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

This inspection was carried out on 8th February 2006.

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

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

Other inspections for this house

Holbeche House Nursing Home 12/03/09

Holbeche House Nursing Home 23/07/07

Holbeche House Nursing Home 02/08/06

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 Richard Eaves Unannounced Inspection 8th February 2006 09:00 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 Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 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.V281079.R01.S.doc Version 5.1 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) 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.V281079.R01.S.doc Version 5.1 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 9th September 2005 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. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by one inspector over one day. The focus of the inspection was on the delivery of care and included case tracking. The inspector had opportunity to speak with many of the service users and those able to communicate were positive regarding life at the home and they all appeared content. There was a relaxed atmosphere among service users and staff. The inspection also included a tour of the building, meeting with service users and inspection of records. What the service does well: What has improved since the last inspection? The home has been very receptive to previous guidance and requirements and has been proactive in implementing these. The extensive grounds and patio areas have been tidied to provide the service users with a safe facility and is currently appropriate to season. The home has made provision for service users to receive visitors in private without need to use their bedrooms by modernising and furnishing the large reception hall. The issue of being responsive to individual wishes for such as food preferences over and above the standard menus has been raised at service user meetings. Trained staff discontinued the practice of re-sheathing needles before disposal. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 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.V281079.R01.S.doc Version 5.1 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.V281079.R01.S.doc Version 5.1 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): 1–5 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home, this is confirmed by contract. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home. EVIDENCE: The statement of purpose and service users guide have been reviewed and updated since the completion of the registration process for the manager. The documents provide current and prospective service users with a good source of information from which to make informed decisions about the suitability of the home and the services they offer. The information is also available on audio cassette and in large print. A copy of the service user guide was seen in each of the bedrooms visited and both were available in the reception area. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 9 A sample of residents files were inspected in both the general nursing and EMI areas and were seen to include a contract and a letter of confirmation that service users needs can be met by the service. The assessment process is thorough, including all activities of daily living and an extensive range of risk assessments, all assessments are subject to monthly review by means of raising a care plan for each assessment undertaken. The file documents information of the service user or representatives involvement in the assessment process. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. The home does not provide intermediate care. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 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 – 11 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: The care plans were seen to be drawn from the assessed needs process and were relevant and maintained to a good standard. The care plans reflect actual care requirements and the service users preferences of how it is to be given. Since the previous inspection contingency planning for the care of diabetes complications has been developed. A plan to manage a known risk of choking was largely preventative and requires to consider action required in an actual event. The files show that the care plans are reviewed monthly. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 11 All service users are registered with a GP who provides a weekly visit routinely, other allied health care providers also attend on a regular basis. Medication administration is undertaken by nursing staff using a monitored dosage system. Discussion with staff and observation of practice confirms that medication administration record (MAR) charts are completed at the time of administrating the medication. The MAR charts examined were completed accurately. Arrangements for all aspects of medication management are robust. The case files include records of the individuals stated preferences for their daily routine such as rising, retiring and bathing. The staff record the life story for each resident that gives insight and understanding of the person of how they were prior to their admission to the home. A limited programme of training is included in the NVQ units and the Nursing staff have experience in care of the dying. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The home provides a well-organised and varied social and recreational activity programme that provides interest and pleasure for the residents. An open visiting policy assists service users to maintain contact with their family and friends. Many aspects of care evidences that service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 13 The home has recently appointed an activities co-ordinator and programmes developed for both the general and dementia units with appropriate activities. A hairdresser visits once per week and a local church service is held at the home monthly. The inspector spoke with many service users who were satisfied with the current level of activities. The home has open visiting and many were seen to come and go over the day and a number of visitors were met and spoke well of the home. Since the previous inspection the entrance area has been furnished and can be used by families to meet in private. The home has a 4-week rolling menu that is well thought out and offering variety and a balanced diet to service users, choice of meal including a cooked option is always available. A record is kept of individual service users intake and meals are taken in the setting of their choice. On the day of inspection service users that were able to communicate their needs expressed their satisfaction with all meals provided. Drinks and snacks are available outside of mealtimes. Special diets are catered for and food for special occasions provided. Nutritional assessment is included as part of the admission process and is kept under review; service users are weighed monthly or more frequently if required and any action taken documented. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18 The home has a satisfactory complaints policy and service users and their supporters can be confident that their views will be listened to and acted upon. Service users rights are protected and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The home has a complaints policy and procedure, a copy of which is available in reception and included in the service user guide. Timescales are given for response and the CSCI address and telephone number is included as an alternative source for complainants. The electoral roll has been completed to enable the residents to participate in elections using postal and evidence of confirmation seen in the case files. The home has robust procedures for responding to any suggestion of abuse and training is given to staff in adult protection procedures. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 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, free from odours and hygienic. EVIDENCE: The home is well presented with a good standard of decoration and carpeting and is furnished comfortably, is clean and hygienic with no unpleasant smells. The premises are set in extensive grounds and these have been tidied since the previous inspection and are now safe and appropriate to season. The home has 8 profiling beds, height adjustable for providing nursing care. A roof leak in the area of room 4 and the hairdressing salon has been repaired but the internal decoration is outstanding making the hair salon unavailable. A number of extractor fans were out of service and some require the covers cleaning. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 16 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. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 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. Care staff with NVQ qualification at level 2 or above exceeds the 50 requirement of the standard. A sample of staff files were inspected and show that recruitment procedures are completed to a good standard with appropriate checks in place. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 18 An inspection of training records shows that mandatory training is up to date and new staff have undertaken TOPPS standard induction and foundation programmes. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 38 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities, resistance by some staff to good management practice potentially could undermine care delivery to service users. 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. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 20 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. The home undertakes a range of quality assurance audits on a regular basis including care plans, medicine administration, the environment and service user finance records and these are also included in the regulation 26 visits undertaken by the area manager. No service users or relatives surveys of views have been undertaken recently. 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. Records required by regulation and the schedules are maintained and kept up to date. 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.V281079.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 22 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. Standard OP24 OP7 Regulation 23(2)(e) 15(1) Requirement The registered person must complete the process of fitting suited locks to bedroom doors. A care plan developed for the prevention of choking should be developed to direct the action to be taken should choking occur. The registered person must ensure that following repairs decoration is returned to good order. The registered person must ensure that extractor fans are maintained clean and in working order. The registered person must survey service users views on their level of satisfaction with the services provided. Timescale for action 30/06/06 08/02/06 3. OP19 23(2)(d) 31/03/06 4. OP19 23(2)(d) 31/03/06 5 OP33 24 30/06/06 Holbeche House Nursing Home DS0000058391.V281079.R01.S.doc Version 5.1 Page 23 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.V281079.R01.S.doc Version 5.1 Page 24 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. 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