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Inspection on 15/05/06 for Comberton Nursing Home

Also see our care home review for Comberton Nursing Home for more information

This inspection was carried out on 15th 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is well presented to prospective clients both in general appearance and in the excellent sources of information provided. The home provides person centred care in a friendly, homely atmosphere and a very pleasantly maintained environment. Residents receive good standards of care and support delivered in an individual way as the residents wish by well-trained staff. The home delivers safe services such as medication administration in a safe and healthy environment and holds adult protection as a priority. Service users are very positive about the home with comments such as, " we looked at other homes, you won`t find a better home" and " the staff are very good and kind", " the staff are very good, very caring". Relatives also commented positively one saying, " Dad settled very quickly and is very happy here". A number of service users commented how much they enjoyed the meals at the home. " The cleanliness of the home and the laundry is good".

What has improved since the last inspection?

The home has reviewed its daily documentation and made changes to make it more informative, they have reviewed and completely overhauled the procedures for the management of medications. Staff numbers are maintained at a consistent level by maintaining a full establishment with minimal use of agency staff. The manager and staff have responded positively to the guidance offered through previous inspection requirements.

What the care home could do better:

While the home provide good sources of information to service users about the home this would be improved if they were able to demonstrate that documents such as the service user guide was provided in formats such as large print as each individual requires. While care planning is identified as being of a good standard it is thought that they could be further enhanced by being more directive of staff in dealing with possible complications in general health care due to conditions becoming unstable. The home has a quality audit tool that has not been used since there have been changes at a senior level, they have identified an audit as a priority and should commence without delay obtaining service users views. Health and safety issues are overall of a high standard but would benefit from further workplace activity risk assessments and regular review. Accident records must be collated in a data protection compliant way.

CARE HOMES FOR OLDER PEOPLE Comberton Nursing Home King William Street Amblecote Stourbridge West Midlands DY8 4EP Lead Inspector Mr Richard Eaves Key Unannounced Inspection 15th May 2006 08:45 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 Comberton Nursing Home DS0000060514.V287506.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. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Comberton Nursing Home Address King William Street Amblecote Stourbridge West Midlands DY8 4EP 01384 262027 01384 76943 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) Mr. Jayantilal James Bhikhabhai Patel Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (8), Terminally ill (8) of places Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: Comberton Nursing Home is located near to Stourbridge town centre. The home is sited in an attractive residential area. The home itself is a large detached property that has been converted and extended to its present form a 36 bedded nursing home. The home comprises of three storeys. Bedrooms are located on both floors. The main living areas, kitchen, offices, laundry and a shower room are on the ground floor, further bedrooms , the bathroom, toilets and the treatment room on the first floor. The lower ground floor accommodates the office and staff room. The home has well maintained gardens to the front and rear and a good sized car park at the front. Comberton is registered to provide care to a maximum of 36 residents who have nursing needs. Additional conditions of registration have been approved allowing the home to provide care to, within this 36, 8 residents who have a physical disability and 8 residents who have been diagnosed as having a terminal illness. Fees for the home range from £391 to £500. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was undertaken by a single Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the unannounced inspection during February 2006, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire, survey responses and records held at the home. The inspection involved a full tour of the home including, bedrooms, communal rooms, service areas and provided an opportunity to speak with many service users, visitors and staff. What the service does well: What has improved since the last inspection? The home has reviewed its daily documentation and made changes to make it more informative, they have reviewed and completely overhauled the procedures for the management of medications. Staff numbers are maintained at a consistent level by maintaining a full establishment with minimal use of agency staff. The manager and staff have responded positively to the guidance offered through previous inspection requirements. Comberton Nursing Home DS0000060514.V287506.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. Comberton Nursing Home DS0000060514.V287506.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 Comberton Nursing Home DS0000060514.V287506.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 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home and receive a contract confirming the terms and conditions agreed for their stay at the home. The home uses comprehensive assessment tools, which means that residents’ needs can be thoroughly assessed but does not demonstrate their involvement to ensure that care needs will be identified and met. EVIDENCE: The home has a statement of purpose available recently revised following the appointment of a new manager, a copy of the service user guide was seen and is available in the reception area. It is recommended that the guide be made available in a format service users can use, to each room. The home uses a comprehensive assessment tool and is supplemented with a range of risk assessments that identify needs and interventions required to Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 9 address and minimise risks. Each of the assessments are subject to regular review. Other assessments seen within the case files were those raised by the care managers at the point of admission and subsequent reviews. A sample of 4 case files were randomly selected for case tracking and show that the assessment process is thorough, including all activities of daily living and an extensive range of risk assessments, assessments are subject to monthly review. The home does not provide intermediate care. Comberton Nursing Home DS0000060514.V287506.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 – 10 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. EVIDENCE: A random sample of 4 case files were selected to be inspected and case tracked. It was observed that the care plans were developed from the assessment process, were relevant and maintained to a good standard. Each file is set out in a consistent way with the assessments, care plans, including short term plans, monthly evaluations, a range of health risk assessments and monitoring records The care plans reflect actual care requirements and the service users preferences of how it should be delivered, while inclusive of contingency plans the inspector considers these to require a more directive approach to guiding staff. In speaking with service users many were able to Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 11 engage in broad conversation on how care is delivered and were complementary about relationships with staff. In addition to each service user having a GP there was evidence that allied health care services, dental, chiropodist etc are being accessed for the service users. Documentation relating to these visits is now recorded in the individual case file. Following an in depth inspection of medication management by the commissions pharmacist last year, the home has fully reviewed their medication policy and practices and implemented fully the guidance provided and now provide a safe service that is audited frequently. The inspection shows that receipt, storage, administration, record keeping and disposal of pharmacy waste all meet the standard. The home has a mix of single and double rooms each door being fitted with a privacy lock and double rooms have privacy curtains. It is accepted practice that staff always knock before entering rooms and they were observed to handle toileting procedures with care to maintain service users dignity. The topic of privacy, dignity and respect is included in the induction training programme. The observed interactions between staff and service users was easy and relaxed and staff related using service users names. Comberton Nursing Home DS0000060514.V287506.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 – 15 The home provides a well-organised and appropriately varied social and recreational activity programme that provides interest and pleasure for the service users. An open visiting policy assists service users to maintain contact with their family and friends. Service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: The home holds regular residents meetings where the range of activities are discussed and chosen. A diary of activities is maintained and photographs are displayed of past activities. Activities regularly undertaken include, Bingo, sing-a-longs, exercises, hand massage and nail care, games, quizzes, gardening and art sessions. Day trips are arranged on a regular basis. Those spoken with said there was always plenty of things happening and they felt free to participate or not as they chose. Entertainers visit on a monthly basis. Visiting clergy provide regular communion for a number of service users. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 13 Visiting arrangements remain unchanged and service users continue to receive visitors at any reasonable time in the day and a number were observed to arrive and leave during the course of the day. Most service users receive their visitors in one of the lounges and there appears to be a good relationship between visitors and other service users. Visitors spoken with said they were very pleased with all aspects of life at the home for their relative. One family whose relative had recently entered the home said “ We always feel welcome here and dad has settled and happy. The case files include a section that identifies personal likes and wishes such as rising and settling time and their ability to make their own choices of clothes to wear. The key worker records maintain these likes and dislikes recognising some want flexibility in their choices while others like a fixed routine. In conversation with service users they were content that these wishes are fully taken into account by care staff in the assistance they provide. One lady said, “ I like to get up early and the carers are always ready to help”. The menus provide for a balanced and nutritious diet and is well received by the residents many able to recall the choices offered at each of the meals and that the breakfast and lunch meals offered a cooked option, supper is include on the menu. The menus have been assessed as nutritionally sound and are put together using a high proportion of fresh produce, the menus should be reviewed obtaining service users views with a view to improving the level of choices at each of the meals. The lunchtime meal observed was served at neatly laid tables, nicely presented and portioned appropriately to individual requirements. Service users requiring assistance were afforded this discreetly without haste on a one to one basis. The kitchens were clean and all aspects of hazard analysis and critical control points were in place to provide a safe food production area. Comberton Nursing Home DS0000060514.V287506.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 complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The complaints procedure is readily accessible to service users and their relatives with reference in the contract and the statement of purpose which is readily available in the entrance. Two concerns have been received at the since the previous inspection and the outcomes record that these were addressed to the satisfaction of the relatives. In speaking with service users and visitors they all confirmed that they new how to raise concerns if things were not to their liking and said they felt able to speak with the staff and manager. A number of relatives spoken with said they new who to speak with but had never had reason to make a complaint. A number of service users recalled that they had voted at the last elections using postal ballots. Advocacy schemes are displayed and the information leaflets available. The home has robust procedures for responding to any suggestion of abuse and in-house training is given in adult protection procedures. It is recommended that the flow chart within Dudley’s adult protection policy be made available for easy reference by staff should it be required. Comberton Nursing Home DS0000060514.V287506.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 provides a good standard of décor, furnishings and managed services providing a safe environment, a comfortable, attractive, and homely place in which to live. The home is clean and hygienic and free from odours. EVIDENCE: A tour of the building including an inspection of some bedrooms that the inspector was invited to see were found to be mostly nicely personalised and included some items of own furniture. The home is in good decorative order and was found to be clean, odour free and hygienic. The level of furnishing is by agreement and a copy of this is kept on the case file. It was observed that approved locks were fitted to the doors and a lockable facility was available in each room. The home has a sluicing disinfector and adequate laundry appliances. Liquid soap, paper towels, gloves and aprons were seen in all high risk areas. No communal items were identified in toilets or bathrooms. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 16 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 – 30 The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: An inspection of the rotas shows that the manager is supernumerary to the allocation and has assistance with administrative duties. The rotas show that staff allocated are 6 and 2 nurses in the morning, 5 in the afternoon and evening with a nurse and 3 overnight with a nurse, each shift includes a senior carer. Currently 60 of carers hold an award of NVQ at level 2 or above which exceeds the requirement of the standard, further staff are currently enrolled. The recruitment and selection practices at the home are good with an equal opportunities policy in place. An inspection of recently appointed staff files showed they included fully completed application, two references CRB and POVA and notes of the interview. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 17 New staff are subject to induction and foundation training to National Training Organisation specification. Mandatory training is provided for fire safety, moving and handling, basic food hygiene, and first aid. Training provided over the past twelve months in addition to mandatory courses have included NVQ in Care, health and safety, COSHH, tissue viability, venepuncture, nutrition and food/diet awareness. Currently planned training includes infection control update, adult protection, Diet and SALT, confidentiality. NVQ’s at all levels are ongoing and the manager is due to complete the registered managers award and the assessors award D32/33. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 18 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 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance, which includes seeking the views of service users and their families. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receives supervision and direction to ensure that the service users receive consistent quality care. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Further risk assessment of activities of work are essential for the safety of staff. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 19 EVIDENCE: The home is led by an experienced manager who is supported in this by a stable committed staff group at all levels. On the day of the inspection it was apparent that there was a very good atmosphere amongst the staff. The manager holds frequent staff meetings and maintains a record of these and actions taken in response to staff inputs. The home has available a range of audit tools to assess the level of quality assurance and service users views. There are no recent results available were of service user and staff views the manager having only recently come into post and this is identified by the home as a current priority. The home does not act as appointee for service users but assists some service users with their personal allowances the records of which are completed thoroughly. Staff supervision is well established and applied in a relevant process that covers all aspects of practice. The home has an up to date health and safety policy for safe working practice with a limited range of risk assessments of workplace activities, these require to be increased in number to cover all areas of work for the safety of staff. Staff receives training and regular updates in health and safety and fire safety. A fire risk assessment was available and this is subject to review as changes occur. Certification of a range of servicing and annual inspections undertaken of all utilities and equipment in the home are maintained and up to date. It was observed that the home continue to use an old style accident record, this requires to be replaced with a Data Protection compliant document. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 20 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15(1) Requirement The registered person and manager must ensure that the care plans take account of contingency planning for specific conditions. The manager must complete the process of registration. The registered person and manager must implement fully a programme quality assurance monitoring that includes obtaining service users and their representatives views. Timescale of 01/04/06 not met. The registered person will undertake risk assessments of activities of work and keep these under regular review. The registered person must ensure that records of accidents are collated on data protection compliant documents. Timescale for action 06/09/06 2. 3. OP31 OP33 9 24 31/08/06 30/09/06 4. OP38 13(4)(c) 30/09/06 5. OP38 17,Sched 3(3)(j) 30/06/06 Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 22 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 OP1 OP15 OP18 Good Practice Recommendations The home should provide a copy of the service user guide to each service user in a format appropriate to each individual. The home should keep the menus under regular review ensuring service users wishes are incorporated in the choices. The home should provide a flow chart for handling adult protection procedures to aid staff should any allegation come to light. Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 23 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 Comberton Nursing Home DS0000060514.V287506.R01.S.doc Version 5.1 Page 24 - 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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