Inspection on 14/12/06 for Moundsley Hall Nursing and Residential Home

This inspection was carried out on 14th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Moundsley Hall Nursing and... 24/10/05

Moundsley Hall Nursing and... 23/06/05

Moundsley Hall Nursing and... 21/10/04

Moundsley Hall Nursing and... 15/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Moundsley Hall Nursing and Residential Home Walkers Heath Road Kings Norton Birmingham West Midlands B38 0BL Lead Inspector Chris Potter Unannounced Inspection 14th December 2006 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 Moundsley Hall Nursing and Residential Home DS0000004127.V324119.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. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moundsley Hall Nursing and Residential Home Address Walkers Heath Road Kings Norton Birmingham West Midlands B38 0BL 0121 433 3388 0121 433 4774 info@moundsleyhall.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Moundsley Hall Nursing Home Limited Mrs Elizabeth Evans Care Home 69 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (69), of places Physical disability (69), Physical disability over 65 years of age (69) Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may also accommodate two named persons with a learning disability, one of whom is over 65 years. The home may accommodate one named person in the category of EMI (nursing) 24th October 2005 Date of last inspection Brief Description of the Service: Moundsley Hall Care Home is registered to accommodate 69 residents requiring both nursing and residential care. The home is registered to accept residents from 55 years of age. The home is purpose built and was first registered in 1996. The new extension for an additional 15 residents was opened in June 2006. The home is located on the outskirts of Kings Norton near Birmingham. It is conveniently located for local amenities, and for friends and relatives to visit. Accommodation is provided in two units on three floors and offers 57 single and 6 double bedrooms. All bedrooms benefit from having en-suite facilities. The home stands in spacious well maintained grounds. When the weather permits, resident’s can access the grounds with ease and garden furniture is provided for them to use. The homes fees range from between £410.00 and £560.00, additional charges are made for hairdressing, chiropody and newspapers. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes key unannounced inspection for 2006/2007. The previous inspection was in October 2005. The visit totalled 9 hours site visit. The inspection focused on the environment, care records, medication management, staff records and the residents’ views of the home were sought. On the day of inspection the home was caring for 65 residents. Since the last inspection the home has completed the new unit and called it Clarence House. The home is currently in the process of erecting a conservatory to link both units. The inspection was positive and comments received from residents and staff were most complimentary about the home and the quality of care provided. What the service does well: What has improved since the last inspection? Medication management has improved since the last inspection. The home has replaced some floor coverings, and provided new furniture in the main home, which has further enhanced the homes appearance. The nurse call system has been replaced, which now records how long it takes staff to answer the resident’s calls. The home was in the process of upgrading the main lounge and new furniture was on order for this room. Clarence house opened in June 2006, providing an excellent standard of accommodation for a further 15 residents. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.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 Moundsley Hall Nursing and Residential Home DS0000004127.V324119.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 standard 6 is not applicable to this home. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ needs are appropriately assessed prior to them moving into the home. All residents are provided with the appropriate information to assist them in making their choice. EVIDENCE: Since the last inspection the home has updated their Statement of Purpose and Service User’s Guide. The home has produced their Service User’s Guide in audio format to assist people with a sensory impairment. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 9 All residents are provided with a contract of terms and conditions on admission to the home. A signed copy is available at the home for reference. Residents are assessed prior to them moving into the home. Since the last inspection, the home has updated their pre-admission assessment to include more information. The managers’ from each unit assess the residents’ needs to ensure the home is able to care for those needs. This was confirmed at the inspection. The residents spoken with confirmed they had been assessed prior to moving into the home. The pre-admission assessment forms the basis of the residents care plan. The new pre-admission assessment provides a reference as to whether the prospective resident or their relatives viewed the home prior to their admission. The new extension named Clarence House opened in June 2006. The residents and staff transferred from a local home, which was closing. The residents and staff expressed their satisfaction about their bedrooms and communal areas of the home. All residents confirmed that they had settled well into the home and were happy that the staff had transferred with them. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care documentation accurately reflects people’s healthcare needs. The management of medication was well organised. EVIDENCE: Random samples of six care plans were reviewed during the inspection, three in the main home and three in Clarence House. The care documentation was comprehensive. It provided detailed information about the residents’ care needs and directed staff in how to meet these needs. Since the last inspection, the home has introduced a new nutritional assessment and this is assisting staff in ensuring the residents’ nutritional needs are being met. All the residents who transferred into Clarence House have converted all their Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 11 information onto the Moundsley Hall homes care documentation. The manager from Clarence House feels this has been an improvement for the residents. The manager and staff on Clarence House were commended for the amount of work involved in transferring all the information and upgrading all the residents care records. Clarence House have a detailed transfer notification in place in case a resident has to go into hospital. The information on this was commended. Since the last inspection the home reviewed their medication procedure following two errors, One involving a missing tablet. The home dealt with both incidents appropriately and is arranging additional medication training for the nurses and care staff who are responsible for administering medication on both units. The home has also updated their Homely Remedies Policy with the agreement with the homes general practitioner. Residents spoken with confirmed that all the staff treat them with dignity and respect. One resident stated, “Nothing is too much trouble for them, the staff are golden.” Staff were observed during the inspection being respectful to the residents. From a recent residents meetings, it was suggested that a sign is used when a resident is bathing to stop any interruptions. This has been actioned. Accident records were reviewed and the home carries out regular audits for any accident that occurs in the home. The residents’ wishes about their deaths are included in their care plans. The home implemented the national gold frame guidelines, which is commended. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and part of 15 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Activities are varied to suit the individual’s needs, however with staff limitations not all residents are able to go out when they choose. The home provides a varied choice of meals, aiming to meet the residents likes and dislikes. EVIDENCE: Since the last inspection the home has appointed a new activities organiser, who is in the process of developing new and interesting activities for the residents on both the units. The home was busy with their Christmas program, shopping, pantomime, Christmas Parties, craft work were just some of the events being organised for the residents. A weekly residents meeting is also held to assist residents who are able to voice their opinions about the home. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 13 Details of the resident’s social activities are recorded in their care records. No problems were expressed from the residents in the main unit about the activities, some residents on Clarence house stated they would like to be able to go out more. This was discussed with the manager who explained that it has to be arranged in advance and staff come in and assist in their own time. It was also confirmed that they are looking to change the times of the activities on Clarence House to mornings. Some comments from residents also expressed that they would like activities at weekends. Standard 15 was not fully inspected at this visit. The menu rotates and provides a varied choice. The home is able to accommodate any specialist diet. Generally the comments received about the food were very good. A couple of the residents on the main house said they would prefer a daily roast, the manager confirmed that this is what they had been used to in their original home which had closed. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Complaints are handled appropriately. The home has a procedure for responding to any potential allegations of abuse. EVIDENCE: Since the last inspection the CSCI has received no complaints about the home. The home has received six complaints in the last twelve months. The home maintains a record of any complaint received, details of the investigation into the compliant and the outcome of the complaint is clearly recorded. Two of the six complaints were partially upheld and the other four were happy with the result of the homes investigation. Residents were aware of the complaints procedure and who to talk to if they had a complaint. The manager feels that the regular residents meetings assist them in expressing their views about the home. The home provides protection of vulnerable adults training as part of their induction training. The home is confident that all staff would report any concerns to them if they had any. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, safe and well-maintained environment for the residents. EVIDENCE: Since the last inspection the home has opened its annexe named Clarence House for fifteen residents. This annexe is of a high standard providing all single bedrooms with en suite bathrooms and spacious communal areas for the residents. The en – suites have a light sensor so the light comes on automatically for the residents. A good-sized shower and toilet facilities. The main home has been upgraded with a new nurse call system; floor coverings and the owners are in the process of decorating the lounge and providing new furniture and furnishings. The owners are in the process of Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 16 having a link erected to join the two buildings to assist staff moving around the home with meals and laundry. The residents in both units expressed their satisfaction with their bedrooms and the facilities of the home. A maintenance operative is employed to deal with any day-to-day problems and monitor when safety checks are due. All servicing records were available and up to date at the time of the inspection. All areas of the home were observed to be clean and tidy, and given the size of the home this is commended. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. The homes staff recruitment procedure is thorough and robust. Staffing levels and staff competencies are suitable to ensure the residents care needs can be identified and met. EVIDENCE: Staffing rota’s were reviewed which showed that the home provides staff numbers to meet the care needs of the residents for the 24 hour period. Both the managers and staff on the units demonstrated a good knowledge and understanding of the residents care needs and communicated easily with them. Residents who were spoken to confirmed how helpful, the staff were and one resident stated, “ They are all golden. “ The home provides good training opportunities for their staff, and maintains a record of all the training which staff has attended and when the refresher training is required. The home should review more specialist training with Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 18 dementia type causes to assist them in meeting the needs of the residents who fall outside their category of registration. Three recently employed staff files were reviewed during the inspection. These showed that the home was adhering to their policy and ensuring that the appropriate checks had been carried out. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is clear leadership; guidance and direction for staff to ensure residents receive consistent care. The health, safety and welfare of the residents and staff are safeguarded. EVIDENCE: The home has committed owners and an administrator who are actively involved with the day-to-day management of the home. They spend many Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 20 hours at the home including weekends to ensure that the service is continued at weekends. The registered manager and the manager for Clarence house are both competent, and both were clearly able to demonstrate the care needs of the residents on their units. Staff confirmed that both the managers were supportive and approachable. Both managers like to work with the staff to monitor and support them, and both responded that this helps them with their communication with both the residents and staff. The home is commended on their quality audit; they have been assisted in developing systems measuring how the home is complying against all the national minimum standards. In addition the home holds weekly residents meeting which gives them the opportunity to air their views about the home, systems and staff. All records inspected that regular health and safety checks are being carried out. The home has completed a new fire risk assessment since the last inspection. The home is still wedging open a few of the residents doors, but confirmed as the rooms are decorated from the damage caused by the fitting of the nurse call system dorguards shall be fitted. The home does not manage residents finances this is the responsibility of their relatives, and the home forwards a receipt for them. A good supervision program for the staff is in place, and all staff receives regular supervision and a record is maintained of this. The home maintains appropriate records and registers and all policies and procedures are regularly reviewed and updated. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 4 4 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 3 3 3 3 3 Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 22 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 Standard OP38 OP30 Regulation 12 13 Requirement The home must ensure that door wedges are not used. The home should provide some specialist training for their staff to assist them in meeting the needs of service users outside their category of registration. Timescale for action 28/02/07 30/04/07 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 OP12 Good Practice Recommendations Review the activities taking into account the residents comments and wishes. Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Moundsley Hall Nursing and Residential Home DS0000004127.V324119.R01.S.doc Version 5.2 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. 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