Inspection on 09/05/06 for Redbrick Court Care Centre

This inspection was carried out on 9th May 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 04/12/06

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 9th May 2006 08:15 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.V293654.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. Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 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 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.V293654.R01.S.doc Version 5.1 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. 3rd October 2005 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, 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. Fees vary between £336 and £500 and are dependant on the needs of the service user. Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by one inspector. The inspection was carried out between 08.15 and 18.15.The inspection included a tour of the building, talking to service users, staff and visitors and a review of records. Seven service users completed questionnaires that asked their views on the home, which positively identified their life at the home. A review of information supplied by the Manager (pre inspection questionnaire) was also reviewed and expanded upon during the visit. Care records were reviewed as part of the “case tracking” of six service users on both the nursing and dementia care unit. The manager is Ms Amanda Shaw. The registered proprietor is Southern Cross Healthcare. Fourteen of the previous twenty-seven requirements have been addressed, nine new requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? The home has a new and experienced manager who has been providing strong and effective leadership. There have been considerable improvements to address existing requirements and develop the home with improvement of care records, increased training opportunities for staff and the safe recruitment of staff. A programme to commence staff supervision has been identified with supervision dates for all staff. The Home has a new Manager for the Dementia unit who had considerable experience caring for people with dementia. The staffing levels and skill mix for dementia care service users has been reviewed and increased. Lobley Hill Nursing Home DS0000004896.V293654.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. Lobley Hill Nursing Home DS0000004896.V293654.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 Lobley Hill Nursing Home DS0000004896.V293654.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): 1,2,3 Information about the home, its facilities and services is available but is not always accessible for all service users. Service users have an assessment of their needs, but is not always complete and does not give assurance that the home is able to meet all service users needs. EVIDENCE: The home has both a statement of purpose and service user guide which give required information about the home and have been updated to include recent management changes. The statement and purpose and service user guide are available beside the front door, but service users should have their own copy of the service user guide to enable them free access to information about the home. Terms and conditions of the home have recently been sent out to all service users but have not yet been returned. All service users have an assessment of their needs prior being admitted to the home. The assessment is undertaken by either the Manager or a senior member of staff. Service users or when appropriate their families, Health professionals and Social Workers are involved in the assessment of needs. Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 9 Assessments seen did not always include all information required by the National Minimum Standards, which must be addressed to give assurance that the home is able to meet their needs. 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.V293654.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): 7,8,9,10 Service users care is planned but does not include all needs and particularly psychological care needs for service users wellbeing. Medicine policies and procedures are satisfactory and safeguard service users. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Service users have a plan of care that is regularly reviewed and which details their health needs. Care plans require further expansion to identify, maintain and develop service users functioning skills and identify their social and psychological needs. One service user was seen to clear his plate from the table and put it back onto the trolley but the member of staff immediately removed it and consequently devalued the service users help. Care plans are developed with the involvement of the service user and are reviewed monthly but this is not always recorded but must be more effectively reviewed. Care plans for the management of pressure sores are not sufficiently detailed and must be more specific to the needs of the individual service user. Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 11 Service users have risk assessments for the risk of pressure sores, moving and handling, nutrition and falls which are reviewed monthly as required. Service users are weighed monthly. It was noted that several service users have gained weight since their admission to the home, but when service users weight is a cause for concern appropriate action is undertaken. Care records and service users identified that they are appropriately referred to and have visits from Health Professionals such as GPs, specialist nurses, dentists, opticians and chiropodists. One service users care records did not include an aggressive outburst with another service user or that he had been injured during this episode. Care records also highlighted that the Commission for Social Care Inspection had not been informed of all notifiable incidents. Visitors spoken to said that they felt that they were informed of any changes in their relative’s health. All medicines in the home are both administered and managed by trained staff. There is an accurate record of all medicines Service users have received. A new treatment room is available but there is a need to remove the carpet and provide additional and enclosed storage cupboards. For additional safeguards please refer to the requirements and recommendations section of the report. Staff were seen to knock on service users bedroom doors prior to entering them. Service users spoken to confirmed that staff respect their privacy. Service users do wear their own clothes and are called by their preferred name. Lobley Hill Nursing Home DS0000004896.V293654.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): 12,13,14,15 Service user’s expectations, preferences and choices are not identified giving little assurance that the daily life within the home meets their needs and preferences. EVIDENCE: There is little information in care records about service users choice and expectations. Staff said that service users in the dementia care unit get up early, and that the majority of service users get up before 6am and go to bed after 8pm. As records are incomplete it is unclear whether this is the service users choice. Although service users had been up since before 6am the service users had to wait until 9.20 for their breakfast. It is usual practice for the nursing unit service users to be served their meals first. It was a concern that a member of staff leaves the dementia unit to collect the food and all crockery and was gone for almost twenty minutes. Staff stated that they give service users a choice of meal as they are serving. It was observed that the beef casserole was almost gone before the dinner trolley was taken over to the dementia care unit resulting in little choice for those service users. There were good staff interactions and it was nice to see that service users had an active choice in their preferred clothing. One lady asked staff to help her to change her skirt for trousers. The lady had no clean trousers a member of staff Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 13 went down to see if she had any more clean trousers in the laundry and returned with a pair of beige trousers, but the lady said that she wanted black trousers and so the carer again went to the laundry and came back with her clean black trousers. The Home has an Activity Organiser but activities were generally considered to be ineffective and not meeting service users needs. It was nice to see services users being encouraged to do spontaneous things with other staff such as feeding the birds and reading magazines. Several service users enjoy trips out with their families but arrangements need to be made for staff to take all service users out should they wish it which can not be undertaken within current staffing levels. Another service user enjoys going out into the garden but further improvements are required to the garden to make it a safe and pleasant place for more service users. It is sad that the potentially lovely garden cannot be fully used. Staff also need to ensure that service users who are able to and wish to take part in daily activities such as laying and clearing the table and tiding their rooms are supported to and this is included in their plan of care Visitors visited the home throughout the day and confirmed that they are able visit at any time and are always made welcome by the staff. The home has a two week menu, although due to recent staffing problems in the kitchen this was not being followed on the day of the visit. As highlighted previously there is a need for the new manager and new Chef to totally review all aspects of food provided from the content of the menu, to ensuring that service users are given choice of meals and review the time and the way that meals are served. Consideration could also be made of providing the dementia care unit with breakfast provisions so that they can have their breakfast at a time that is suitable to them. Service users when they are able to should also be enabled and supported to pour their own cereals and butter their own toast, pour their tea, add milk and sugar when and how long they are able to. It was nice to see staff on the dementia unit encouraging a service user to have their breakfast offering them a choice of breakfast and prompting her to continue to eat. Lobley Hill Nursing Home DS0000004896.V293654.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 appropriate policies and procedures to highlight concerns and complaints and to safeguard service users. 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. Two complaints have been made to the home since the appointment of the new manager. Records seen show that she has undertaken a comprehensive investigation of the concerns and will ensure that any required actions will be implemented. 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, but it needs to be made accessible for staff. The home has appropriate policies to ensure that staff who are not suitable to work with vulnerable people do not do so by robust recruitment and selection procedures. Staff training in the Protection of Vulnerable Adults is ongoing. 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.V293654.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 is clean, pleasantly decorated and generally well maintained, required repairs are not always timely undertaken. EVIDENCE: The home is clean, homely, pleasantly decorated and generally well maintained. Recent leaks have required the removal of ceiling tiles and there is a need to repaint ceiling in a number of bedrooms visited. 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. There are extensive gardens at the rear of the home. The gardens are unfortunately not fully used as they are currently unsuitable for the majority of the service users requiring improved and safe access and to be made more attractive. 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.V293654.R01.S.doc Version 5.1 Page 16 The home was found to be clean and free from any offensive odour throughout. The home’s infection control procedures were reviewed and were found to be satisfactory to minimise the risk of cross infection. Lobley Hill Nursing Home DS0000004896.V293654.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): 27,28,29,30 The home has insufficient staff to meet all service users needs. Recruitment and selection procedures are robust and safeguard the service users. Staff have more training opportunities available to them to assist them in caring for the service users. EVIDENCE: Staffing levels identified at both this and the previous two inspections were found to be insufficient to meet residents needs. Staffing levels are currently for 17 nursing residents: 8am-2pm 1 trained Nurse and 3 Care Staff 2pm-8pm 1 Trained Nurse and 3 Care staff 8pm-8am 1 Trained Nurse and 1 Care Staff. For 10 residents requiring dementia care: 8am-2pm 2 Care Staff with the addition of one carer between 9am and 1pm 2pm-8pm 2 Care staff 8pm-8am 2 Care Staff. The number of staff for nursing residents has decreased since the previous inspection from four carers in the morning to the current three carers and from three carers at night to just one carer. One service users has said “ The staff are very good, they help me when they can as they know I sometimes need help but I know they are short staffed”. It is acknowledged that the number of Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 18 service users has also decreased since the last inspection from 25 to 19. There has been an increase in staff for the dementia unit since the last inspection with an additional member of staff on night duty and an additional carer also on duty between 9am and 1pm. Staffing levels on night duty for the nursing unit were the subject of one complaint received by the home. The current night staffing levels on the nursing unit require that there are times during the night when one member of staff works alone despite the majority of service users requiring the care of two staff. The home currently has 6 of its 22 care staff (24 ) with required qualifications and has considerable work to do to achieve the required 50 of care staff with National Vocational level 2 or equivalent. The home has induction training for all new staff that meets National Training Organisation standards. Staff are supported to undertake further training with the majority of staff receiving dementia care training. Lobley Hill Nursing Home DS0000004896.V293654.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): 31,33,35,36,38 The home’s manager is developing and strengthening management arrangements giving assurance of the development of the home and the protection of its service users. EVIDENCE: The home’s manager is Amanda Shaw who was appointed as Home Manager in February 2006. Ms Shaw is s registered general nurse and has three years previous experience as home manager. Southern Cross homes have an identified Quality plan. Quality audits are undertaken monthly by the home manager and are validated by the Regional Manager with corrective actions identified. 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). A Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 20 monthly review of the action plan to address outstanding CSCI requirements is also undertaken. A service user survey has been undertaken by the manager, with a report and action plan to address the findings. The required documented visits by an identified Responsible Person within the organisation are undertaken regularly. Secure facilities are available for the safe keeping of service users personal money and valuables if required. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Service users money stored in the safe was randomly checked and was satisfactory and were being externally audited at the time of the inspection. The majority of services users have their finances managed by their families or by the Court of Protection. The home’s staff do not manage the finances of any service users. Procedures to protect service users include regular checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. There has been a considerable increase in statutory training since the appointment of the new manager. Staff receive mandatory training in fire safety, moving and handling, food hygiene, protection of vulnerable adults and health and safety. Plans are in place for further training that will include first aid and infection control. A programme of supervision has been identified by the manager and was due to commence the week of the inspection. Maintenance records and contracts were reviewed and were found to be up to date. Lobley Hill Nursing Home DS0000004896.V293654.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 2 1 2 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 2 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 1 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 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 is available for both new and prospective service users and are available in all service users bedrooms To ensure that each Service User is provided with a statement of terms & conditions/ contract at the point of moving into the Home. Part met. Manager has sent out terms and conditions of residency but have not yet been returned. This requirement is outstanding from the inspection on 26/6/02 3 OP3 14 31/05/06 The registered provider must 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. DS0000004896.V293654.R01.S.doc Version 5.1 Page 23 Timescale for action 30/05/06 2 OP3 14 30/06/06 Lobley Hill Nursing Home 4 OP7 15 5 6 7 OP7 OP8 OP8 15 16 37 8 9 OP9 OP12 13(2) 16 Partially met, assessments not always complete. Care plans must reflect all service users needs including their psychological and social needs. Care plans for pressure sores must identify all aspects of the care required. Care records must detail all information about the service user. The Commission for Social Care and inspection must be notified of all incidents that have affected service users health and wellbeing The treatment room must be easily cleaned and the carpet removed. The home must perform an audit of the residents’ interests and preferences. 31/05/06 31/05/06 10/05/06 10/05/06 30/06/06 31/05/06 10 OP12 12(3),15 Not met This requirement is outstanding since the inspection undertaken on the 14/7/03 The home must provide activities 31/05/06 to meet the needs of service users and as identified within their plan of care. Not met This requirement is outstanding since the inspection undertaken on 28/6/04 and should have been addressed by the 30/9/04 Staff must ensure that there is a record of service users choice and expectations and whenever possible these are met. A review must be undertaken of food served at the home to ensure that service users, receive an adequate choice, of DS0000004896.V293654.R01.S.doc 11 OP14 12 30/06/06 12 OP15 16(2)(l) 30/06/06 Lobley Hill Nursing Home Version 5.1 Page 24 tasty nutritious food served at times that meet service users needs. 13 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 The home’s Adult Protection policy must link into the Local Authority Adult Protection Policy. Partially met- new policy is available but there remains a need to link it to the Local Authority adult protection procedures. This requirement is outstanding since the inspection undertaken on the 3/10/05 The home’ s garden must be tidied, lawns are cut and the gardens are made accessible to service users. Part met grass has been cut but remains untidy and does not provide safe access for service users. This requirement should have been addressed by 30/06/05. The registered provider must ensure the home has sufficient care staff to meet service users needs. Not met. Previous staffing concerns have been addressed but staffing levels remain insufficient and there is a need to forward staffing Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 25 30/06/06 14 OP18 13(6) 31/05/06 15 OP19 23(2)(o) 30/06/06 16 OP27 18 31/05/06 17 OP28 18 18 19 OP36 OP36 18,19 18,19 20 OP38 18 proposals for the home to CSCI. 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. Partially met- number of qualified care staff has increased from 19 to 25 . The registered provider must reintroduce annual staff appraisals The registered provider must implement a formal supervision system, ensuring care staff receive a documented supervision session a minimum 6 times each year. Partially met. A programme staff supervision has been identified and is due to commence within the week after the inspection. This requirement has been outstanding since the inspection undertaken on the 26/6/02 Staff must have all required mandatory training: Fire safety (every six months), first aid, moving and handling, food safety, health and safety awareness. Partially met. A considerable amount of training has been arranged, with an ongoing training programme identified. All staff (including night staff) must have a fire drill every six months. Partially met- but remains a DS0000004896.V293654.R01.S.doc 31/05/06 31/05/06 30/06/06 31/07/06 21 OP38 23(4) 31/07/06 Lobley Hill Nursing Home Version 5.1 Page 26 need to ensure that all night staff have had a fire drill. 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 2 3 Refer to Standard OP8 OP9 OP15 Good Practice Recommendations All staff are made aware of the requirement to inform the Commission for Social Care Inspection of all incidents that affect service users health and well being. The Dementia care unit has its own medication storage cupboards located within the unit, so that staff do not have to leave the unit to get additional medicines. Alternative breakfast arrangements are made for service users residing in the dementia care unit. Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lobley Hill Nursing Home DS0000004896.V293654.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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