Inspection on 09/11/05 for Himley Mill Nursing Home

This inspection was carried out on 9th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 06/06/06

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 Unannounced Inspection 9th November 2005 09:30 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.V264678.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 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) BUPA Care Homes Limited 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.V264678.R01.S.doc Version 5.0 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 May 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. 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. 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. Gill Howarth, the newly appointed manager, has been in post for 4 months. She is to become the registered manager and an interview date will be arranged in the near future. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on the 9th November 2005 at 09.30hrs. The lead inspector and two co-workers using the National Minimum Standards for Older People as a reference undertook the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 20hrs. The care manager was in the home the staffing levels were found to be adequate to meet the needs of current residents in the home. The inspection included the following elements; a tour of the three units, observation and inspection of records relating to provision of care, discussions with many residents, discussions with the staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection in May 2005 there had been 4 additional visits made for vulnerable adult situations. It was evident that aspects of care had been addressed, with residents able to choose the home following an assessment and invitation to visit the home. Service user plans had been well written, based on the community care plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for residents were being upheld. The home was in general found fit for purpose, with a few requirements made. The home provided a safe environment for the residents and staff. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were adequately provided. Health and safety aspects had been given a high priority and no shortfalls were noted. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were good with some staff turnover. Staff training had been given, with induction training being followed by NVQ training, and staff had received supervision. The home appeared to be managed well by a qualified and competent care manager. Ms Howarth is yet to be registered with the CSCI. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures were in place. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 6 What the service does well: 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.V264678.R01.S.doc Version 5.0 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.V264678.R01.S.doc Version 5.0 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): 3, 4 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 DS0000022340.V264678.R01.S.doc Version 5.0 Page 9 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, 8, 9 and 10 Individual health, personal and social care needs had been established. Some care records were incomplete but generally needs were being met by staff that possessed sound knowledge and skills. EVIDENCE: The care plans inspected were comprehensive and included short term and long-term problems, which were generally well reviewed. Some care records on Kingswood (as identified) were not up dated and this was disappointing to find. 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, and most were 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 DS0000022340.V264678.R01.S.doc Version 5.0 Page 10 Kingswood unit provides care for severely disabled younger adults and as such many could not communicate fully with staff. The inspectors spoke with several 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 on all units and 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. Staff were again seen to comfort confused residents on Beeches Unit with great empathy and care. Relatives spoken to at the inspection were very complimentary of the home and the staff. They felt the staff was very approachable and should he have a problem they felt sure 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 care and kind attention they received. One lady resident said she had felt much better since coming to the home. One resident was unwell and was being managed by the staff exceptionally well. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 11 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, 14, 15 The home provided residents with a flexible routine and activities were taking place, particularly on the Beeches and Kingswood units, however some of the record keeping did not adequately demonstrate the nature of activities and whether all residents had the opportunity to engage in activities. There was a requirement for the management to review the provision of equipment provided for residents, which was identified to be in an unacceptable condition. EVIDENCE: The majority of the residents in Beeches were served a soft or pureed diet to suit their needs. Residents were served food in an area of their preference; mainly within the lounge. The inspector had grave concerns as to the condition of the cups used by the residents; in all the units. The condition was unacceptable with dark brown stained cups. The microwave in the small kitchen area within “Beeches” was in need of replacement where the enamel inside the compartment was chipped and appeared rusty. The kitchen areas in general could be improved in its hygiene this could be achieved by a deep clean of the flooring. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 12 The main kitchen transferred meals via a heated trolley to the units. The necessary temperatures were well maintained Beeches. The routines within the unit were flexible with residents able to get up at a time of their choosing and having their breakfast when the got up. Residents could spend time in their bedrooms or in the communal areas. Residents went to bed when they wanted and those that tended to get up in the night could sit in the lounge and could have drinks and snacks. Residents had the freedom to move around the unit and to go into the enclosed garden. The unit had two part time activity staff and they undertook a range of activities both for small groups and on a one to one basis. Activities included entertainers coming in to the unit, games, sing a longs and trips out of the home including going out for pub lunches, trips to a garden centre and walks. The home had a hairdresser that visited. The activity staff were well motivated and were aware of each residents individual likes and dislikes and tried to provide activities that residents enjoyed. Residents were provided with chose over their meals. Kingswood. The unit went out its way to be as flexible as possible. Residents were provided with choice over when they got up, went to bed and how they spent their time. Staff were aware of the communication methods of those without verbal speech and were alert to non verbal methods such as facial expressions to indicate likes and dislikes. Those that were able chose where to spend their time, either in the communal areas or in their bedrooms. The unit provided a range of activities and the activity staff were aware of the individual preferences and interests of the residents. Discussions with the activity staff confirmed that they spent time with each resident on a daily basis. The activity staff undertook a range of individual activities with residents including supporting residents to use the sensory room, activities relating to improving their physical abilities, doing art activities, reading and supporting residents to use computers. Residents were supported and encouraged to access the community. They were provided with the opportunity to go out for pub lunches and shopping. Recently a group had visited Walsall illuminations and the unit had a fireworks display planned. Although records were being kept these were not fully identifying the nature and level of activities each individual was undertaking. Choice of meals was available over meals. Woodlands. The unit tried to be as flexible as possible providing residents with choices over meals, when to get up and go to bed. Breakfast was provided when residents got up in the morning. The unit provided some activities but due to the absence of the activity staff member and the confusing records it was not completely clear over the level of activities taking place and that all residents were being provided with the opportunity to engage in activities. One resident stated that she had been out on trips in the past but could not recall activities within the unit. The available records did indicate that three residents had been shopping recently, two had been to a local park and Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 13 several had their nails manicured. It was ascertained that the Church of England provided a service to residents if this was requested. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home provided a complaints procedure made available to any person wishing to raise a concern. Staff training records ensured that staff are provided with the appropriate training to protect the residents. EVIDENCE: There had been no complaints made about this home to the Commission or the management. 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 20 staff had completed NVQ level II in Care; three more were involved in the process. Some staff had been nominated for NVQ level III in Care Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,23,24,25,26 The Beeches and Kingswood were warm and comfortable, residents were provided with a homely environment. Residents had the opportunity in all units to personalise their bedrooms. The continued decoration programme will further enhance the “Beeches” There was a requirement for the management to provide acceptable living accommodation for the residents in “Woodlands” EVIDENCE: Located on the complex “Beeches” provided accommodation for people with a mental frailty. At the time of this inspection there were four vacancies. Resident’s communal accommodation as were the corridors well maintained. Bedrooms were for single occupancy, the majority of them being secured during the day. A sample identified that the routine programme for decoration Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 16 continued. There was at the time of the visit building work going on to create an office central to the home. The standards of hygiene were maintained on a daily basis by the housekeeping staff. With the exception of the assisted baths and toilets “Beeches” residents required no specialist equipment to enhance their life style. A small sample of bedrooms identified that personal possessions were encouraged; each bedroom had a memory box on the wall outside the resident’s room. The staff provided a safe and secure environment. “Woodlands” unit was in general hygienically well maintained, the inspector had grave concerns as to the condition of the carpet in the communal areas. This carpet was unacceptable, it was badly stained and despite being cleaned remained in a poor condition. The inspector had been lead to believe that this particular carpet was due for replacement in 2004. “Kingwood” was a pleasant unit with residents sitting around the lounge. The environment was clean and tidy. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30 There was a requirement for the management to urgently review the staffing levels for the afternoon shifts on “Woodlands” There were sufficient staffing levels on the “Beeches” to meet the needs of the residents. “Kingswood” unit had sufficient staff at the time of the inspection to enable the residents to continue with their life style. EVIDENCE: The staff on each unit confirmed that they were offered training sessions, often external to the home environment. This was evidenced from the training records available. On any one shift there would be trained nursing staff supported by the carers, housekeeping and activity personal. At the time of the visit the unit “Woodlands was without an activity person. “Woodlands” unit had been experiencing difficulties with the management of a resident, the inspector identified that while the resident required assistance from two staff at all time, the staffing levels reduced by three for the afternoon shift. The unit had a high degree of heavily dependent residents and this reduction of staff could leave other staff and residents at risk. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 18 The staffs over the complex were helpful and assisted the inspector during the inspection. One relative in “Woodlands” told the inspector that her husband was so well looked after his appetite had improved since his admission. She felt very welcome and assist the staff with his care. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 The residents were benefiting from a home that reviewed its practices and identified areas where it could improve the service. 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 in the main protecting the residents but the home needed to ensure that all fire prevention measures were being undertaken and that the water temperatures were always within the required limits. There was a requirement for the obligatory training for all the staff in respect of fire procedures to protect the residents and to ensure their safety. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 20 EVIDENCE: The home had systems in place to ascertain the nature of the service provided. These included reviewing aspects of the environment; the care plans and included the views of residents and relatives. An external manager of the company was undertaking monthly visits. 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. A sample of residents accounts were examined and this identified the ingoing and expenditure and clearly identified the reasons for the expenditure. The care staff were not receiving formal supervision but were receiving daily oversight from senior care staff and nursing staff. The home had a policy on supervision but this had not as yet been implemented with the care staff. The home did have an appraisal system that looked at career development and it was hoped to combine the appraisal and the supervision procedures. The home system for staff training was good and there were ongoing plans for staff to 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. The home was undertaking the necessary servicing of equipment including hoists and wheelchairs and fire prevention equipment. The home was 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 not too hot for residents but there were instances when the level had slightly exceeded 44 degrees. The home had procedures in place for the testing of fire prevention systems and sampling of two units showed that the fire alarm and the emergency lighting was being tested appropriately. There were fire drills taking place but there was an absence of any records evidencing a fire drill during 2005 for one unit. 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. The home maintained records of accidents. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 21 There was no evidence of a fire drill being executed during 2005 for “Kingswood” unit, despite one of the staff members being trained for fire precautions and practices. There was evidence in the records for “Woodlands” that only one fire drill had been undertaken September 2005 The weekly testing of the fire system was evidenced as satisfactory. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 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 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 2 2 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 1 2 2 Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 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. 2. 3. Standard OP38 OP19 OP12 Regulation 23(4d,e) 16(j) 16 (m, n) Requirement The staff must be suitably trained in fire prevention and provide evidence of fire drills. A programme of routine renewal of the carpets in the premises is to be implemented. To ensure that there is evidence available to identify the nature of activities and to show that all residents have the opportunity to take part in activities. To ensure that the temperature of water accessible to residents does not exceed the required level. The home must ensure that persons working in the home are appropriately supervised. Records required at the visits must be made available and kept up to date as required in the regulations. Residents’ cups must be suitable to drink from. Timescale for action 09/12/05 09/12/05 01/01/06 4. OP38 13(4c) 09/11/05 5. 6. OP36 OP37 18(2) Sch 3, 4 01/01/06 09/12/05 7. OP15 23 (2c) 09/12/05 Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 24 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 OP27 OP7 Good Practice Recommendations Staffing levels must be monitored with regard to residents dependency levels at all times to ensure that residents needs are being met. The Unit managers must ensure that audits on care records include the signing and dating of all reviews, risk assessments and care plans. Himley Mill Nursing Home DS0000022340.V264678.R01.S.doc Version 5.0 Page 25 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.V264678.R01.S.doc Version 5.0 Page 26 - 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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