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Inspection on 02/08/06 for Holbeche House Nursing Home

Also see our care home review for Holbeche House Nursing Home for more information

This inspection was carried out on 2nd August 2006.

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

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 home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided. The home provides very person centred personal care in a friendly, homely atmosphere and a very pleasantly maintained environment. Assessment and care planning processes remain good but delivery does not always reflect this. Staff interact with residents with respect and sensitively to protect service users dignity.

What has improved since the last inspection?

The home has surveyed service users and their families for their views on the services provided and prepared a report of the findings along with action proposals. The manager has reviewed care plans to ensure they are exhaustive in guiding staff through the many eventualities that service users face in their health risks. The home has undertaken decoration following repairs in a timely way. The maintenance and cleaning of extractor fans is established on a programmed basis.

What the care home could do better:

Since the last inspection there has been a significant deteriation in the behaviour of some service users on the general side resulting in them being out of category their mental health needs having overtaken any general health concerns that originated their admission. The home requires to be more responsive to such deteriation to maintain the safety of other service users who may be frail. Staff and managers must report incidents however minor they may seem and use the adult protection procedures appropriately. Staff must monitor the impact of new medications and report problems to the GP in a timely way. When medication is refused or otherwise omitted staff must document the reason. Where service users use aids, systems must be provided to ensure they are maintained in working order and allied health care inputs are arranged routinely. A record must be maintained of the involvement of service users or representative in the assessment, care planning and review processes. Staff require training to ensure they can make good judgements in respect of reporting concerns and incidents that enables senior staff to take appropriate actions to address issues. The home must take action to achieve a satisfactory level of NVQ trained staff and achieve this consistently. The manager must take action to ensure references received on behalf of an employer are authorised to represent that company. The process of fitting privacy locks to bedroom doors must be completed and service users assessed for their ability to hold a key.

CARE HOMES FOR OLDER PEOPLE Holbeche House Nursing Home Wolverhampton Rd Wall Heath Kingswinford West Midlands DY6 7DA Lead Inspector Richard Eaves Key Unannounced Inspection 09:00 2nd August 2006 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 Holbeche House Nursing Home DS0000058391.V302008.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. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holbeche House Nursing Home Address Wolverhampton Rd Wall Heath Kingswinford West Midlands DY6 7DA 01384 288924 01384 296733 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) www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Margaret Lane Care Home 49 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (27), of places Physical disability over 65 years of age (8) Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 27 OP, 8 PD(E) and up to 22 DE(E) One service user (male) accommodated at the home may be in category A. This will remain until such time that the service users placement is terminated. One service user (female) accommodated at the home may be in category LD(E). This will remain until such time that the current service users placement is terminated. The home meets the following minimum staffing levels: EMI Unit for 22 DE(E) service users 08:00 - 14:00 1 RMN/RN and 4 care staff 14:00 - 20:00 1 RMN/RN and 4 care staff 20:00 - 08:00 1 RMN/RN and 3 care staff General Nursing Unit for 27 service users: 08:00 - 14:00 1 RN and 5 care staff 14:00 - 20:00 1 RN and 4 care staff 20:00 - 08:00 1 RN and 2 care staff A RMN or RN with an ENB N11 or equivalent qualification is on duty for at least 40 hours each week to plan and evaluate the care for service users with dementia. All care staff will have training in the care of service users with dementia. Service users in the category DE(E) may be aged 60 years and over. 5. 6. 7. Date of last inspection 8th February 2006 Brief Description of the Service: Holbeche House Care Centre is a large Jacobean style Grade Two listed building set in extensive grounds. The home has recently undergone a major refurbishment programme to provide accommodation for up to forty-nine residents. The home provides accommodation on two floors, the first floor can be accessed by a passenger lift. The home has two lounges, two dining rooms and two lounge/dining rooms. The home has a separately staffed Dementia Care unit, which provides accommodation for up to twenty-two mentally infirm residents. The home has one double bedroom, all other bedrooms are single occupancy with many having en-suite facilities. The current scale of charges range from £450 - £580. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two inspectors from the Commission for Social Care Inspection it took eight and a half hours to complete. A range of methods was used to gain information and knowledge of the service the action plan submitted by the home to the unannounced inspection in undertaken during February 2006, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire, comments from service users and relatives and records held at the home. The inspection involved a full tour of the bedrooms, communal rooms and service areas and provided an opportunity to speak with most of the service users. We also included talking with the manager, service users and staff throughout the day. Service user files were case tracked and staff files inspected. All of the key standards were assessed during this inspection. What the service does well: What has improved since the last inspection? The home has surveyed service users and their families for their views on the services provided and prepared a report of the findings along with action proposals. The manager has reviewed care plans to ensure they are exhaustive in guiding staff through the many eventualities that service users face in their health risks. The home has undertaken decoration following repairs in a timely way. The maintenance and cleaning of extractor fans is established on a programmed basis. Holbeche House Nursing Home DS0000058391.V302008.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. Holbeche House Nursing Home DS0000058391.V302008.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 Holbeche House Nursing Home DS0000058391.V302008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 The overall outcome for this group of standards was judged to be poor. Service users generally have an adequate assessment of their needs however this is not transferred into ensuring that their needs may be met alongside other service users that the home accommodates. The failures seen not only breach the homes registration but have also put service users at risk whilst also not meeting their needs. EVIDENCE: The home is part of the Southern Cross group of homes. Southern Cross have a range of contracts which vary depending by whom the service user is funded by. These contracts generally include all required information but the contract completed by the “ receiver “ did not detail the service users room number as required. Service users are admitted following an assessment of their needs undertaken by the Manager or a senior nurse. Service users are whenever possible involved in their assessment of needs but this is not always recorded. Assessments of service users who are admitted for respite or short stay do not Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 9 always include all areas required by the National Minimum Standards, which needs to be addressed. The home accommodates service users who have dementia and also service users who are elderly and frail. Concern was highlighted during the inspection that the home accommodates more service users with dementia than it is currently registered for. The nursing unit was accommodating service users who have also dementia with some service users also exhibiting challenging behaviour, this was in addition to the service users accommodated on the Dementia Care unit. This is a serious breach of the Care Standards Act 2000 and may make the home liable for prosecution. An immediate requirement was made on the home not to admit further service users with dementia until proposals are made that ensure the home meets its registration requirements. Staff both on the dementia care unit and the nursing unit have not all had training in caring for people with dementia. Staff need specialist training to meet the needs of this client group. There is also a need to assess the environment of the home by a specialist with an expert knowledge and understanding of service users with dementia and to update the environment to ensure that it meets the needs of service users with dementia. Holbeche House Nursing Home DS0000058391.V302008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The overall outcome for this group of standards is judged to be poor. The home does meet service users healthcare and personal care needs but does not always meet these needs safely. Service users are treated with sensitively and with respect. The administration and safe keeping of medicines demonstrates that nursing staff do not protect service users by ensuring that they proactively question the use of, alongside a lack of review of medicines compromise the health and well being of service users. EVIDENCE: Each service user has a care plan that generally reflects their needs. Care plans and risk assessments are reviewed monthly but there was no evidence seen to suggest that service users or their representative are involved in this process. One care plan seen identified that the service user should have a bath or shower weekly, with no information identifying this was their choice. Care records seen suggested in fact this service user had only had a shower twice in July. It was pleasing that the Home Manager had recently undertaken an audit of all care plans, although concern about service users safety had not been identified. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 11 Risk assessments for pressure sore risk development, moving and handling, use of beds rails risk of falls and nutrition are in place. Although required and identified actions are not always undertaken. Service users are not always weighed at least monthly or frequently when required. It was a concern that staff do not act quickly when service users lose weight. One service users nutritional risk assessment identified that if they lost weight they should be weighed weekly until their weight is stable. One service user had lost 16kgs since their admission but was only referred to a Dietician in July when they had already lost 7kgs since April with no action previously undertaken. One service user admitted for respite care had no weight recorded despite being a resident at the home for a month and frequent inclusion in care records identifying their reluctance to eat and drink. Another service user who displays behaviour that the staff find challenging to manage had no management plan that clearly instructed staff on how to deal with this physical aggression. Service users do receive visitors from other professionals such as dentists, chiropodists, and opticians. One relative raised concern that that their relative does not wear either her hearing aid or dentures. This resident care plan did not detail that she required a hearing aid. When the Manager was questioned about this she stated that the resident no longer liked to wear the hearing aid and manages better with a pureed diet. It was later discovered that the hearing aid had been lost and a referral had since been made to the local audiology clinic. Given that this same service user had lost a considerable amount of weight a referral to a dentist is required for assessment of new dentures. Daily records were detailed and reflected the service user’s day although there were not records to suggest that concerns identified within the daily records had been addressed- examples are included throughout this report. The administration, safe- keeping and storage of medicines is undertaken by nursing staff. There is a record of medicines service users receive, although when medicine is not given the reason that it has not been given is not evident as staff do not enter the required code. One service user is prescribed supplement drinks although staff have not recorded that she has received any. The nurse in charge confirmed that she does require them and also receives them, but it was not evident how many and how frequently she receives them. Staff record the temperature of the drugs fridge temperature and treatment room and both ensure that medicines within them are stored at the required and safe temperature. One service user had been seen by the Tissue Viability Nurse Specialist who had advised that this service user required additional pain relief. Medication or care records did not show that this service user had been seen by a Doctor for the consideration of additional pain relief. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 12 One relative highlighted to staff that her relative was sedated too much, staff assured her that they would not give the sedation if not required, however this treatment sheet could not be found to determine how often the sedation had been given. Care records identified that this service user did deteriorate rapidly within 24 hours of the sedation being commenced. In addition no care plans were seen for the use of “as required medication”. Over the period of the inspection staff were observed to interact with residents with respect and sensitively to protect service users dignity. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 The overall outcome for this group of standards is judged to be poor. The daily life and social activities of the home do not meet service users needs, capabilities and preferences. EVIDENCE: The home displays a list of activities that are available for all service users to take part in if they choose. Activities advertised do not always take place as the home was without an Activity Coordinator for some time. A new Activity Organiser has recently started working at Holbeche and is currently undertaking his induction and a review of activities that are suitable for service users abilities and preferences. Service users did have a record of their preferred activities within their individual files but this now needs to be developed into a social plan of care. On the day of the inspection staff were playing Frank Sinatra tapes for residents to listen to other residents were colouring pictures. One service user frequently exhibited aggression kicking fire doors, hitting out at staff and a wish to abscond including one occasion when he managed to leave the home without staff being aware. Staff said that his main wish was to walk in the grounds and this generally limited his behaviour although this was not included in a care plan nor was he encouraged to go out before he started his extreme behaviour. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 14 Visitors are welcome at any time and those met said that they felt welcome. Care plans identify residents individual likes and dislikes and choices about their individual routines such as whether they prefer a bath or a shower, getting up and going to bed. Breakfast is served from 8.00 am onwards. Lunch is served about 12.30 although more dependent service users who required feeding are fed around 12 o clock and are not brought to the table. Tea is served about 16.45. The home has a four week menu which offer a choice at each meal for service users. Meals served were presented well and portion sizes were good. On the day of the inspection the main meal of the day was Cornish pasty or cauliflower cheese with potatoes carrots and peas, desert was chocolate pudding and chocolate ice cream. Staff were seen to frequently offer residents both hot and cold drinks throughout the day with jugs of black currant and orange squash also out for residents to help themselves to when they required. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 15 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): 16,18 The overall outcome for this group of standards is judged to be poor. The home has appropriate policies to highlight concerns and complaints but staff do not always action the required procedures. EVIDENCE: The complaints procedure is on display in the main hall and is in the terms and conditions of residency. Care records of two service users identified that relatives had highlighted concerns but these concerns were not included in the complaints log to ensure that appropriate action had been undertaken. The home has appropriate policies for staff to highlight concerns whilst feeling safe to do so. The home has appropriate policies to ensure that staff who are not suitable to work with vulnerable people do not do so by robust recruitment and selection procedures. It was of enormous concern that staff had failed to undertake required action to prevent vulnerable service users being at risk. One service user who resided in the nursing unit had assaulted the same service user on four different occasions although required adult protection notifications had not been made. Service users had left the home without staff being aware but again required notifications had not been undertaken there were other records of service users falling out of bed with the bed rails left down and the service user left unattended by staff. The Manager had also not reported unexplained bruising to a service users wrists. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 16 The adult protection policy has been reviewed and is available to guide staff, however not all staff have yet received training and the guidance would be enhanced by the development of a flow chart. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 17 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 & 26 The overall outcome for this group of standards is judged to be good. The home provides a good standard of décor, furnishings and managed services providing a safe environment and an attractive, comfortable and homely place to live. The home is clean, largely free from odours and hygienic. EVIDENCE: The home is set in extensive grounds but with only small parts allocated as service user garden facility. These small areas have been attended since the previous inspection but remains a poor facility due to poor accessibility to the sensory garden because of the uneven path surface. Internally the home has two lounge areas in each wing and both have small quiet areas the main house has a separate dining room. Furnishings in these rooms were comfortable and in good condition. Overall the home is maintained clean to a good standard, a bathroom fluorescent light was observed to have a lot of dead wasps. The decoration is in good condition Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 18 although it was observed that wall paper in some rooms on the EMI area had been picked and requires attention. The upper corridor of the EMI area was being painted during the inspection. The home has a well-equipped laundry with washing machine capable of sluicing and disinfection of linen. There are sluice disinfectors fitted around the home. Hand washing facilities for staff are available with a safe hot water supply promoting good infection control practices, however water was found to be hot in one sluice and the kitchenette hand wash. The newly appointed staff toilet requires the fitting of liquid soap dispenser and disposable towel dispenser. One bedroom was noted to be malodorous and staff identified the cause as being due to the service users behaviour and that they make every effort to address the issue. The hairdressing salon has been refurbished. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 19 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 The overall outcome for this group of standards is judged to be good. The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home continues to make progress in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: The home allocates staff to each of its identified areas to provide consistency and in such numbers that reflect the dependency needs of the service users. Usual allocations are one nurse and 3 carers on both the general nursing and the EMI unit during the day with 1 nurse and 2 carers on each overnight. These numbers are appropriate for the dependency levels of the current service users. The numbers of permanent staff, carers and RMN,s are sufficient in numbers to obviate the use of agency staff since the end of last year. Student nurses are allocated to the home in a supernumerary position. Ancillary staff are allocated in sufficient numbers to meet catering, housekeeping and maintenance duties. Previous numbers of staff holding an NVQ qualification met standard but since the last inspection an increased number of carers and leavers means that the Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 20 standard is not now achieved. The manager advises that staff are enrolled on training. A sample of staff files were inspected including new starters to check recruitment and selection practices. Each was completed to a good standard and included all necessary checks including CRB, POVA and Nurse PINS. It was observed that one referee was a colleague rather than the employer. An inspection of training records shows that mandatory training is up to date and new staff have undertaken TOPPS standard induction and foundation programmes. Established staff files show that individual training records are maintained, containing training certificates for each course undertaken including all mandatory training. The managers training matrix shows training completed and planned and demonstrates that extensive opportunities exist. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 21 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 and 38 The overall outcome for this group of standards is judged to be good. Leadership of this home is good. The home regularly reviews its performance which, includes seeking the views of service users and their families. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. EVIDENCE: The home is led by an experienced and well qualified nurse manager and is supported in this by a stable committed staff group at all levels. On the day of the inspection it was apparent that there was a very good atmosphere amongst the staff. The manager holds frequent staff meetings and maintains a record and actions taken in response to staff inputs. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 22 The manager undertakes regular surveys of service users, relatives, staff and other stakeholders views and uses the findings to influence and improve the delivery of services. Since the previous inspection surveys were undertaken during May. The home does not act as appointee for service users, arrangements with full accounting practice is in place for personal allowances held for safekeeping. Supervision is well established and the records show these to be up to date and the content of sessions relevant to the activities of work. Staff receive training in health and safety at induction with ongoing updates at appropriate intervals. During the tour of the building it was observed that all corridors were clear of obstructions and the premises are kept in a safe condition. Inspection of the health and safety monitoring records show these to be up to date and that good standards are being maintained consistently. Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 23 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 2 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 24 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. Standard OP24 Regulatio n 23(2)(e) Requirement The registered person must complete the process of fitting suited locks to bedroom doors. Previous timescale 30/06/06 not met. Terms and conditions of residency must include all requirements of the regulations including the room number allocated. Service users and their representatives must be involved in the assessment of needs and a record must be available that confirms this. The home must only accommodate up to the maximum number of service users with needs that it is registered to accommodate. The registered provider must forward their proposals to address the breach of the homes registration All staff must receive dementia care training that includes the management of service users with challenging behaviour and de-escalation techniques. DS0000058391.V302008.R01.S.doc Timescale for action 30/09/06 2. OP2 5(1)(b) 31/08/06 3. OP3 14 31/08/06 4. OP3 14 31/08/06 5. OP3 14 31/08/06 6. OP3 18(1)(c) 31/10/06 Holbeche House Nursing Home Version 5.2 Page 25 7. OP22 16(2) 8. OP7 15 9. OP8 12(1)(a) 10. OP8 12(1)(b) 11. OP8 15 The home is assessed by with a report with actions is identified by a specialist with an expert knowledge and understanding of service users with dementia to ensure that it meets the needs of service users with dementia. Service users and their representatives must be involved in the planning and review of their care and a record must be available that confirms this. Service users must be weighed at least monthly or more frequently as identified by their plan of care. Service users must be weighed within 24 hours of admission. Short stay service users should be weighed before they are discharged. A system must be put in place to ensure that service users receive all required care such as having their hearing aid in and ensuring that it is working appropriately. Service users are regularly seen by a dentist. PA is referred to a dentist for consideration for new dentures. A management plan must be available that clearly identifies how physical aggression and challenging behaviour is managed. 31/10/06 31/08/06 31/08/06 31/08/06 31/08/06 12. OP9 13(2) 13. OP12 12(3) Service users care plans must be 31/08/06 kept up to date with healthcare needs including specific directions for medicine to be given on a when required basis. Staff must sign the medicine charts for the administration of medication or an appropriate code is documented to show the reason why medicine omitted. The home must provide activities 31/08/06 to meet the choice needs and capabilities of service users DS0000058391.V302008.R01.S.doc Version 5.2 Page 26 Holbeche House Nursing Home 14. 15. OP12 OP16 15 22(3) 16. OP18 13(6) All service users must have a social plan of care. Staff must be made aware of a need for the Home Manager to be made aware of all concerns to ensure that these concerns are recorded and appropriately investigated. The registered person and manager must ensure that all incidents of abuse are reported in accordance with Dudley Adult Protection Procedures (incidents highlighted during the inspection must be reported retrospectively). Are reported to the CSCI in accordance with Regulation 37. 31/08/06 31/08/06 31/08/06 17. OP38 37 18. 19. OP28 OP29 18(1) 19(1)(a) All incidents that adversely affect service users health, safety or welfare must be reported to the Commission for Social care and Inspection. A minimum number of 50 of care staff must be trained to NVQ level 2. The manager must ensure that referees are appropriate and include the last employer. 31/08/06 31/10/06 31/08/06 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 Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Holbeche House Nursing Home DS0000058391.V302008.R01.S.doc Version 5.2 Page 28 - 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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