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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

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Enforcement action taken

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

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

The provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

We spoke with people living at the home but their feedback did not relate to this standard.

Our inspection of 28 June 2012 identified that a number of the issues raised from our previous visit of 9 May 2012 had not been addressed. We had also identified continuing concerns in the home that the registered manager or registered provider failed to improve. Following the previous inspection, the provider sent us an action plan to tell us that the regional manager would be providing support, audits would be completed to identify shortfalls, and action would be taken to address this, which would be tracked.

During this inspection, we found that the registered manager and the registered provider had again failed to make necessary improvements for better outcomes for people living at the home. We found that actions that the provider had told us were completed had not been completed. For example, the action plan stated that the regional manager had identified that some records were not completed appropriately. However, we continued to find instances during this inspection where records were not completed. In one instance, a senior manager had audited one person’s care record in July 2012 and September 2012 and found similar gaps. We looked at the person’s care records and found that the gaps had still not been addressed. This meant that systems were not in place to ensure action was taken once shortfalls were identified.

Our inspection of 28 June 2012 found that not all accidents and incidents were being reported. The provider sent us an action plan to tell us that all incidents would be reported electronically and analysed monthly to review changes. We found that not all incidents we identified from one person’s care records were reported electronically. The manager was unable to use the system to find out how many incidents one particular person was involved in over the month. We saw a monthly print out of the incidents with a description of the incident, which would identify trends. However, we were unable to see how this information was used to minimise risks and make improvements.

We found that the home was failing to identify concerns and make improvements across other regulations that we inspected.