home can meet the assessed needs. 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. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 standard(s) 7-10 Individual health, personal and social care needs had been clearly established and was being met by staff that possessed sound knowledge and skills. EVIDENCE: The care plans inspected were very comprehensive and included short term and long-term problems, which were reviewed regularly. There were risk assessments in place for pressure sore prevention, manual handling, nutrition, catheter care, incontinence support, and any other individual identified risk. All entries were legible, dated and signed. There was a meaningful daily statement entered into the body of the care plans. Residents had full access to all NHS entitlements. Visits from external professionals had been documented and where possible residents had input into their care planning. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 11 Kingswood unit provides care for severely disabled younger adults and as such many could not communicate fully with staff. The inspector spoke with 11 residents on this unit and found them to be very well cared for, with lots of attention paid to personal hygiene requirements. Medication was checked and all was found to be in order. A trained nurse in line with NMC requirements administers all medication. The home has a robust medication policy, which is closely adhered to. Controlled drugs were checked and tallied with the stock register. The medication fridge was found to be at the correct temperature for storing drugs. MAR sheets were examined and no anomalies were found. There were areas in the lounge and toilets that were not as clean as could be expected. This was discussed with the care manager who will follow this up. During the visit to Beeches unit several residents were engaged in conversation. Two men sat outside for a cigarette and although one gentleman was very confused and did not know why he was being kept in the home, the other resident spoke highly of the caring staff and had no complaints at all. Staff were seen to comfort the confused gentleman with great empathy and care. A relative was engaged in conversation and could not speak highly enough of the home and how welcomed he was when visiting his wife. This gentleman was very upset as his wife did not recognise him when he came to visit but went on to explain how supportive the staff were to his and his wife’s plight. He had never had cause to complain and felt the staff was very approachable and should he have a problem he was clear that it would be remedied as quickly as possible. During the visit to Woodlands the inspector met with many residents who were willing to discuss the wonderful care and attention they received. Two residents said they had felt exceptionally ‘well’ since coming to the home. Care records were extensive and personalised. Records were up to date and descriptive of resident’s current condition. All necessary documentation was included relating to manual handling, nutritional intake and risk assessments. No issues were raised relating to medication. The staff were evidenced to know the residents exceptionally well, enjoying comical banter and in-house jokes! Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 standard(s) 12-15 As far as could be ascertained residents were satisfied with their lifestyle in the home. Contact is promoted with relatives and friends of residents. Activity aspects were very good, all residents could expect interaction for leisure pursuits, exercise and one to one sessions, from very caring staff. EVIDENCE: A check on the records and discussions with residents, a relative and several members of staff evidenced that activities, and entertainment was very well organised and enjoyed by all. Records of events were maintained. The activities on Woodlands were organised daily by the unit’s activity coordinator. She was enthusiastic with the service users and this motivated them to join in groups such as the ‘Dominoes Club’. Trips out and gardening sessions were planned for the summer. Staff stated that there was a good choice of food at mealtimes and cultural needs and special diets were met. Some resident on Kingswood are fed by a ‘Peg’ system, as they did not have the ability to swallow properly. Soft diets were provided which were presented well. The home kept a record of residents weight at regular intervals. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 13 The kitchens were evidenced to be in good working order and exceptionally clean. Menus were varied throughout the seasons and residents’ preferences were catered for. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 standard(s) 16-18 Residents and relatives were confident that their complaints were listened to, taken seriously and acted upon. Residents’ legal rights were ensured and they were protected from abuse by the strict policies and procedures in place. EVIDENCE: A clear BUPA complaints procedure is posted around the home. A record of complaints is maintained and was observed by the inspector. The Commission For Social Care Inspection had received no complaints. Residents had access to advocacy services as required and had recently voted at the election by either post or in person. The staff at the home was trained to ensure that they were fully aware of types of abuse and were given appropriate training to avoid such occurrences. The BUPA policies and procedures were in place and used as part of training and necessary update. The staff were aware of the Vulnerable Adults Procedure and Whistle Blowing procedures. Strict BUPA procedures were in place with regard to residents’ finances and computerised ledgers were kept and audited by head office. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 standard(s) 19- 26 Whilst the home is suitable for the needs of the residents on the day of the inspection some areas of the home were not as clean as they could be. EVIDENCE: A brief tour of the home was undertaken and rooms were of a good size and well personalised. One resident who had not been very well had her bedroom moved near to the nurses station for optimum observation. This was done with consent from the family. Various aids and adaptations were in place including chair lifts in baths, mobile hoists and all other equipment for moving and handling was in operational order. A nurse call system is available in all residents’ areas. One resident who was wheelchair bound and unable to speak had been provided with a small typing/talking machine. He enjoyed speaking to Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 16 inspector through this system. He was very satisfied with the care in the home and enjoyed the food. This gentleman was beaming and appeared very happy. Bedrails and bumpers were in place where required following a risk assessment and signed consent. Adequate hand washing facilities were available throughout the home. Grounds were kept tidy, safe and attractive. The homes gardener maintains the individual areas. The building complies with the fire and environmental health department. No CCTV is used at the home. Appropriate bathing facilities were sited throughout each unit. Residents were surrounded by their personal possessions in their bedrooms and several residents showed me family photographs and special belongings. The residents felt very comfortable in the unit communal areas, but also liked being in their own space. The furniture and fittings were in good condition and monitored to maintain a homely appearance and comfortable surroundings. Rooms were centrally heated but individually controlled. Emergency lighting was tested and recorded appropriately along with water temperatures and its storage. The home, although clean and hygienic in some areas was not consistently of a good enough standard. The domestics require more leadership in task allocation to ensure that deep cleaning and furniture moving is planned on a schedule. Laundry facilities were in good working order and well managed. Infection control policies and procedures were used as working documents along with the TOPPS training. Distance learning packages were being cascaded throughout the staff in the home. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27- 30 The assessed needs of residents had been met by an adequate number of suitably trained staff. Recruitment procedures were in place, which had contributed to the protection of service users. Staff training is taken very seriously, the home have a Training Manager to oversee this. EVIDENCE: Staffing rosters were checked and were in order. 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. In addition to the manager there had been six trained nurses and 15 care staff throughout the three units and the other shifts were suitably staffed also. Adequate numbers of ancillary staff were rostered. The records seen evidenced that in addition to the manager the home employed 14 care assistants, of which 8 (60 ) were trained to NVQ level 2 or above. The BUPA recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 18 Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. The staff were able to discuss job descriptions and contracts of employment. Residents when asked stated that the staff were available when they wanted them, and that the staff were very good to them. Training had been given a high priority and the training records of individuals were seen. The records evidenced that all staff had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Staff told the inspector that they had been afforded the time off and encouraged to study. Training had been provided for staff and the Training Manager managed this. The inspector saw records to evidence this. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-38 The home appeared to be well managed and residents lived in a relaxed atmosphere, supported by the staff that provided high standards of care. EVIDENCE: From observations made, discussions with residents, relatives and staff it was evident that the home was being run in the best interests of the residents. 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. 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. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 20 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 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. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 19 26 Regulation 16 16(j) Requirement The programme of routine maintenance is ongoing re decor Maintain satisfactory standards of hygiene throughout all areas of the home. Timescale for action 04/07/05 13/06/05 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 37 Good Practice Recommendations Adive given to commence an acute care plan for residents who have fallen, to observe for bruising nd injury. Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Himley Mill Nursing Home E51-E09 S22340 Himley Mill V218633 090505 Stage 4.doc Version 1.30 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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