Inspection on 23/07/07 for Holbeche House Nursing Home

This inspection was carried out on 23rd July 2007.

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

Holbeche House Nursing Home 12/03/09

Holbeche House Nursing Home 02/08/06

Holbeche House Nursing Home 08/02/06

Holbeche House Nursing Home 09/09/05

Holbeche House Nursing Home 14/12/04

Holbeche House Nursing Home 20/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Holbeche House Nursing Home Wolverhampton Rd Wall Heath Kingswinford West Midlands DY6 7DA Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 09:00 23rd July 2007 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.V340839.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.V340839.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 holbechehouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited 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) Margaret Lane Care Home 49 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (8) Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 22 OP, 8 PD(E) and up to 27 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 27 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 22 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 2nd August 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 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 with dementia. The home has one double bedroom, all other bedrooms are single occupancy with many having en-suite facilities. There are extensive grounds and beautiful gardens for residents to enjoy. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 5 The home charges between £360 and £733 per week for residents to live there. This fee does include the Registered Nurse Care Contribution (RNCC) where appropriate. Other services available to residents at extra cost include hairdressing, chiropody, newspapers and magazines and organised outings. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home. It lasted one day and during this time we collected evidence to help make the judgements in this report. We spent time with the residents and staff to help us find out what life is like for the people living at the home. We looked at resident’s files as part of our case tracking process. This process enables us to look at selected residents care in depth and to make decisions about whether the home is meeting their needs. Staff files were also examined to make sure that the home is continuing to recruit people in a manner that safeguards its residents. Information given to the Commission for Social Care Inspection (CSCI) in the home’s Annual Quality Assurance Assessment (AQAA) has also been included in the body of this report. Some of the comments that resident’s made in the questionnaires we sent to them have also been included. The inspectors would like to thank all of the residents and staff for their hospitality throughout the day. What the service does well: What has improved since the last inspection? Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 7 The dementia care unit has been decorated by children from the local primary school. The unit is brightly decorated and offers a stimulating environment for the residents. The manager has also introduced “doll therapy” for residents to take part in should they choose to do so. The grounds have been tidied up and are now well maintained, making them more pleasant for residents to look at. The home now has its own “in house” trainer to ensure that all staff are kept up to date with changes in practice thus ensuring that residents receive care based upon current best practice. 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. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 8 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.V340839.R01.S.doc Version 5.2 Page 9 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): 2,3,4,5,6 Quality in this outcome area is good. People wishing to live at this home will have the information they need to make an informed choice. They can be confident that their needs can be met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Terms and conditions of residency were available in the majority of the residents records seen and contained all required information. Terms and conditions are not always available when the residents first move to the home and there can also be a delay in their return. Some residents have raised concerns when answering the questionnaire about the fees they are paying, they indicated that they are unsure about who is paying them and whether or not they are receiving their Registered Nurse Care Contribution (RNCC). The manager will need to address this so that all residents are clear about who is paying their fees. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 10 The manager visits all prospective residents prior to admission to complete a full needs assessment and to satisfy herself that the home will be able to meet those residents needs. In addition to the assessment that looks at the activity of daily living, the manager will also complete an additional assessment for those residents who have dementia. Once this has been completed the resident is encouraged to spend time at the home to ensure that they will like it and make their own mind up. Typically most residents spend a day at the home or will stay for lunch so that they have the opportunity to talk to other residents. In some cases a trial visit has not been possible and relatives have made a choice on behalf of the resident, one such resident said “they made a good choice don’t think I could’ve done better”. At present the manager does not write to residents confirming that the home can meet their needs, there is a more informal verbal agreement in place. The manager must consider writing to prospective residents so that they can be sure the home will meet there needs upon their admission. The staff at the home do undertake training in both dementia and behaviour that challenges us, the numbers have become a little diluted but there are plans in place to begin training the new workers in the near future. However resident should feel assured that staff on the dementia unit have the skills and knowledge to be able to meet their needs. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10 Quality in this outcome area is adequate. People who live in the home can feel confident that their needs will be met provided their care plans are kept up to date. Medicines are administered safely and residents can feel assured that they will be treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s files were seen as part of our case tracking process. This means that resident’s plans are examined to ensure that an assessment and a plan of care has been implemented, that it is kept under review and that residents are involved in that review. It was pleasing to see that all of the files seen contained an assessment of need, in some cases there were two, one from the social worker and one from the home manager. Needs identified in these assessments had been transferred into individual care plans for each resident. In addition to the care Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 12 plans the home also has risk assessments in place for the identification of malnutrition, pressure sore development, falls and moving and handling. We found that some of the care plans needed to be updated to show that they were a true reflection of residents needs. Some of the care plans were disorganised, confusing and in some cases not available, whilst others were duplicated. For example one resident had care plans for “nutritional risk and PEG feed complications”, this resident also had problems taking an oral diet and fluids but this had not been included in his plan of care. Equipment available in his room demonstrated that he was receiving mouth care, this was not included in his care plan. Another resident had 19 different care plans and although there was a care plan to minimise the risk of diabetic neuropathy he had no care plan to demonstrate how staff were going to manage his diabetes. He had episodes of low blood sugar where staff had sought medical advice. Records did not include the frequency that his blood sugar should be monitored and actions to be taken if blood sugar was outside required levels. . This information should have been included in his plan of care but care records had not been updated. A visit to this resident in his room identified that his catheter bag was left in his bed and not on a stand that would have assisted the drainage of urine. Placing the drainage bag on a stand would reduce the possibility of complications associated with the catheter from occurring. This was bought to the managers attention who has since addressed this problem. One lady had lost weight and there were concerns that she was not eating. The care plan stated staff should “ monitor weight weekly” but this has not been completed. Other entries in the care plan included “do not remove dentures”, the resident did not have any dentures in during the inspection. We spoke to staff about the care of residents and it was clear that they were aware of the individual needs of their residents. They were able to give detailed descriptions of the care and attention needed by each resident. This was discussed with the manager during the inspection. Whilst it appears that there are omissions in care for residents it may also be poor recording practices by the staff. The manager must explore this further to ensure that residents are always met. Medication practices within the home were generally satisfactory. There are good systems in place for the ordering, receipt and storage of medicines. Staff are regularly recording the temperature of the medicines fridge this will ensure that those medicines requiring cold storage are kept at recommended temperatures. Only trained nurses are responsible for the administration of medication. The storage and recording of administration for controlled drugs was satisfactory. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 13 All of the residents we spoke to said that staff treated them well and that they actively helped them to maintain their privacy and dignity. One resident said “the care and attention I am receiving is enabling me to keep my dignity despite my condition. I am content”. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 Quality in this outcome area is adequate. People who live in this home will be encouraged to maintain contact with their families and friends. Mealtimes could be more organised to ensure that everyone’s needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents now benefit from an activity therapist. It was pleasing to see that throughout the inspection most of the residents enjoyed some “one to one” attention from him. Residents clearly enjoyed this time. There are ample activities throughout the home for residents to take part in although some may need more prompting than others to take part. Responses from those residents who completed our questionnaires varied when we asked if there were enough activities in the home, some said “always”, others said “usually”. One relative commented “most are elderly and like the television but little attention paid, the music is more suited to teenage music”. This was apparent during the inspection, we heard the local radio station on in the background that may not have been the residents first choice Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 15 for music. In the smaller lounge on the dementia unit more relaxing classical music was being played for the residents to listen too. Relatives said that they were always made to feel welcome by the home and that they were included in the care of their loved ones. The home operates a relaxed approach to visiting but visitors are asked to given consideration to the needs and wishes of the residents. We observed lunchtime on the dementia care unit. We found it to be chaotic. Staff bring meals to the table two at a time. They then select two residents to come to the table to eat the meals. We saw that once the residents had been seated at the table, the staff left and the residents got up to follow them. This meant that throughout lunchtime there were only four residents actually seated at the table for their meals whilst the others were walking around the unit. One resident was able to eat four meals because staff kept putting them on the table for other residents, when they turned away she ate them. Staff did not appear to know which resident had eaten what, we noticed that one resident did not have a meal because of this chaotic situation. This was bought to the manager’s attention during the inspection, it must also be noted that once lunch was completed the resident who had not eaten was given sandwiches. It was felt that a more organised approach to meal times would help ease this situation as staff were clearly struggling to meet all of the residents needs during this time. Staff attempt monitor residents diet and fluid intake. One resident’s records indicated that for the previous two days they had only had 400mls of fluid. Another resident was recorded as having had a lunch and pudding but had in fact left the table and her meal was eaten by another resident. It is not surprising to find that staff are unable to maintain clear and accurate records of dietary and fluid intake given our observations of meal times. This was also discussed with the manager during the inspection. She has agreed to reassess this situation for the benefit of both residents and staff. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. The people who use this service can feel confident that their views will be listened to and acted upon. They will be protected from abuse and kept safe from harm This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy that is readily available to all residents. Larger print is available upon request. Most of the residents who completed the questionnaires, said that they had never had cause to complain but they were aware of the process if the need arises. “On the occasions we have approached them to complain it has been dealt with actively”. Once a complaint has been made the manager logs this information into the complaints log and the information from it is used as part of an audit to improve practice. The home works alongside the Local Authority in any adult protection issues that may arise. Since the last inspection one referral was made to the Adult Protection Team but no action has been taken as a result. The home works in a proactive manner to ensure that no resident is placed at risk. Staff receive regular training in adult protection and are aware of their roles in this process. When talking to the staff, it was clear that most of them had a good Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 17 understanding of what abuse was and what they would do if they suspected abuse had occurred. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 18 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): 19,26 Quality in this outcome area is good. The home is generally well maintained and is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the home was undertaken. The home has recently taken a lot a damage from heavy rainfall and flooding. Some of the residents bedrooms have been badly affected, we saw the ceiling in some rooms has been extensively damaged and will required urgent repair. It is recommended that no residents use these rooms until the repairs have been completed. In other rooms the walls were still wet from where the water has leaked in. Carpets need to be replaced on the ground floor and the corridor to the dementia care unit. There was an offensive odour coming from them. The manager did point out that the insurance company had been contacted and Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 19 that repair and replacement of damaged items was in the process of being sorted. The dementia care unit is in the process of being decorated and the home has agreed to let the local primary school help with the decoration. Corridors have been painted with a nautical theme, a nursery theme for the doll therapy corner and there is an artificial garden area in the small lounge. Other lounges are pleasantly decorated and residents said that they felt at home there. Some of the furnishings were in need of a deep clean as they were stained and dirty. Bedrooms were personalised and felt relaxing. It was also pleasing to see that residents have access to all of the appropriate equipment they need to meet their needs, such a pressure relieving mattresses and cushions, bed rails and bed wedges, wheelchairs and assisted bathrooms. Some of the toilets and bathrooms had gloves and aprons in them for staff to use to reduce the risk of cross infection to residents. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 Quality in this outcome area is good. There are sufficient staff on duty at all times to meet the needs of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs sufficient staff to meet the needs of the residents. In addition to the care staff, the home is supported by house keeping, kitchen and maintenance workers who keep the home looking clean and tidy. When we asked “do the care staff listen and act on what you say” residents responded “it’s the little things they do, you only have to say something once and it’s done”. When we asked if staff were available when you need them residents responded “all staff are available day and night”. The home is continuing it’s programme of training staff to NVQ Level 2 they are still under target but have identified staff who will undertake this training in the near future. Staff files were seen and examined to assess whether the home is continuing to safeguard service users through robust recruitment practices, with the exception of a few minor shortfalls it was pleasing to see that all of the Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 21 required checks were in place including the PoVA and CRB disclosures. The homes administrator was in the process of updating all staff files on the day of inspection. New workers do have a structured induction programme that meets the Skills for Care Standards and new workers are supported during their first few months of employment. The home also employs an “in house” trainer who is responsible for delivering all of the mandatory training that staff require. This means that the trainer is able to readily identify those staff who need to take part in training to ensure that their skills and knowledge are kept up to date. We also observed nursing students on placement at the home. the home has had good reports back from the University of Wolverhampton who supply to students to the home. The student we spoke to said that the placement had been enjoyable and that she had learnt a lot whilst she had been there. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38 Quality in this outcome area is good. The home is well managed and run in the best interests of the people who live there This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been no change in the management of the home since the last inspection. The manager runs the home in the best interests of the service users and has obtained the necessary qualifications to do so. In order to maintain standards at Holbeche the manager completes monthly audits, these include medication, complaints, falls and the environment. Where any issues are highlighted the manager will then form an action plan to address this. Residents are included in this process and are asked to Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 23 complete a questionnaire on yearly basis, this questionnaire gives each service user a chance to tell the home what it is they are doing well and what it is that they could do better. The manager did say that at times some of the service users find it difficult to complete the questionnaires, it was suggested that the use of an independent advocate or reviewing the format of the questionnaires should be considered. This will mean that all of the residents will then have the opportunity to take part if they choose to do so. We also looked at the systems in place for dealing with residents monies. The company has a computerised system that keeps the individual expenditure of each service user up to date. The home obtains receipts for all purchases and records transactions appropriately. Some of the resident’s monies were spot checked and were found to be in order. The health and safety management in the home is good and again there are systems in place that address the knowledge and skills training for each staff member. There is a computerised system that alerts the manager when each staff member is due for refresher training. Staff can expect to receive training in health and safety, moving and handling, fire safety, food hygiene and first aid. This will ensure that they are practicing safe working at all times and not placing service users at risk. Some of the home maintenance checks for the hoist, wheelchairs and the lift were seen to make sure they are up to date. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 24 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 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 12 (1) (a) Requirement Residents must be weighed as their care plans indicate. The manager must ensure that this happens so that residents needs are met. (previous timescale of 31/08/06 part met) Timescale for action 30/08/07 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 OP2 Good Practice Recommendations Residents need to be clear about the fees that will be expected to pay, the terms and conditions of their residency, the role and responsibility of the provider and their rights and obligations as residents. the manager must take steps to ensure that this is done. The home must be able to show how they involve residents in the assessment, planning and review of their care. Greater number of staff should receive training in dementia, diabetes and epilepsy so that they have a greater understanding of residents needs DS0000058391.V340839.R01.S.doc Version 5.2 Page 26 2 3 OP3 OP4 Holbeche House Nursing Home 4 5 6 OP7 OP8 OP15 7 8 OP19 OP19 Residents care plans need to reflect all of their needs and must be updated as those needs change. Staff need to make sure that the information they know about residents needs are also written down in their care plans to ensure that everyone is aware of their wishes. The arrangements for serving meals to residents on the dementia unit must be reviewed so that all residents have their meals and staff are able to monitor what is being eaten and take appropriate action when problems arise. The carpets in the corridors and some bedrooms will need to be replaced and the offensive odour addressed for the comfort of residents Consideration should be given by the manager to delaying the allocation of those vacant bedrooms where there is ceiling damage until such time as they are repaired. Holbeche House Nursing Home DS0000058391.V340839.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Office Ground Floor, West Point Mucklow Hill Office Park Mucklow Hill Halesowen B62 8DA 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. 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