Inspection on 23/06/05 for Moundsley Hall Nursing and Residential Home

This inspection was carried out on 23rd June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Moundsley Hall Nursing and... 14/12/06

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

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

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

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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 MOUNDSLEY HALL Walkers Heath Road Kings Norton Birmingham B38 OBL Lead Inspector Christine Potter FINAL - Unannounced 23 June 2005 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. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Moundsley Hall Address Walkers Heath Road Kings Norton Birmingham B38 OBL 0121 433 3388 0121 433 4774 info@moundsleyhall.com Moundsley Hall Nursing Home Limited 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) Mrs E Evans CRH 54 Dementia - over 65 Old age Physical disability Physical disability - over 65 Terminally ill 15 54 54 54 5 Category(ies) of DE(E) registration, with number OP of places PD PD(E) TI MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 21 October 2004 Brief Description of the Service: Moundsley Hall is registered to accommodate 54 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 registered in 1996. The home is located on the outskirts of Kings Norton, conveniently located for visitors to access. The home is within easy access for several shopping centres, garden centres, theatres and pubs. Accommodation for residents is available on two floors in 42 single and 6 double bedrooms. The bedrooms benefit from having en-suite facilities. The home stands in spacious well maintained grounds. When the weather permits, residents can access the grounds with ease and garden furniture is provided for them to use.. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two part days totalling eleven hours. The inspection focused on the requirements from the last inspection, tour of the environment, care documentation, staff and health and safety records. On the days of the inspection the home was accommodating 49 residents. During the inspection five residents and two relatives were interviewed. Staff questionnaires were left for staff to complete and return to the CSCI. What the service does well: What has improved since the last inspection? Decoration and furnishings in some areas has been upgraded since the last inspection this has further enhanced the homes appearance. A second passenger shaft lift has been fitted since the last inspection to further assist residents to access all areas of the home. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 6 Care plan documentation for the residents has improved since the last inspection. Staff training and supervision records have been improved. Activities have further developed and the comments from residents and staff confirmed how they were enjoying the enthusiasm of the activities coordinator. 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. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 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 standard(s) 1,2 & 3 The admission procedure is appropriate; residents are assessed prior to moving into the home and are given all the information needed to assist make their choice. EVIDENCE: A copy of the Service User’s Guide and Statement of Purpose was available and residents and relatives confirmed they had received a copy prior to admission. One resident said “From the minute he walked into the home he was made to feel welcome.” Residents are admitted to the home following a pre-admission assessment. The manager normally completes the pre-admission assessment to ensure the home can fully meet the residents care needs. Residents and relatives said the manager had visited them prior to admission. The pre-admission assessment is then incorporated into the residents care plan and a random sample of care plans reviewed showed this. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 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 standard(s) 7,8,9 &10. Significant progress has been made on improving arrangements to ensure that the health care needs of residents are identified and met. EVIDENCE: Six residents care plans were reviewed during the inspection. The care documentation showed that the home had improved the care plans since the last inspection. It was documented that all the appropriate recordings had been done. Appropriate risk assessments were in place and regular review was being completed. The residents, and relatives confirmed that the care was excellent, and staff were very caring and hardworking. Accident records showed that the home completes them with the appropriate information. The manager completes a monthly audit of all accidents in the home, which is considered good practice. The management of medication was reviewed and there were no issues, this showed medication was managed safely. Observations made during the inspection showed staff spoke appropriately and respectfully to residents. They were seen to knock on doors and heard to give MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 10 choices to residents. Residents spoken to said, “All staff are helpful and respectful.” . MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 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 standard(s) 12,13 &15 The meals provided are well balanced and provide a varied selection of food. Social activities are suitable and varied for all the residents. EVIDENCE: Since the last inspection the home has recruited an activities organiser, who has significantly improved the activities and entertainment facilities for the residents. She maintains a record within the residents care plans of the activities undertaken. Residents stated that the activities were appropriate to their needs. Two residents recommended that more outings are provided. Residents and staff were complimentary about the quality and choice of food available at the home. The inspector observed the lunch being served the food was well presented, and the care staff was helping residents who required assistance. During the inspection, some relatives were seen visiting people, and staff greeted visitors politely. Residents spoken to said that they could receive visitors at any time of the day. Relatives confirmed that there were “no restrictions” on visiting. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 12 MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 13 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 Complaints are handled objectively and residents are confident that their concerns will be listened to, taken seriously and acted upon. A vulnerable adults procedure has been developed to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a simple and clear complaints procedure, and the complaint records indicated that this is followed. A copy of the complaints procedure had been given to all residents, and was available to visitors and relatives. Residents and relatives spoken to were confident that concerns could be raised with the home. A procedure for responding to allegations of abuse is available. Staff confirmed they were confident in taking action if there were any concerns about abuse. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 14 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) 19,21,23,24,25 &26. Investment within the home continues to maintain a high environmental standard, creating a comfortable and safe environment for those living there and visiting. EVIDENCE: The home provides a safe comfortable and well maintained environment, which also has a homely atmosphere. All the rooms have been personalised by the residents. The home has two lounges, and a large dining room that is able to accommodate all the residents at any time if they chose to eat in there. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 15 Residents stated to the inspector they were pleased with their rooms and found them more than comfortable. One said “my room is excellent and the bed really comfortable.” The home has an ongoing program for routine maintenance and a system for checking safety aspects. The home was clean and tidy and the management of odours was commended given the size and dependency of the residents. The manager advised the inspector a protocol is place for cleaning bedrooms of residents with severe incontinence problems. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 16 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) 27,28,29 & 30 Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met. EVIDENCE: There were suitable nursing and care staff on duty to provide care and support for the 49 residents. In addition to nursing and care staff, there was also administration and ancillary staff on duty to support service provision. Training has been provided to staff, and includes infection control, first aid and moving and handling. Training was identified as a result of the needs of residents, to ensure that care delivered was appropriate to and in response to the needs of residents. Residents confirmed that all the staff was hardworking and nothing was too much trouble for them. A resident confirmed that the night staff responded quickly when called during the night. The recruitment procedure was being followed appropriately by the home. A formal staff supervision program has been commenced for all grades of staff, and staff confirmed this was most helpful. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 17 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) 31,32,33,36,37 & 38. There is clear leadership, guidance and direction to staff to ensure residents receive consistent care, resulting in practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The registered manager is appropriately qualified and has completed the registered manager’s award. Staff, residents and relatives communicated easily and were on first name terms with her. They confirmed that the manager was approachable and always’ made herself available to them. Formal staff supervision is in place and records are maintained. MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 18 The home operates a good quality assurance audit and the results of this are positive and available at the home. Records inspected indicated that regular health and safety checks are carried out including fire safety tests. There are systems in place for risk assessments to ensure the safety of residents and staff at all times. . MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 19 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 x x 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 x 15 3 COMPLAINTS AND PROTECTION 3 N/A 3 x 3 3 3 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 Standard No 16 17 18 Score 3 x 3 4 3 3 x x 3 3 3 MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 20 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. Standard Regulation Requirement Timescale for action 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 Good Practice Recommendations MOUNDSLEY HALL E52 S4127 Moundsley Hall V223244 230605.doc Version 1.30 Page 21 Commission for Social Care Inspection John Comyn Drive Droitwich Road Worcester WR 3 7NW 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. 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