Inspection on 03/10/05 for Redbrick Court Care Centre

This inspection was carried out on 3rd October 2005.

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

Redbrick Court Care Centre 24/04/07

Redbrick Court Care Centre 04/12/06

Redbrick Court Care Centre 09/05/06

Redbrick Court Care Centre 11/04/05

Redbrick Court Care Centre 30/11/04

Redbrick Court Care Centre 28/07/04

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 Lobley Hill Nursing Home High Street Wordsley Stourbridge West Midlands DY8 5SD Lead Inspector Mrs Amanda Hennessy Unannounced Inspection 3rd October 2005 13:30 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 Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lobley Hill Nursing Home Address High Street Wordsley Stourbridge West Midlands DY8 5SD 01384 571752 01384 75391 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 Centres Limited Sinelisiwe Jubane Care Home 38 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (26) of places Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users in the category OP may be 63 years and over, 5 of whom may be in the category PD(E). A senior care assistant (with NVQ level 2 or above) is on duty within the dementia care unit twenty four hours a day. The 12 residents with Dementia DE(E) require personal care only. 2 service users, named in variation report dated 5.9.05, may be in the category SI (E) Sensory Impairment. These placements to remain for the lifetime of the identified service users whilst the home is able to meet their needs. The placements to revert back to category OP on termination of the placement. 11/4/05 Date of last inspection Brief Description of the Service: Lobley Hill Care Centre is a large detached property, which has been considerably extended and improved. The home is currently registered for 38 older people, of which 12 may require dementia care. The Home is situated in its own grounds, set back from the main Stourbridge to Wolverhampton Road, near to Wordsley. There is ample parking at the front of the Home. To the rear there are extensive gardens, which provides an attractive outdoor environment. The home is privately owned by Southern Cross Healthcare. The home is on three floors with the lower ground floor accommodating the laundry. Service users are accommodated on the ground and first floor with access to the first floor by a passenger shaft lift. There are thirty-two single bedrooms of which sixteen have ensuite facilities and three double bedrooms with two having ensuite facilities. The interior of the Home is pleasantly decorated and has been recently refurbished. The home provides four lounges and two dining rooms, an assisted bathroom and toilet facilities, bedrooms and offices on the ground floor. A range of single and double bedrooms, assisted bathing and toilet facilities are also provided on the first floor. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was carried out by two inspectors Mrs Amanda Hennessy and Mrs Mandy Beck. The inspection was carried out between 13.30 and 17.30 and followed two complaints which has resulted in an adult protection investigation. Care records were reviewed of four service users accommodated in the recently opened dementia care unit and one nursing resident. Two staff files of recently recruited staff were also reviewed. Other time on the inspection was spent touring the dementia care unit and talking with staff, service users and visitors. The registered manager is Ms Nellie Jubane. The registered proprietor is Southern Cross Healthcare. Fourteen of the previous thirty-one requirements have been addressed, ten new requirements were made as a result of this inspection. The home was found to be in breach of a condition of its registration that requires that senior carer (with National Vocational qualification level 2 or above) to be on duty in the dementia care unit at all times. A breach of registration can result in prosecution and this matter and its seriousness is being addressed with the registered provider. An immediate requirement was also given to the home at the time of the inspection that required that there was sufficient staff with required skills to meet residents needs. What the service does well: What has improved since the last inspection? Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 6 Some improvement has been made in care records and care risk assessments for nursing service users although considerable improvement is required for service users requiring dementia care. A new Activities Coordinator has also been employed and is reviewing residents social and recreational interests and activities that are available for residents. 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. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users have a detailed pre admission assessment of their needs, however despite this some residents have needs outside those that the home is able to meet. EVIDENCE: All service user files reviewed during the inspection had a comprehensive pre admission assessment completed by the service users own social worker. Assessments seen had no documented evidence that service users or their representatives were involved in the assessment of their care needs. The homes assessment paperwork had not been completed for all four of the service users files reviewed. The manager stated that lack of care assessments was due to new owners of the home introducing new paperwork for every resident and that they were in the process of completing the them. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 9 Service users who had been admitted with dementia had greater needs that the home can accommodate. The registered manager must ensure that the home can meet all the needs of the service users particularly those who have dementia. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 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 Plans of care are drawn up for all service users, however the healthcare needs of service users are not always accurately identified. Medicine policies and procedures are generally satisfactory but there is a need to ensure consistent practice to safeguard service users. Service users are treated with respect and dignity. EVIDENCE: Each of the case files reviewed had care plans which detailed how care should be delivered. Further development is required to ensure that service users or their representative take an active part in the planning process. One service user has a history of multiple mental health problems but there was no care plan to identify this. Plans are basic and have a task orientated focus to them and need to be more pro active and person centred in their planning. Risk assessments for pressure sores, nutrition, falls, and moving and handling were incorrectly completed in some cases and failed to identify the degree of risk and how it should be managed. For example nutritional risk assessments were inaccurately scored, the accurate score increased the service user’s risk Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 11 of malnutrition/dehydration. These shortfalls have the potential to place service users at risk. Service user weights are being recorded monthly. The homes policies and procedures for the safekeeping and safe administration of medicines were reviewed and found to be generally satisfactory. One complaint received by the Commission for Social Care Inspection identified that a service users medication was out of stock which had resulted in their admission to hospital. There was no record that the service user had received their inhaler since May although no record was available to identify that it had been discontinued. Staff were observed knocking doors before they entered, all of the service users were reportedly in their own clothing and are spoken to in their preferred form of address at all times. Service users receive visitors in the privacy of their own rooms if they wish to do so. All mail is received unopened and given to the service user or their representative. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 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): 14,15 Service users retain control over their lives within the home. Service users receive tasty and nutritious food in pleasant surroundings. EVIDENCE: Services users are able to exercise personal autonomy and choice and retain control over their lives in the home. The home has a four weekly menu which offers choice tasty and nutritious food. Breakfast is served from 8.15 until approximately 10.30am Lunch is served around 12.30. Tea is served at 16.30. Service users and staff confirm that snacks and a supper are available should they require anything later in the evening. Service users or their families are asked for their choice of meal for the next day. The home also prepares soft, pureed and diabetic meals for the residents which it currently accommodates. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 13 Dining rooms have been refurbished and are pleasantly decorated. Staff were seen to offer discreet assistance to service users cutting up their food and feeding those residents who are totally dependent. The kitchen was found to be clean and well organised with all required food safety records being maintained. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 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 appropriate policies to highlight concerns and complaints but need to ensure that these procedures are fully adhered to ensure that residents are safeguarded from abuse. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 15 EVIDENCE: The home has a detailed complaints procedure. The complaints procedure is displayed in the main reception area of the home and is also included in the service user guide. The home have received two verbal complaints but no records of these complaints or their outcomes were available. Two complaints about the home have been received by the Commission for Social Care Inspection, both complaints were found to be upheld. The home are addressing the concerns highlighted. Residents and relatives spoken to said if they had any concerns they would discuss them with the Home Manager. There is a need to ensure that the Home Manager is more proactive when concerns are highlighted. The home also has appropriate policies for staff to highlight concerns whilst feeling safe to do so. The adult protection policy needs to link into the Local Authority Adult Protection Policy to ensure that residents are safeguarded. A programme of adult protection training is ongoing. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 16 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 The home is well maintained and pleasantly decorated, urgent maintenance and repairs must be undertaken immediately when required. EVIDENCE: The home is well maintained, pleasantly decorated, homely and clean. Adaptations to the home to accommodate residents who require dementia care in a separate unit have been thoughtfully and appropriately implemented with advice from a dementia care specialist. A recent complaint identified that there are problems with the central heating that have resulted in some areas of the home being cold. The central heating has since been repaired however it is essential that all urgent and required maintenance is undertaken immediately when ever necessary. There are extensive gardens at the rear of the home although the gardens need general tidying and improved access so that residents can access the garden safely. There is good access throughout the building where residents are accommodated, with a range of aids and adaptations available for dependent people. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 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): 27,28,30. The number of care staff and skill mix of staff is not sufficient to meet the needs of the residents or safeguard them from harm. Further training is required to ensure that staff have the skills and knowledge to meet residents needs. EVIDENCE: Staffing levels were identified at both this and the previous inspection not to be sufficient to meet residents needs. Staffing levels are currently: for 25 nursing residents: 8am-2pm 1 trained Nurse and 4 Care Staff 2pm-8pm 1 Trained Nurse and 3 Care staff 8pm-8am 1 Trained Nurse and 3 Care Staff. For 10 residents requiring dementia care 8am-2pm 2 Care Staff 2pm-8pm 2 Care staff 8pm-8am 1 Care Staff. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 18 The nursing unit is frequently at least one member of care staff short and is often two short. The numbers highlighted above for nursing residents for the morning shift is one member of care staff less than at the previous inspection. Care staff in the nursing unit stated that they frequently had to work in the dementia care unit, which meant a shortage of care staff for nursing residents. An immediate requirement was made at the time of the inspection that staffing levels and skills meet the needs and dependency of service users. The Home was also required to identify a Manager for the Dementia unit who had experience of caring for people with dementia and review the skill mix of staff within the dementia care unit. The Home is also in breach of the condition of its registration that a senior and qualified care assistant is on duty within the dementia care unit at all times. The home currently has just 4 of its 21 care staff (19 ) with required qualifications and has considerable work to do to achieve the required 50 of care staff with National Vocational level 2 or equivalent by the end of December 2005. The home has induction training that meets National Training Organisation standards. There is a need for staff to continue with developmental training, particularly in caring for people with dementia. A training plan for the home and its staff would be helpful to ensure that the home meets its residents needs. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 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): 33,35,38 Improvements and further review is required to demonstrate that the home is run in the best interest of service users. Staff do not receive sufficient mandatory training to safeguard residents. The home needs to ensure that staff receive the mandatory training to safeguard its residents EVIDENCE: Southern Cross homes have an identified Quality plan. Quality audits are undertaken six monthly with corrective actions identified, with a copy of the audit sent to both the Regional Manager and Regional Director. The home undertake audits of pressure sores, service users weights, accident statistics, vacancies and recruitment, the kitchen and a review of all regulation 37 notifications that have been sent to the Commission for Social Care Inspection (CSCI). Service user surveys are undertaken by the company but details of the Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 20 findings are not consistently communicated with the Home Manager. There is a need for the Manager to undertake a survey of service users, relatives and visitors views of the home. The required documented visits by an identified Responsible Person within the organisation has not been undertaken regularly as a result of changes in personnel. The number of ongoing requirements of the home made by the Commission for Social Care Inspection is cause of concern. Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Money that was randomly checked in the safe was found to be correct and equal the balance identified. The Administrator and Regional Manager undertake regular audits of service users personal money. The majority of services users in the home have their finances managed by their families. The Administrator is responsible for one service user’s finances. The Inspector stated that this responsibility should be transferred to the family if available or the Court of Protection to safeguard both the service users and the member of staff. Procedures to protect service users include regular checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points, shower heads, bedrails and window restrictors. Hot water temperatures are undertaken but there is a need to record the flow and return temperature of the hot water. Mandatory training has been undertaken in fire, manual handling, food hygiene, health and safety, COSHH, First aid, abuse awareness and infection control but not all staff have completed training. Maintenance records and contracts were reviewed and were generally up to date. The home must forward copies of the unavailable or renewed contracts (see requirements list). The home had been experiencing problems with the central heating and hot water system, which has since been addressed following concerns highlighted during the inspection. Staff have not had all required mandatory training. Records seen identify that: Five of the twenty-two staff have received moving and handling training, no staff have receive fire safety training within the previous six months, eleven of twenty staff have received basic food hygiene training, no staff have received health and safety awareness training, no staff have received first aid training, eight staff have received training the protection of vulnerable adults and seven staff had control of substances hazardous to health (COSHH) training. Fire drills are undertaken regularly but no records were available that identify that night staff have had a fire drill. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x x STAFFING Standard No Score 27 1 28 1 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 2 x x 1 Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 22 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 OP3 Regulation 14 Requirement To ensure that each Service User is provided with a statement of terms & conditions/ contract at the point of moving into the Home. Not assessed during this inspection. This requirement is outstanding from the inspection on 26/6/02 2. OP3 14 The registered provider must 30/11/05 ensure that all prospective service users have a comprehensive assessment of their needs prior to their admission to the home A record of this assessment must include whenever possible a written record of the involvement of the service user or their representative. Partially met, concern partially highlighted about the assessment of service users requiring dementia care. The registered manager must ensure that the home only DS0000004896.V256020.R01.S.doc Timescale for action 31/10/05 3 OP3 14 04/10/05 Page 23 Lobley Hill Nursing Home Version 5.0 4 OP7 15 admits residents whose needs can be met by the home. All service user plans must be reviewed, revising and expanding the format ensuring that it contains long and short term goals, objectives, monitoring and evaluation to meet the new standards; that plans are reviewed and updated monthly and signed by the service user or their representative. 31/05/05 5. OP8 15 6. OP12 15 7. OP12 8 This requirement is partially met however it is outstanding since the inspection undertaken on 26/6/02 31/05/05 The registered provider must ensure that care risk assessments are accurate and clearly identify the identified risk to the service user. Partially met. Inadequate risk assessments available for residents requiring dementia care. This requirement should have been addressed by 31/5/05 The home must have activities 30/11/05 available to meet the needs, preferences and capabilities of service users who are accommodated. Partially met. Activities Organiser is now in post and is reviewing available activities. This requirement should have been addressed by the 31/5/05 Care plans must be available 31/10/05 that reflect the social isolation of service users who are cared for in their bedrooms. Not assessed this requirement should have been addressed by DS0000004896.V256020.R01.S.doc Version 5.0 Page 24 Lobley Hill Nursing Home 8. OP12 16 31/05/05. The home must perform an audit of the residents interests and preferences. 31/10/05 9. OP12 12(3),15 This requirement is partially met but outstanding since the inspection undertaken on the 14/7/03 The home must provide activities 30/11/05 to meet the needs of service users and as identified within their plan of care. This requirement is partially met but is outstanding since the inspection undertaken on 28/6/04. A record must be available of all complaints made about the home and the outcome of the complaint. The home’s Adult Protection policy must link into the Local Authority Adult Protection Policy. The home s garden must be tidied, lawns are cut and the gardens are made accessible to service users. Not met garden remains untidy and is not accessible to nursing residents. This requirement should have been addressed by 30/06/05. The Registered Manager must document the actual staff on duty and include the dependency levels and number of residents on the duty rota. Not met. This requirement is outstanding since the 29/1/04 and should have been addressed by the 1/5/04. The registered provider must ensure the home has sufficient DS0000004896.V256020.R01.S.doc 10 OP16 22 31/10/05 11 12. OP18 OP19 13(6) 23(2)(o) 31/12/05 30/06/05 13. OP27 18 31/10/05 14. OP27 18 31/10/05 Page 25 Lobley Hill Nursing Home Version 5.0 care staff to meet service users needs. Not met. This requirement is outstanding since the inspection undertaken on the 30/11/04 and should have been addressed with immediate effect. The home must have a plan to ensure its meets the requirement of 50 qualified care staff. The registered provider must obtain and hold information and documents in respect of persons carrying on, managing or working at a care home as listed in Schedule 4 of the Care Home Regulations 2001. Partially met. This requirement is outstanding since the inspection undertaken on the 26/6/02 The registered provider must provide all staff with Care of the Dying Awareness training. Partially met. This requirement has been outstanding since the inspection undertaken on the 26/6/02 All care staff receive training in the care of residents with dementia The home must have strong and effective leadership. Partially met. Concern highlighted about the management of the dementia care unit. The record of the monthly unannounced visit by the responsible individual or their representative must be forwarded to the Commission for DS0000004896.V256020.R01.S.doc 15 OP28 18 31/12/05 16. OP29 19 31/10/05 17. OP30 18,19 31/12/05 18 19. OP30 OP31 18 9 31/12/05 31/10/05 20. OP31 26 31/10/05 Lobley Hill Nursing Home Version 5.0 Page 26 21 OP33 24 22. OP35 20(3) Social Care Inspection. Partially met-one monthly report visit has been received since the previous inspection A survey of service users views of the home with its results shared with service users and other stake holders including the Commission for Social Care Inspection must be undertaken. The registered provider must ensure that no member of the homes staff manage or are responsible for service users money. Partially met. This requirement is outstanding since the inspection undertaken on the 30/11/04 and should have been addressed with immediate effect. 31/12/05 31/10/05 23. OP36 18,19 The registered provider must implement a formal supervision system, ensuring care staff receive a documented supervision session a minimum 6 times each year. Not met. This requirement has been outstanding since the inspection undertaken on the 26/6/02. A copy of the five year electrical installation test (due on the 11/10/05) is forwarded to CSCI. The water chlorination certificate must be forwarded to CSCI following completion of the work to repair the central heating/ hot water system. Staff must have all required mandatory training: Fire safety (every six months), first aid, moving and handling, food safety, health and safety DS0000004896.V256020.R01.S.doc 30/11/05 24 25 OP38 OP38 16,23 13(3) 31/10/05 30/11/05 26 OP38 18 31/12/05 Lobley Hill Nursing Home Version 5.0 Page 27 awareness. 27 OP38 23(4) All staff (including night staff) must have a fire drill every six months. 31/10/05 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 OP30 Good Practice Recommendations The home has an identified training plan. Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 28 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 Lobley Hill Nursing Home DS0000004896.V256020.R01.S.doc Version 5.0 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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