Inspection on 31/01/06 for Coombe Hill And Blenheim Lodge Nursing Home

This inspection was carried out on 31st January 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

Coombe Hill And Blenheim Lodge... 26/09/07

Coombe Hill And Blenheim Lodge... 17/10/06

Coombe Hill And Blenheim Lodge... 16/02/05

Coombe Hill And Blenheim Lodge... 07/09/04

Coombe Hill And Blenheim Lodge... 28/01/04

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Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Coombe Hill And Blenheim Lodge Nursing Home 1-3 Adelaide Road Surbiton Surrey KT6 4TA Lead Inspector Margaret Lynes Unannounced Inspection 2.10pm 31 January 2006 st 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 Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 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. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coombe Hill And Blenheim Lodge Nursing Home Address 1-3 Adelaide Road Surbiton Surrey KT6 4TA 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) 0208 399-3388 0208 399 8771 Titleworth Ltd Dorothy Cromwell Care Home 40 Category(ies) of Dementia - over 65 years of age (31), Learning registration, with number disability (9), Old age, not falling within any of places other category (31), Physical disability (9), Sensory impairment (40), Terminally ill (40) Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2005 Brief Description of the Service: Coombe Hill and Blenheim Lodge are situated close to Surbiton town centre. There are good bus and train links to surrounding areas and central London. The home is in a residential area and the River Thames is within fifteen minutes walking distance. The home offers care for persons who have physically disabilities aged eighteen and upwards, within a designated unit. Other categories of care provided for include learning disability, mental disorder and sensory impairment, along with nursing care. There are a variety of activities on offer for service users, such as cinema, shopping and day centres. The home has a heated exercise pool, which is used frequently and benefits from a physiotherapist being employed to supervise and plan appropriate exercises for service users. The home has a landscaped garden with areas where service users can talk with their family and friends in private or enjoy some solitary time. Visitors are welcome at any time. Overnight accommodation can be arranged by prior agreement for visitors. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was to determine if the home had taken steps to meet the ten requirements that were made following the annual (announced) inspection in May 2005. It was pleasing to note that eight requirements had been met, while one was in the process of being actioned. Just two requirements have been repeated, one relates to the medication administration records, where errors were again found, while the other relates to the need to evidence checks of portable electrical equipment. What the service does well: What has improved since the last inspection? What they could do better: A mentioned above, there were again a number of mistakes found in the medication administration records. These were brought to the attention of the manager. The requirement relating to portable electrical equipment has also been repeated, as although steps have been taken to action this requirement, it is not yet fully met. The previous report contained a requirement regarding the length of shifts some staff were working, and also that on occasion staff were working a night shift immediately after a day shift. The rota provided on this visit did not indicate that this latter issue has re-occurred. Staff are still Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 6 routinely working 13 hours shifts however and it is recommended that further consideration be given to this matter. 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. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 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 Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 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): Not assessed on this visit. EVIDENCE: Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 9 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): 9 A number of errors were noted on the medication administration records. This clearly is not acceptable as mistakes with medication can have serious consequences for service users. EVIDENCE: All of the medication charts were examined. A number of gaps were identified, as were a number of instances were staff had clearly overwritten their original entry. This suggests that staff may be signing the charts in advance of medication being given. Improvements in recording are clearly necessary. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 10 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): Not assessed on this visit. EVIDENCE: Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 11 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): 18 Recent revisions to the adult protection procedure means that provided the correct procedure is followed, it should now offer sufficient protection to service users. EVIDENCE: At the last visit it was noted that the homes own adult protection procedure stated that any issues under this procedure would be investigated by the manager. A requirement was therefore made for the procedure to be revised so that it was in line with the multi agency adult protection procedures, as followed by the local Authority. An additional page has now been added to the aforementioned in-house procedure, which states that the local Authority procedure must be followed. While this is satisfactory, it would be helpful if the original procedure could be removed, as it provides conflicting advice, or if the new page could be incorporated into the old procedure, thus replacing reference to the home manager investigating issues. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 12 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 The home was generally well-maintained, and the two requirements made after the last inspection have been dealt with. This means that in this respect, it was felt that the home offered a safe environment for its residents. EVIDENCE: The aforementioned two requirements related to minor repairs that were required to furniture, and a WC that needed repainting. Both these matters have been attended to. A full premises inspection will be repeated at a future visit. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 13 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 It was again noted that some staff work excessively long shifts, which means that it is unlikely that they can provide a continuously good level of service, which in turn means that mistakes are more likely to be made. EVIDENCE: The previous report contained a requirement regarding the length of shifts some staff were working, and also that on occasion staff were working a night shift immediately after a day shift. The rota provided on this visit did not indicate that this latter issue has re-occurred. Staff are still routinely working 13 hours shifts however and it is recommended that further consideration be given to this matter. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 14 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): 33 and 38 Quality assurance systems were in place to monitor the performance of the home. This means that the manager and her team are able to determine where improvements are needed, which results in a service that is being run in the best interests of the service users. Improvements in health and safety measures means that the health, safety and welfare of both service users and staff is being promoted and protected. Once the home can evidence checks on portable electrical equipment then this Standard will be fully met. EVIDENCE: A survey of the views of the service users, relatives and friends and relevant professionals had been recently carried out and the manager was in the final stages of preparing a report for circulation. The responses from service users were positive – 59 of them returned a questionnaire, and in response to Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 15 each of the questions the majority of the residents answered positively. The manager and her staff also regularly carry out a number of other audits, some involving the service users. This enables the staff to determine where improvements can be made, and to gather useful suggestions from service users. The last inspection report contained three requirements relating to health and safety. On this visit, COSHH substances were out of reach of service users, while the premises have now been given an electrical safety certificate. The third requirement related to the need for checks of portable electrical equipment to be evidenced. This is in progress. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 16 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 17 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 OP9 Regulation 13 Requirement The manager must ensure that the medication administration sheets are fully completed at all times. The previously set timescale for this requirement has not been met. The home must be able to evidence that a competent person has periodically carried out safety checks on all portable electrical equipment. The previously set timescale for this requirement has not been met. Timescale for action 31/01/06 2 OP38 13 28/02/06 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 OP27 Good Practice Recommendations Staff are still routinely working 13 hours shifts and it is recommended that further consideration be given to this matter, with a view to shortening the shifts or reducing the number of such shifts that are consecutively worked. DS0000026251.V256491.R01.S.doc Version 5.0 Page 18 Coombe Hill And Blenheim Lodge Nursing Home Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V256491.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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