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Inspection on 09/08/05 for Comberton Nursing Home

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

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Comberton is a detached property located in a pleasant residential area. It has generous size gardens and car parking facilities. The property overall is maintained to a good standard, although some rooms are still in need of maintenance work. The home has a range of aids and adaptations to enhance mobility, independence and safety. The registered person has a number of other homes offering additional support networks to this home. A number of positive comments were received from relatives and residents` which included " The staff are very good, very caring". " The cleanliness of the home and the laundry is good". One resident said, " They are good to us". Another resident commented, " We have jolly good food, we can have what we want for breakfast, that`s important". Another said, " I dare say improvements could be made, but nothing at the moment affects me. Overall I think I am quite happy". A relative commented " The staff look after the residents` with endless patience".

What has improved since the last inspection?

There were records available for the ordering and receipt of medication. Photographs of residents` were attached to their medication records. A homely remedy policy was available. A handyperson has been employed since the last inspection. The home has been redecorated in a number of areas both internally and externally. New carpets have been provided in a number of bedrooms, communal areas and corridors. The home has purchased a quality assurance/ quality monitoring system. A number of requirements from previous inspections have been met.

What the care home could do better:

Record keeping in all areas needs to be improved. Care plans and risk assessments are of a poor standard in terms of content and instruction. An incident occurred where there was a delay in obtaining appropriate medical attention for one resident who had a fall. It was not until five days later that she went to hospital where it was identified that she had sustained a fracture. Work is needed to ensure that residents` choices are determined in respect of daily routines and to enhance dignity and privacy. Staffing processes and supervision of staff require more diligence to ensure that they all work to the required standards and follow instructions. The quality assurance package must be implemented to ensure that the manager can identify non-conformances in respect of work methods, policies, procedures and processes and apply corrective actions. Greater control of the home is required to ensure that everything is operating correctly to promote the health, well being and safety of each resident.Record keeping is poor. Some entries seen were written in blue or red pen, handwriting in some instances illegible.Staff need to improve medication documentation to ensure that medication records are accurate, reflective of what medication has been prescribed and administered to residents`. Medication stock control needs to be addressed to prevent over-ordering and poor stock rotation.

CARE HOMES FOR OLDER PEOPLE Comberton Nursing Home King William Street Amblecote Stourbridge West Midlands. DY8 4EP Lead Inspector Cathy Moore Unannounced 9 August 2005 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 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 E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Comberton Nursing Home Address King William Street Amblecote Stourbridge West Midlands. DY8 4EP 01384 262027 Telephone number Fax number Email 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. J. J. Patel Margaret Farrington Care Home 36 Category(ies) of OP Old Age (36) registration, with number of places Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 8 Physical Disability Elderly ( PD(E). 8 Terminally Ill ( TI). Date of last inspection 24.01.05 Brief Description of the Service: Comberton Nursing home is located not far from 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 copmprises 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. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted during the course of one day by one Regulation Inspector and one Pharmacy Inspector between 07.55- 16.15 hours. The inspection was carried out as the first of the homes two routine statutory inspections for this inspection year. Parts of the premises were assessed which included the main lounge/ dining area, the laundry, ground floor corridors two bathrooms and two toilets. Three residents’ were selected for case tracking purposes. Their files were perused to include care plans and daily care records. Five residents and two relatives were spoken to in detail. Two staff files were assessed to include personal documents and recruitment information. The deputy manager, one trained nurse and the business manager were involved during the day in the inspection process. What the service does well: Comberton is a detached property located in a pleasant residential area. It has generous size gardens and car parking facilities. The property overall is maintained to a good standard, although some rooms are still in need of maintenance work. The home has a range of aids and adaptations to enhance mobility, independence and safety. The registered person has a number of other homes offering additional support networks to this home. A number of positive comments were received from relatives and residents’ which included “ The staff are very good, very caring”. “ The cleanliness of the home and the laundry is good”. One resident said, “ They are good to us”. Another resident commented, “ We have jolly good food, we can have what we Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 6 want for breakfast, that’s important”. Another said, “ I dare say improvements could be made, but nothing at the moment affects me. Overall I think I am quite happy”. A relative commented “ The staff look after the residents’ with endless patience”. What has improved since the last inspection? What they could do better: Record keeping in all areas needs to be improved. Care plans and risk assessments are of a poor standard in terms of content and instruction. An incident occurred where there was a delay in obtaining appropriate medical attention for one resident who had a fall. It was not until five days later that she went to hospital where it was identified that she had sustained a fracture. Work is needed to ensure that residents’ choices are determined in respect of daily routines and to enhance dignity and privacy. Staffing processes and supervision of staff require more diligence to ensure that they all work to the required standards and follow instructions. The quality assurance package must be implemented to ensure that the manager can identify non-conformances in respect of work methods, policies, procedures and processes and apply corrective actions. Greater control of the home is required to ensure that everything is operating correctly to promote the health, well being and safety of each resident. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 7 Record keeping is poor. Some entries seen were written in blue or red pen, handwriting in some instances illegible. Staff need to improve medication documentation to ensure that medication records are accurate, reflective of what medication has been prescribed and administered to residents’. Medication stock control needs to be addressed to prevent over-ordering and poor stock rotation. 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 E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 9 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 standard(s) 3,4,5 Assessment of need processes in operation must be more diligent to ensure that no resident moves into the home without having the assurance that their needs will be met. Relatives and prospective residents’ are given the opportunity to visit the home prior to admission to assess the quality and services provided by the home. EVIDENCE: There was ample documentary and other evidence available to demonstrate that assessment of need processes are in operation. One relative commented “ Matron went to assess my brother whilst he was in hospital”. Concern was raised however, in that one resident had been assessed, offered a placement and is accommodated in the home who it appears has a primary diagnosis of dementia. The home is not registered to provide care to residents’ who have this diagnosis. Two residents’ and two relatives confirmed that they had visited the home prior to their or their relatives’ admission to the home. One relative said “ we visited the home unannounced, just before lunch and were satisfied with our findings”. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 Care plans are unsatisfactory in that they are basic and do not contain sufficient information. Further diligence is needed to ensure that residents’ health care needs are met. Major shortfalls are evident in respect of medication systems presenting a potential risk to residents’. Processes must be implemented to ensure that all treatments/ assessments are carried out in an area which promotes privacy and dignity. EVIDENCE: Care plans were in place for each resident. Changes were identified in relation to care plans to indicate that action has been taken to improve care planning processes. Care plans seen however, were of a poor standard in terms of content and instruction. One resident’s daily records revealed that she had, had at one time suicidal thoughts, another had a fall following which her condition deteriorated yet these occurrences / concerns were not reflected in their care plans. Care plans seen were dated by month only and were not all signed by the person who had produced them. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 11 There was evidence that health care services (dental, chiropodist etc) are being accessed for the residents’. One relative said “ My brother has been seen by the dietician and speech therapist since he was admitted to the home”. Documentation relating to these visits however, is being recorded in the communication book rather than the residents’ personal files. Residents’ are being weighed regularly although it was identified that the weighing scales may be inaccurate. According to records one resident in one month had lost 7 kgs in weight. There was inadequate record keeping to demonstrate that the full spectrum of personal care is being provided on a daily basis. One relative commented “ The staff provide all the personal care to my brother”. She indicated that this was carried out to a good standard. Concerns were raised in that there was a delay in obtaining appropriate medical assessment in respect of one resident who had a fall even though she had shown signs of deterioration since the fall. It was determined days later that this resident had sustained a fracture. The dentist was observed treating one resident in the ground floor bathroom/toilet, which could have infection control implications. A Commission pharmacist carried out an audit of the homes medication and medication systems. Despite an improvement in records for ordering and receipt the control of medication stocks was poor. Due to poor medicine management a full medication audit could not be undertaken. Comberton is registered to provide nursing care, therefore registered nurses have responsibility for medication systems and administration. All Medication administration records were inspected during the morning administration of medication with the following serious errors noted; no strength was documented for medication where there was more than one strength available for example co-beneldopa, diazepam, digoxin and metaclorpramide. Incorrect units of strength were documented for digoxin, ‘mg’ instead of ‘mcg’. For one resident their digoxin had been written as 6.25 mg instead of 62.5 mcg. Different spelling of medication was used compared to the pharmacy labels e.g bendroflouazide instead of bendroflumethiazide. Latin abbreviations were documented instead of full instructions as detailed on the pharmacy-dispensed label e.g. ‘B.D’ instead of ‘ to be taken twice daily’. There were omissions on the medication administration records with no signature for a record of administration or an appropriate code used where medication had been refused or omitted. It was observed that one resident was administered risedronate at 10.20am instead of the instructed 30 minutes before food detailed on the pharmacy label. An audit was undertaken of a course of Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 12 antibiotics, which highlighted a discrepancy between the actual amount in the container compared to the signatures for administration. One relative commented, “ The nurses see to my brothers medication and I am happy with this”. During the inspection a resident was heard shouting. On investigation it transpired that the dentist was attending to this resident in a ground floor bathroom with the door open not in the treatment room or the residents’ bedroom where her privacy and dignity would have been better ensured. There was little evidence available to suggest that the preferred form of address of each resident is determined on admission. Staff were heard giving residents’ choices. They were observed communicating to the residents’ in a respectful manner. It was positive that one resident’s care plan stated, “ encourage to choose own clothing”. Bathroom and toilet doors checked had locks on the doors to promote privacy and dignity. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 13 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 standard(s) 12,13,15 Further development is needed in terms of determining and where possible honouring the preferred daily routines of each resident to ensure that the lifestyle offered by the home matches resident expectations. The home actively encourages residents’ to maintain contact with family and friends. Although fine tuning is required in respect of evidencing food consumption, residents’ in general receive a wholesome appealing diet. EVIDENCE: Two residents’ who are fairly independent were spoken to. They intimated that they are satisfied with their daily routines. One said, “ I get up pretty early, can’t help it I always have done”. There was a lack of evidence to demonstrate that the preferred routines of residents are determined on admission. The home has a dedicated activities co-ordinator. A weekly programme of activities is produced and given to each resident. Another resident commented” I do not do a lot of anything because I do not want to. The home provides activities but you do not have to join in if you do not want to”. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 14 Individual activity programmes were not seen on care plans or other documents. The home provides a lounge come dining room. The breakfast time was observed. The tables were nicely laid. Staff were on hand to give assistance. One relative commented, “ Some of the residents’ are fed by the staff.” Choices were given at breakfast time. Fruit juice and grapefruit was offered in addition to a range of cereals and hot options. Milk and sugar was provided on the tables for residents’ who are able to help themselves. There was interaction and conversation between residents’ during breakfast. Staff serving food wore blue aprons. The menu covers four meals per day, breakfast, lunch, tea and supper. Food and fluid consumption charts were not all completed with diligence, as they did not reflect all meals taken. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 15 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 standard(s) Nil No standards were assessed in this section during this inspection. EVIDENCE: Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 16 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 standard(s) 19,26 In general residents’ live in a safe, well-maintained environment. The laundry requires improvements. Other areas of the home appeared to be clean and hygienic. EVIDENCE: The homes environment has improved considerably over the last 10 months. A handyperson has been employed who works full time. A maintenance programme is in operation. The outside of the home, bedrooms, communal areas and corridors have been redecorated within the last 10 months. New carpets have been fitted in a number of bedrooms, communal areas and corridors. Residents’ where possible have been given a choice of colour in their bedrooms. Overall the home appeared to be clean and hygienic. One relatives’ response when asked about the cleanliness of the home was “ very good”. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 17 The laundry was seen to be very cluttered with vases and other items. The sink had water marks where water had dripped from the mattress protector sheets that had been washed and left to drain. The laundry is in need of redecoration. The home has a sluicing disinfector and adequate laundry appliances. Liquid soap, paper towels, gloves and aprons were seen in all high risk areas except the toilet by G9 where there were no gloves. No communal items were identified in toilets or bathrooms. The home had an outbreak of diarrhoea in June 2005 although Dudley’s infection control agency was informed there was no Regulation 37 notification received by the Commission. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Staff require more support and development. Staffing numbers and skill mix require further exploration to ensure that all residents’ needs are met. More diligence is required to ensure recruitment processes safeguard residents’. EVIDENCE: Concerns were raised in respect of staffing numbers. One resident was particularly challenging early in the morning. The nurse was trying to supervise her and administer medications at the same time. There was no evidence that the home is using the approved Department of Health staffing tool. A concern was raised in that confidential information had gone outside of the home not in accordance with the homes confidentiality processes or Whistleblowing procedures. Another concern was identified in that one staff member, it appears, had not followed instructions detailed on a residents’ file. Staff recruitment processes have improved in respect of obtaining correct documents etc for staff before they commence employment. However, further improvements are required. One staff member had been allowed to commence employment with a POVA first not a full enhanced disclosure. A reference had not been obtained from one staff member’s direct last employer and there was no evidence of interview questions and answers. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,37 The home newly purchased quality assurance/ monitoring procedures must be put into operation to ensure that the home is run in the best interests of the residents’. Residents; are not safeguarded by the homes record keeping. Overall observance is paid to health and safety, although some issues need to be addressed. EVIDENCE: The home has recently purchased the Mulberry House quality assurance package. To date not much work has been undertaken to implement this package. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 20 Record keeping in a number of areas requires improvement. The handwriting of one nurse was illegible. Red and blue ink was seen used on some records. A communication book was seen to be in use where residents’ personal information was documented. The kitchen was not assessed during this inspection. Staff mandatory training requirements are being addressed. The home has produced a training programme for this year. Concerns were raised about the moving and handling of one resident in particular. Commode chairs are used to transport residents’ which does not promote infection control or safety as at least one resident was in a chair without footrests. Bedrails had not been checked since 5/05. The in-house checking of the emergency lights and fire doors had not been undertaken since 06/05 and 05/05 respectively. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x x x 1 2 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14(1)(a) 14(1)(d) Requirement The registered person and manager must ensure that all information gained during the assessment of need process for example written reports and documentation from previous care providers, doctors, funding authorities is taken into account when making the decision to offer a placement to any prospective resident/. The registered person and manager must ensure that no placement is offered to any prospective resident who has needs which fall outside the categories the home is registered for. Timescale 09.08.05 A serious concern letter was sent to the registered persons in which this requirement was included. The registered person and manager must fully assess the situation in respect of resident (PA) to determine if the home can meet all of her needs. This Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Timescale for action 09.08.05 2. OP4 14(1)(a) 14(1)(b) 09.08.05 20.08.05 Page 23 Version 1.40 decision must be made taking into consideration the residents accommodated (both present and future) and your category terminally ill. Evidence that this has been done and the outcome (action taken) must be provided to the CSCI. Timescale 20.08.05. A serious concern letter was sent to the registered persons in which this requirement was included. The registered person and manager must decide if Comberton can meet (PAs) needs ( and all other residents needs at the same time) then an application to vary the homes registration must be made to the CSCI. Information to accompany the variation application must include; An up to date care plan reflecting all (PAs) needs. Risk assessments covering all aspects/concerns examples being suicidal thoughts. Access you have secured to support ( PAs) care for instance a CPN. Certificates to demonstrate that all staff have received training in dementia care, dementia awareness and violence and aggression. Staff rotas detailing the increased numbers of staff during waking hours (plus night time if concerns/ falls have Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 24 occured) to provide the required supervision this resident requires. Timescale 20.08.05. A serious concern letter was sent to the registered persons in which this requirement was included. 3. OP7 15(1) 15(2)(b) The registered person and manager must ensure that management strategies are available within each service users care plan where a risk or concern has been identified examples being falls risk assessment, tissue viability etc. Timescale of 7.2.05 not fully met. The registered person and manager must ensure that; Care plans are precise and include all needs identified. Care plans must clearly state what the need/ problem/ concern is. (personal care, nursing care, diabetic care, continence promotion etc). 25.08.05 4. OP7 15(1) 01.09.05 5. OP7 15(1) 6. OP7 15(1) 15(2)(a) (c ) what has to be done, when, how, how often and by whom. The registered person and 09.08.05 manager must ensure that care plans are dated when produced by day, month and year and that they are signed by the person who produced them. The registered person and 09.08.05 manager must ensure that the resident or their representative Version 1.40 Page 25 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc 7. OP7 15(2)(b) 8. OP8 12(1)(a) 13(1)(b) are involved in the production of their care plan and or consulted with about any changes or review of their plan. The registered person and manager must ensure that each residents care plan is reviewed when changes occur. The registered person and manager must ensure that (T.P) is referred to Occupational Therapy moving and handling team for assessment in respect of his mode of internal transport. Timescale of 7.2.05 not met. 09.08.05 01.09.05 9. OP8 12(1)(a) 10. OP8 12(1)(a) 12(1)(b) 11. OP8 12(1)(a) 12(1)(b) An assessment can be requested from Parkes Hall, Dudley SSD OT section. The registered person and 01.09.05 manager must ensure that evidence is available at all times to demonstrate that the full spectrum of personal care has been provided to each resident depending on needs (personal cleansing, oral care, foot care etc). The registered person and 01.09.05 manager must ensure that the weighing scales are accurate and in good working order at all times. 09.08.05 The registered person and manager must ensure that immediate appropriate medical attention is obtained where there is a suspected injury, change of health/ condition following a fall or other concern. A serious concern letter was sent to the registered persons in which this requirement was included. The registered person and manager must ensure that 12. OP8 12(1)(a) 12(1)(b) 09.08.05 Page 26 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 doctors or others are fully informed of any circumstances preceeding a concern or change of condition and that records are made to evidence this. A serious concern letter was sent to the registered persons in which this requirement was included. The registered person nad manager must carry out a full investigation to determine; Why the shortfalls (in respect of the delay in obtaining appropriate medical attention following the residents fall and her deterioration). To determine how the information relating to this incident was communicated outside of the home. Nursing staff must all be asked to read, sign and date the NMC codes of conduct and practice. A copy of all investigation records,outcomes and actions you have taken in respect of individual staff members must be forwarded to the CSCI office. A serious concern letter was sent to the registered persons in which this requirement was included. The registered person and manager must ensure that a policy is produced instructing all staff what procedures they must follow to ensure shortfalls in terms of medical assessment delays do not occur again. This policy must be completed, disseminated to all staff which 13. OP8 12(1)(a) 12(1)(b) 22.08.05 14. OP8 12(1)(a) 12(1)(b) 15.08.05 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 27 they must read, sign and date. A copy of the policy must be forwarded to the CSCI. A serious concern letter was sent to the registered persons in which this requirement was included. 15. OP8 13(4) The registered person and manager must ensure that all staff are aware of risk assessments/ care plan documents in respect of each resident and that they are formally reminded that they must at all times work to instructions in care plans or other documents. written documentation to evidence that this requirement has been met must be forwarded to the CSCI no later than 17.00 hours 15.08.05. A serious concern letter was sent to the registered persons in which this requirement was included. The registered person and manager must ensure that all assessments and/ or treatments are carried out either in the treatment room or the residents bedroom depending on circumstances and the choice of the resident. All staff must be formally notified of these instructions and this must be evidenced at all times. A serious concern letter was sent to the registered persons in which this requirement was included. The registered person and 15.08.05 16. OP8 12(1)(a) 12(1)(b) 13(3) 09.08.05 17. OP8 17(2) 09.08.05 Page 28 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 18. OP9 13(2) 19. OP9 13(2) manager must ensure that all healthcare and other visits are recorded on the residents individual personal files. The registered person and manager must ensure that the medication administration record MAR) charts are accurate and correspond to the pharmacy label. The registered person and manager must ensure that all medication adminstration records are signed immediatley after medication has been administered or an appropriate code used where medication has been refused or omitted. Timescale of 24.1.05 not met. The registered person and manager must ensure that the date of opening of containers is recorded to ensure an audit trail of medication can be undertaken. The registered person and manager must consider changing the homes medication system to a monitored dosage system. The registered person and manager must ensure that medication details including changes are documented and recorded in the residents care plans. The registered person and manager must ensure that all stock is rotated in date order and stocks are at an adequate level for the residents requirements (no excess stock). The registered person and manager must ensure that the amount of tablets administered where the dose is one or two is documented. 09.08.05 Immediate and ongoing. 09.08.05 Immediate and ongoing. 20. OP9 13(2) 09.08.05 Immediate and ongoing. 09.08.05 Immediate 09.08.05 Immediate and ongoing. 09.08.05 Immediate and ongoing. 30.09.05 21. OP9 13(2) 22. OP9 13(2) 23. OP9 13(2) 24. OP9 13(2) Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 29 25. OP9 13(2) 26. OP9 13(2) 27. OP9 13(2) The registered person and manager must ensure that the medication policy is reviewed and accuratley reflects the current practice of the home. The registered person and manager must ensure that two staff check and countersign the hand-written Mar charts. The registered person and manager must ensure that all staff are fully aware of the medication instructions and side effects of each medication they administer and that instructions are fully complied with. Timescale of 24.1.05 not met. The registered person and manager must ensure that the homes pharmacy provider assists in the revision of the medication policy/procedures. Timescale of 12.1.05 not fully met. The registered person and manager must ensure that the privacy and dignity of each resident is maintained at all times to include whilst receiving healthcare assessments and treatments. All staff must be formally notified of these instructions and that this can be evidenced at all times. A serious concern letter was sent to the registered persons in which this requirement was included. 30.09.05 09.08.05 09.08.05 28. OP9 13(2) 09.09.05 29. OP10 12(4)(a) 09.08.05 30. OP10 12(4)(a) The registered person and manager must ensure that the preferred form of address in 01.09.05 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 30 31. OP12 12(2) 32. OP12 15(1) 16(2)(n) (m) 12(1)(a) 13(4)( c) 17(2)Schedule 4 ( 13). 33. OP15 34. OP26 13(3) 23(2)(d) respect of each resident is determined on admission and is recorded on their personal file. The registered person and manager must ensure that the preferred daily routines of each resident are determined on admission and recorded on their personal file. The registered person and manager must ensure that activity programmes are recorded on each residents file and care plan. The registered person and manager must ensure that where it has been assessed as being required a food consumption/ fluid input chart is in operation for each resident. These charts must then be completed diligently and consistently detailing all food/ fluids consumed over each 24 hour period. The registered person and manager must ensure that the laundry is : Free from clutter at all times. Ensure that risk assessments are carried out in respect of the laundry concerning equipment and for the prevention of contamination between clean and dirthy washing. These must be displayed in the laundry together with appropriate management instructions. Ensure that the laundry is redecorated in accordance with standard 26. Timescale of 20.2.05 not met. 01.09.05 01.09.05 01.09.05 26.09.05 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 31 35. OP26 37(1)(b) (e) 36. OP27 18(1)(a) The registered person and 09.08.05 manager must ensure that the Commission is informed of any outbreaks of infectious disease in the home. The registered person and 15.09.05 manager must ensure that sufficent staffing hours are provided at all times in accordance with Department of Health guidance and Regulations. The DOH guidance must be obtained. www.socialcareassoc. com/carestaffing ot telephone 020 8397 1419 Must provide the CSCI with the dependancy levels of each resident together with the assessment process used to determine these dependancy levels. Timescale of 20.2.05 not fully met. 37. OP27 13(4)( c) 18(1)(a) The registered person and manager must ensure that resident (PA) is appropriatley supervised at all times by providing sufficent staffing numbers and competent staff to enable this. Evidence of this must be provided to the CSCI. A serious concern letter was sent to the registered persons in which this requirement was included. 12.08.05 38. OP27 12(4)(a) 12(5)(a) (b). 18(4). The registered person and manager must ensure that all staff read, sign and date the homes confidentiality policy. 15.08.05 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 32 Staff must however, be reminded of the difference between breaches of confidentiality (which must not occur) and the purpose of the homes Whistle - blowing policy where bad practice reporting to appropriate agencies/ others must be encouraged and supported). A serious concern letter was sent to the registered persons in which this requirement was included. 39. OP27 13(4) 18(1)(a) The registered person and manager must ensure that all staff are aware of risk assessments/ care plan documents in respect of each resident and that they are formally reminded that they must at all times work to these instructions in care plans or other documents. A serious concern letter was sent to the registered persons in which this requirement was included. 40. OP29 13(6) 19(2) The registered person and manager must ensure that staff do not commence employment before a full enhanced disclosure /POVA list check is completed/ received. If extrordinary circumstances arise where staff need to be employed with just a POVA first and not the CRB then the CSCI must be informed. The registered person and manager must ensure that at least one referrence is obtained from each staff members LAST previous employer. 09.08.05 Ongoing. 15.08.05 41. OP29 13(6) 19(2) 09.08.05 On-going. Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 33 42. OP29 13(6) 19(2) 24 43. OP33 44. OP37 17(2) The registered person and manager must ensure that a record is made of all interview questions and answers. The registered person and manager must implement fully the newly purchased quality assurance/ monitoring system. The registered person and manager must ensure that all records made are legiable. A serious concern letter was sent to the registered persons in which this requirement was included. 09.08.05 01.10.05 12.08.05 45. 46. OP37 OP37 17(2) 17(2) The registered provider must ensure that all records are made in black ink/ pen only. The registered person must ensure that residents personal information, doctors visits etc is not recorded in the communication book but their personal file only. An immediate requirement was issued to this effect during the inspection. The registered person and manager must ensure that approriate forms of transport are available within the home that: Promote safety with footrests. Promotes infection control by not being used directly over the toilet. The registered person and manager must ensure that (TP) is referred to Occupational Therapy moving and handling team for assessment in respect of his mode of internal transport. Timescale of 7.2.05 not met. 09.08.05 09.08.05 47. OP38 13(3) 13(4)(c ) 23(2)(n) 01.09.05 48. OP38 13(4) 23(2)(n) 01.09.05 Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 34 49. OP38 13(4) 23(4) The registered person and manager must ensure that the: Fire doors are tested weekly. Emergency lighting supply is tested monthly. That the bedrails are tested weekly at least. A record of all of these tests must be made. 01.09.05 50. OP38 13(4)(a) The registered person and manager must ensure that Dudley Environmental Health Department are asked to provide written confirmation as to whether or not the home requires a gas landlords safety certificate. A copy of this written confirmation must be forwarded to the CSCI. 15.09.05 51. 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 Good Practice Recommendations Comberton Nursing Home E55 S60514 Comberton NH V243676 090805 stage 4.doc Version 1.40 Page 35 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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. 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