Inspection on 04/12/06 for Redbrick Court Care Centre

This inspection was carried out on 4th December 2006.

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 09/05/06

Redbrick Court Care Centre 03/10/05

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 Key Unannounced Inspection 4th December 2006 08:30 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.V323066.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. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lobley Hill Nursing Home Address High Street Wordsley Stourbridge West Midlands DY8 5SD 01384 571752 01384 75391 lobleyhill@schealthcare.co.uk 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 Position vacant 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.V323066.R01.S.doc Version 5.2 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. 9th May 2006 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 thirty- eight people. 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 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 en-suite 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 five lounges and two dining rooms, assisted bathrooms 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. Fees vary between £335 and £630* and are dependant on the needs of the service user and the room accommodated. * Please note fees will include the free nursing care contribution when applicable. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two inspectors. The inspection was carried out between 08.30 and 17.00. The inspection included a tour of the building, talking to service users, staff and visitors and a review of records. Care records were reviewed as part of the “case tracking” of six service users on both the nursing and dementia care unit. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The home is currently without a permanent manager and is currently being managed on a temporary basis by Annette Mole. The registered proprietor is Southern Cross Healthcare. Eleven of the previous twenty-one requirements have been addressed, eight new requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? All care records have been updated and are now reviewed regularly. A new Activity Organiser has been employed and it is anticipated that there will be more activities available to service users that meet their needs. A review of the food served within the home has been undertaken with a review of menus and also the way that meals are served. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 6 The garden has been tidied, made more secure and more accessible for service users. Paths have been laid out in the dementia care unit garden in a way to enable service users to wander safely if they wish to. The manager has now put into place a system of staff supervision this means that all staff will have the opportunity to discuss their training and development needs and ensure that they are up to date with current good practice. Staff training has also improved and service users can now be assured that staff will have the skills and knowledge they need to care for them. 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. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has all required information about the services it provides and the terms and conditions of residency. There is a need to ensure that this information is both available at all times and has been provided. Service users have an assessment of their needs giving some assurance that the home is able to meet their needs. EVIDENCE: The home has both a statement of purpose and service user guide which give required information about the home. The statement and purpose and service user guide are available beside the front door and in service users rooms within the nursing unit, however it can frequently be removed by service users in the Dementia care unit where they were not available. There are no records available to evidence that the service user guide is given to either prospective Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 9 or current service users or their representatives which is crucial as service users with dementia are unable to recall what documents they are given. Terms and conditions of residency were available in the majority of the service user records seen and contained all required information. Terms and conditions are not always available when the service user first move to the home and there can also be a delay in their return. Again it is crucial that this information available and is given to them prior to their move into the home. All service users have an assessment of their needs prior to being admitted to the home. The assessment of the service users needs is undertaken by either the Manager or a senior member of staff. The home has also been exploring service users social needs but until the week before the inspection had been without an activity coordinator and so staff were not always meeting service users social needs. – for further information see section 3 of this report. Service users or when appropriate their families, Health professionals and Social Workers are involved in the assessment of needs. Assessments seen generally included all required information. The Manager writes to prospective service users to confirm that following the assessment of need that the home is able to meet their needs. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care planning records are generally good within the nursing unit but the unavailability of some records and the inaccuracy of others within the dementia care unit does not ensure that required care will consistently be given. Medication practices that the home has a responsibility for are generally good but the lack of review of service users by General Practitioners put service users at risk from unnecessary and duplicated medicines. EVIDENCE: The home has a good range of care planning information available with required assessments and risk assessments identified. The home manager/ acting manager also undertakes regular audit of care plans to review their content to ensure that all required information is included. Unfortunately on the day of the inspection a number of care plans of service users with dementia had been removed from the home for updating and although they were returned at the end of the day it was difficult to fully determine their full content, particularly as these were newer service users to the home- an Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 11 additional visit will be made to the home to review care plans at a later date. It was of further concern that staff were not aware of the absence of care records, questioning the frequency that they are consulted and their effectiveness. Service users within the nursing unit all had a plan of care that is regularly reviewed and which details their health needs. Care plans are developed with the involvement of the service user and are reviewed monthly. The key worker also undertakes monthly assessments of the service user which is generally undertaken alongside the service user or their representatives. It was pleasing and reassuring that all service users have risk assessments for the risk of pressure sores, moving and handling, nutrition, continence and falls which are reviewed monthly as required. Service users are not weighed regularly and there no record of any weight for newer service users case tracked. Staff reported that there had been problems with the new weighing scales. The lack of record of service users weights resulted in risk assessment being inaccurate and there is no assurance that timely action will be undertaken. Service users are regularly seen by different health professionals but unfortunately this is not always recorded which does not give confidence in the consistency of care. Services users who reside in the nursing unit have all their medicines both administered and managed by qualified nurses. Services users who reside in the dementia care unit have all their medicines administered by care staff who have undertaken additional training in the safe handling of medicines. There is an accurate record of all medicines service users have received. Staff undertake all precautions such as recording the drugs fridge temperature and treatment room temperature to ensure that service users medicines are stored securely although medicines awaiting collection for destruction are not kept locked in the treatment room. Staff generally but not always consistently record the opening date of medicines with a short life such as calogen and liquid antibiotics. There was no evidence that service users had been reviewed or had also had their medication reviewed with concern in relation to the amount of sedatives service users with dementia were receiving. In addition one service user in the dementia care unit was inappropriately receiving two different medicines to help them sleep, which also questioned staff knowledge of the actions of different medicines. Staff were observed to treat service users with respect and have positive interactions with service users. Staff were seen to knock on service users bedroom doors prior to entering them. One service users said ; “ They are all very kind.” Service users do wear their own clothes and are called by their preferred name. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user’s expectations, preferences and choices are being reviewed by staff to give increased assurance that daily life within the home can be flexible and meet service users needs and preferences. EVIDENCE: Staff have been exploring service users life history which includes choices such as the time they prefer to go to bed or get up in the morning, their preferred bed time routine and their social and leisure interests. With records seen are much improved since the previous inspection. Care staff are developing activities for service users for dementia. Service users appreciate the new “garden room” with its coloured lights and interesting stencils for them to look at whilst also enjoying the view of the garden. There is a “mock nursery” where service users may if they choose to interact with the dolls as “doll therapy”. Service users are able to go out with families but Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 13 generally have limited opportunities to take part in a variety of activities outside the home. A new Activity Organiser commenced employment at the home the week before the inspection and expectations are that there will be a full activity programme that meets the needs and expectations of service users. There is an activity programme but this has not been followed whilst the home has been without an Activity Organiser. Visitors are welcome to the home at any time. Visitors spoken to during the visit said that staff always made them feel welcome and fully involved in the care of their relative. A review of mealtimes, menus and the way meals are served is being undertaken and improved. There is a choice of meal and meals looked and smelt appetising and are served in pleasant surrounding with service users having a choice whether or not to have meals in the dining room or in their own rooms. However service users commented that they were not happy with the meals and that they didn’t like the food on some occasions, “the food is so so”, “it’s not presented very nicely”, “there’s not much choice”. Requiring a need for further review and consistency of the food served. Other improvements since the previous inspection has been the new kitchenette within the dementia care unit enabling service users to either make their own cereals and toast and hot drinks or have them whenever they wish. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has appropriate policies and procedures to highlight concerns and complaints but to fully safeguard service users must record actions taken and the outcome of complaints. EVIDENCE: The home has a detailed complaints procedure, which is displayed in the reception area of the home and also in the service user guide. Nine complaints have been made to the home since the appointment of the last inspection. Records were available of the outcome of complaints since the current Acting Manager has been managing the home but there remained uncertainty about the outcomes of other complaints. Service users and their families spoken to said if they had any concerns they would discuss them with the Home Manager. The home has appropriate policies for staff to highlight concerns whilst feeling safe to do so. The home has updated its Adult Protection policy which meets all regulations and good practice guidance. Staff training in the Protection of Vulnerable Adults is ongoing with staff undertaken required training when necessary. Staff spoken to had appropriate knowledge of what is abuse and what actions they must take if any allegation of abuse is made to them. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean, pleasantly decorated and well maintained, plans to address difficulties in access will further enhance the home for its service users. EVIDENCE: The home is well maintained, clean and free from odour. A considerable amount of effort and thought has gone into the design and decoration of the dementia unit. The unit offers plenty of different experiences for those service users, the garden room being particularly popular. The home has an ongoing refurbishment programme, on the day of the inspection a lounge on both units were being redecorated. The home has assisted baths on both unit but the assisted shower is currently out of order. Lack of space means that service users are being put into the Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 16 lifting hoist in the reception area ready to go in to the toilet because there isn’t enough space for them the get in. The manager has stated that there are plans to convert a large room at the side of the reception area into two toilets to address this problem, the home had a gas leak in the summer which has been addressed. There were issues with the water temperature not reaching the required warmth. This was bought to the manager’s attention during the inspection and she will take action to rectify this promptly. Since the previous inspection the garden has been tidied, made more secure and more accessible for service users. Paths have been laid out in the dementia care unit garden in a way to enable service users to wander safely if they wish to. The outside of the building was littered with leaves and rubbish upon our arrival the manager stated that they were in the process of cleaning this up and it was expected that it would be completed in the morning. The home has satisfactory infection control practices to minimise the risk of infection for its service users. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment and selection processes are adequate, the manager has a plan in place to ensure that all staff will receive an appropriate induction, there have been improvements in the number of NVQ trained workers with more enrolled. The manager is aware of the shortfalls within this group of standards and is taking steps to reduce the risks to service users as a result. EVIDENCE: The staffing levels on the day 1 registered nurse and 3 care 1 registered nurse and 3 care 1 registered nurse and 1 care of the inspection were staff am staff pm staff night. The Dementia unit has 12 service users with two care staff on duty at all times however this does not take into account busy periods during the day such as lunchtime and tea times especially. Some of the staff did complain that they did not have enough time to complete the records for service users and were staying over to get them done. Care records had even been removed from the Dementia care unit to enable staff to update them in their own time. The Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 18 manager stated that the Dementia Care manager has 5 hours supernumery for this purpose. Most of the staff at the home have now completed the dementia training, the exceptions are the domestic, cook and maintenance man. More recently staff have completed challenging behaviour training to update their skills. Staff training in general is much improved and staff have nearly all attended required mandatory training. The number of care staff with National Vocational Level 2 qualification (NVQ) remains lower than minimum requirements but this will be improved when new staff join the team. At present there are 5 staff qualified to NVQ level 2 and 4 others have just registered to complete their NVQ level 2. Staff files seen were generally satisfactory, with only minor shortfalls such as missing photographs, clarification of a work permit for one worker. One of the new workers files examined had details of an induction programme that they had undertaken and appeared to meet the Skills for Care standards but this generally was not the case with no formal induction record available for other workers. Some of the staff files contained job descriptions and terms and conditions of employment but not all, the manager stated that the staff are in the process of having new contracts with Southern Cross and this may be why these documents were missing. An audit of the staff files would be beneficial to ensure that all required information is present and staff files are up to date. Records seen identify that staff do not receive the required supervision, although the Manager has put a system in place to address this and has also identified key members of senior staff that will help her in this process. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home requires consistency in management. The Acting manager has identified areas of improvement in the home and has begun work to address this. Presently the home is well maintained, staff training in health and safety has improved and service users can be assured that their monies will be kept secure and handled safely. The Quality assurance system within the home needs further work to ensure that the home is operating in the best interests of the service users. EVIDENCE: The home has had three different managers within the last eighteen months and is currently without a registered manager. Annette Mole is currently managing the home on a temporary basis and has been at the home since Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 20 September. Mrs Mole appears to be turning the home around, there is a more relaxed atmosphere and systems have been put into to place to ensure that all staff will receive supervision at least six times a year. Key members of staff have been highlighted to perform supervision for staff. There are plans in place for all staff appraisals to be completed in December. Southern Cross has a quality assurance programme for all its homes that includes regular audit of all areas of the home. No service users surveys have yet been undertaken but there are plans to address this but given other required actions the manager felt that there were other more urgent areas of management that required her attention first. Service users surveys have been designed with the needs of the service users in mind, they have devised a pictorial questionnaire for the people with dementia to use. Service users monies were satisfactory with good systems in place to protect service users, policy for handling and safekeeping of money has been reviewed following a robbery at another southern cross home. The service users monies checked all were balanced and transactions could be accounted for. The maintenance of the building is managed effectively, maintenance contracts seen were all up to date and provided the appropriate cover. Hot water temperatures were not up to required temperature and this was discussed with the manager during the inspection. Staff training is much improved including fire training, food hygiene and health and safety, there are some gaps but the manager is working towards a plan to ensure that all staff receive required training. The home now has an appointed trainer who is responsible for the training provision in the home. The manager is aware of the shortfalls and is working hard to address them. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 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 2 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 2 2 x x x x 3 STAFFING Standard No Score 27 2 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 1 x 2 Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 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 OP1 Regulation 5 Requirement A copy of the service user guide must be available for both new and prospective service users and are available in all service users bedrooms Part met To ensure that each Service User is provided with a statement of terms & conditions/ contract at the point of moving into the Home. Not met. Not all service users have a copy of the terms and condition of residency. This requirement is outstanding from the inspection on 26/6/02 3 OP7 15 Care plans must reflect all service users needs including their psychological and social needs. Part met but not all services had care plans available 31/01/07 Timescale for action 31/01/07 2. OP3 14 31/01/07 Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 23 4 5 OP7 OP8 5 15 Service users care records must be retained within the home at all times. Care records must detail all information about the service user. Part met. This requirement should have been addressed by the 10/05/06 All service users must be weighed regularly and when appropriate within 48 hours of their admission to the home to enable staff to effectively plan their care. Care risk assessments must be accurate and reflect the risk to service users to enable required actions to be undertaken. All service users and the medicines that they are in receipt of are reviewed in accordance with the National Framework for Older People. The home must perform an audit of the residents’ interests and preferences. Part met This requirement is outstanding since the inspection undertaken on the 14/7/03 15/12/06 31/12/07 6 OP8 12 31/12/06 7 OP8 12 31/12/06 8 OP9 13(2) 31/12/06 9. OP12 16 31/01/07 10. OP12 12(3),15 The home must provide activities 31/01/07 to meet the needs of service users and as identified within their plan of care. Part met – New Activity Organiser commenced employment 27/11/06. This requirement is outstanding since the inspection undertaken on 28/6/04 and should have been addressed by the 30/9/04 and then 31/05/06 Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 24 11. OP16 22 A record must be available of all complaints made about the home and the outcome of the complaint. Part met- record of complaints available but outcome not always recorded. This requirement is outstanding since the inspection undertaken on the 3/10/05 then the 30/06/06 The assisted shower must be repaired and available for use by service users. The home must have sufficient toilets that are accessible for use by service users without compromising their dignity. The home must have a plan to ensure its meets the requirement of 50 qualified care staff. Partially met- number of qualified care staff has is increasing (previous timescale of 31/05/06 not met) The registered manager must ensure that all staff files are audited to ensure that they contain the required information The registered manager must ensure that all staff receive an induction programme that meets Skills for Care standards and that written records are kept of this induction, The registered provider must reintroduce annual staff appraisals. To be assessed at random inspection The registered provider must implement a formal supervision system, ensuring care staff receive a documented DS0000004896.V323066.R01.S.doc 31/12/06 12 13 OP21 OP21 16,18 16,18 15/01/07 31/01/07 14. OP28 18 31/03/07 15 OP29 19 sch 2 and 4 19(11) 31/12/06 16 OP30 31/01/07 17 OP36 18,19 31/01/07 18 OP36 18,19 31/01/07 Lobley Hill Nursing Home Version 5.2 Page 25 supervision session a minimum 6 times each year. Partially met. This requirement has been outstanding since the inspection undertaken on the 26/6/02 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 OP7 Good Practice Recommendations Staff are made aware of the importance of care records and their use. Lobley Hill Nursing Home DS0000004896.V323066.R01.S.doc Version 5.2 Page 26 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: 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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