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Inspection on 24/10/05 for Moundsley Hall Nursing and Residential Home

Also see our care home review for Moundsley Hall Nursing and Residential Home for more information

This inspection was carried out on 24th October 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The proprietors, director, manager and staff are committed to the home and work hard to maintain and improve their standards. They have regular relatives meetings, and act upon ideas to further improve their provision. From a recent meeting relatives had commented they were not sure whom their relatives named nurse or key worker was. The home has addressed this by providing a record in every resident`s bedroom with a photograph of their nurse and key worker. A copy of the service user`s guide is available in every bedroom, and a comment sheet for relatives to use to pass on information. The manager confirmed this has further improved communication with relatives. A pleasant atmosphere is evident in the home, and staff were observed interacting well with the resident`s and other staff. The manager is complimented on her knowledge and understanding of the residents.

What has improved since the last inspection?

The home has further developed an idea proposed from the residents meetings to further improve communication between residents and staff. The homes quality assurance program has further developed.

What the care home could do better:

The home should provide appropriate door guards if the resident wishes to have their bedroom door open.

CARE HOMES FOR OLDER PEOPLE Moundsley Hall Nursing and Residential Home Walkers Heath Road Kings Norton Birmingham West Midlands B38 OBL Lead Inspector Unannounced Inspection 24th October 2005 10:00 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.V252036.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. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Moundsley Hall Nursing and Residential Home Address Walkers Heath Road Kings Norton Birmingham West Midlands B38 OBL 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 Elizabeth Anne Evans Care Home 54 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (54), of places Physical disability (54), Physical disability over 65 years of age (54), Terminally ill (5) Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 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 two named persons in the category of EMI (nursing) 23rd June 2005 Date of last inspection 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 first registered in 1996. The home is located on the outskirts of Kings Norton near Birmingham. It is conveniently located for the local amenities, and for visitors to access with ease. Accommodation is provided on three floors and offers 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, resident’s can access the grounds with ease and garden furniture is provided for them to use. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on the 24th October 2005 by two inspectors. The visit totalled eight hours of inspector time. The inspection focused on the environment, care records, medication management, staff records and residents’ views of the home. On the day of the inspection the home was caring for 53 residents with one resident in hospital. The manager was on duty and assisted the inspectors throughout the visit. The inspection was positive and comments received from residents and relatives during the visit were complimentary about the home and staff. Moundsley Hall is building an extension to accommodate additional residents. The building work is well in hand and appears to have caused minimal disruption for the residents. What the service does well: What has improved since the last inspection? Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 6 The home has further developed an idea proposed from the residents meetings to further improve communication between residents and staff. The homes quality assurance program has further developed. 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 Nursing and Residential Home DS0000004127.V252036.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 Moundsley Hall Nursing and Residential Home DS0000004127.V252036.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 All residents are appropriately assessed prior to moving into the home, and provided with appropriate information to assist them in making their choice. EVIDENCE: A sample of three residents care records were reviewed which included their pre-admission assessment. The manager or registered nurse visits the potential resident and completes the pre-admission assessment. The assessment is based on the resident’s health problems and their physical needs. This assists the manager in ensuring the home can fully meet their needs. The pre-admission assessment then forms the basis of the residents care documentation. A resident and relative confirmed that the manager had visited and completed the pre-admission assessment prior to being admitted to the home. They confirmed that appropriate information had been given to them to assist them in making their choice. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.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 and 9 Resident’s care documentation accurately reflects people’s health care needs. However, the homes medication procedure was not being complied with, and this has the potential to place residents at risk due to medication errors occurring. EVIDENCE: A random sample of three residents’ care documents was reviewed. The documentation appeared to reflect the care needs of the residents. Appropriate risk assessments were in place and regular review being completed by the nurses. Residents and relatives stated they were pleased with the care and how hard the staff worked. Accident records showed that the home completes them appropriately. The manager completes a monthly audit of all accidents in the home, which is considered good practice. The medication round being undertaken was not following the homes procedure. The nurse was seen dispensing tablets into medicine pots with a piece of paper with the name of the resident on. This constitutes secondary Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 10 dispensing, and is poor and potentially dangerous practice, which must cease immediately. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.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): 12,13 and 15 The home provides a varied choice of meals catering for the residents’ likes, dislikes and special diets. Activities for the residents’ are varied to suit the individual needs. EVIDENCE: The activities organiser continues to develop the social activities for the residents’. Records are maintained within the residents care documentation of their choices of social activities. At the time of the visit the activities organiser was conducting a group activity in the small lounge. Other residents were watching the large screen television in the main lounge. Some residents were in their bedrooms or wandering around the home. Residents were most complimentary about the quality and choice of food available at the home. The catering staff were well-organised, and appropriate records and safety checks were being undertaken. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 12 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): Complaints are handled appropriately. The home has a procedure for responding to any potential allegations of abuse. EVIDENCE: The home maintains detailed records of any complaint made, these records were available and showed that the homes procedure had been followed. The CSCI has received one complaint since the last inspection, this is currently being investigated by the home and the CSCI. Written policies and procedures are in place in order to ensure the protection of residents, which includes a whistle blowing policy. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 13 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, 21,24 and 26 Investment into 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 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. Since the last inspection the home has started building an extension to provide additional accommodation to meet the demand for accommodating residents’. The building is well under way and the manager confirmed that the building work had caused minimal disruption for the residents. Residents and relatives confirmed they were pleased with the home and the homes facilities. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 14 The home has an ongoing program for routine maintenance and a system for checking safety aspects. All areas of the home were clean and tidy. The management of incontinence is commended. There is a need to ensure that the domestics’ cleaning trolleys are stored away safely. The trolleys were observed left out when domestic staff were on breaks, presenting a potential risk to residents from deliberately or accidentally accessing cleaning fluids which could be hazardous to health. Personnel toiletries, razors, soaps, etc was observed in bathrooms with no identity. To reduce the risk of cross infection, all toiletries should be stored within the owner’s bedroom. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 15 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): 27,29 and 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 54 residents. In addition to the nursing and care staff, there was also administration, ancillary, and catering staff to support the service provision. Training has been provided to staff, and includes infection control, first aid, fire, moving and handling. Residents confirmed that all staff were helpful and hardworking and nothing was too much trouble for them. The recruitment procedure was being followed appropriately and a formal staff supervision program is in place. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 16 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,and 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 people using the service. EVIDENCE: The registered manager is appropriately qualified and has completed the registered manager’s award. The manager demonstrates a good knowledge and understanding of the residents and their care needs. All residents’ conversed easily with the manager. The home operates a good quality assurance audit and the results of this are positive. Records inspected indicated that regular health and safety checks are carried out including fire safety tests. There are systems in place for risk assessments. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 17 Several bedroom doors were wedged open at the time of the inspection. The need to provide an appropriate device to allow the residents’ door to be opened safely is required. Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 18 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X x 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X X 3 X 2 Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? no 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 4 Standard 38 38 26 9 Regulation 12 12 13 13 Timescale for action Cleaning trolleys must not be left 24/10/05 unattended around the home. The home must ensure that door 24/10/05 wedges are not used. To reduce the risk of cross 24/10/05 infection, toiletries must not be left in bathrooms unidentified. The home must ensure that 24/10/05 secondary dispensing must cease. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 20 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: 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 Moundsley Hall Nursing and Residential Home DS0000004127.V252036.R01.S.doc Version 5.0 Page 21 - 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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