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Holbeche House Care Home Requires improvement

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 22 October 2012
Date of Publication: 4 December 2012
Inspection Report published 4 December 2012 PDF | 94.61 KB

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Enforcement action taken

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 22 October 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and talked with stakeholders.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People did not experience care, treatment and support that met their needs and protected their rights.

Reasons for our judgement

Our inspection of 28 June 2012 found that care was not always planned and delivered in a way that met people’s needs or in a way that ensured people’s safety and welfare. The provider sent us an action plan telling us that people who went to live at the home would have their care records completed within seven days. We were informed that care plans were updated regularly, risks were identified and managed, and activities would be taking place particularly in the dementia unit.

During this inspection, we found that improvements had not been made to ensure that care was planned and delivered in a way that met people’s needs or in a way that ensured people’s safety and welfare. We looked at four people’s care records.

We looked at one person’s care records who had recently gone to live at the home. The care records indicated that staff had identified that the person had sore skin at admission. The person’s care records stated that they should be encouraged to walk around the home to improve circulation in their feet. We observed that staff did not carry this out throughout the day appropriately. This meant that the person’s needs were not met to manage their health condition. We found that this person did not have all aspects of their care plan completed although they had been at the home for over seven days. For example, there was no information about how staff should communicate with the person. It was important for staff to know this as the care plan stated that staff should prompt the person to walk frequently. This meant that the action the provider had told us they had taken, had not been completed.

We looked at another person’s care records and found that they had sore skin of a serious nature. We found instructions in the care records that staff should turn the person in different positions every two hours to relieve pressure in the area of the sore skin. We looked at the charts, which showed how often the person was turned and what position they were turned to. We found that records for some days indicated that they were turned on the side, which they should not have been turned on and in other instances, there were gaps, which indicated that the person might not have been turned. We spoke with different staff about the care the person should have received and we found that all staff gave us different information about this. This meant that people might not receive care that met their needs. One person told us, "Care is OK."

One person’s care plan about their continence needs, mentioned that they had poor vision. We could not find any other information in the person’s care record about their vision and how this might affect the delivery of care. We asked the home manager about the reason for poor vision, who informed us what this was but also stated that there was no treatment for this. We spoke with staff about this person and two out of three staff were aware that the person had poor vision. This meant that we cannot be assured that consistent care was delivered and that the correct care was being provided in the absence of further information relating to the condition.

We saw that the television was on although this was not loud enough and people were not watching it. We continued to see lack of stimulation and activities, especially in the dementia unit. We found that improvements we had seen at the previous inspection were not being followed during this inspection, like people playing instruments. This meant that the improvements made previously were not consistent to ensure that people had a stimulating and meaningful lifestyle.

We saw one registered nurse administering medicines to one person using their finger, which they put in the person’s mouth. They then continued to cut another person’s food using their hands. The staff member did not follow procedures to wash their hands to minimise the risk of spreading infection.

In the afternoon, we heard music was playing in the background. However, people