Inspection on 25/08/05 for Corbett House

This inspection was carried out on 25th August 2005.

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

Corbett House 01/12/08

Corbett House 30/10/07

Corbett House 20/07/06

Corbett House 28/02/06

Corbett House 25/02/05

Corbett House 06/09/04

Corbett House 22/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Corbett House Piper Place Amblecote Stourbridge DY8 8DF Lead Inspector Mike Kirton Unannounced 25 August 2005 th 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Corbett House Address Piper Place, Amblecote,Stourbridge,West Midlands, DY8 8DF 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) 01384 441885 01384 441885 Mr Billingham, Mrs Jenkins and Mr Anthony Hartland Jenkins Mr Robert Taylor Care Home 11 Category(ies) of Mental discorder, excluding learning disability or registration, with number dementia (11) of places Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th February 2005 Brief Description of the Service: Corbett House is registered to provide residential care services for 11 people aged between 18 and 65 who are experiencing mental ill health. The home aims to enable its service users to return to living independently in the community whilst recognising that some may require longer-term care. Originally built in the 1960’s as nurses’ accommodation it was converted in the mid 1980’s and is managed by the Carlton Care Group in 1993. The home is situated in a cul-de-sac close to Brierley Hill and Stourbridge shopping centres, with good access to all local amenities and public transport networks. Accommodation is provided in 3 units, over 3 floors, each consisting of 3 bedrooms, a dining kitchen, lounge, bathroom and toilet. A further unit designed for greater independence provides two bedrooms with en-suite facilities, lounge and kitchen. Additionally there is a large communal lounge with kitchen area. Car parking is available at the front of the building with gardens at the rear. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours and included interviews with the registered manager, 2 staff members, and 8 of the service users. Additionally 2 staff files, 2 service user files and the medication records were examined. What the service does well: What has improved since the last inspection? 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. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4&5 Improvements have been made to the admissions procedures and the home ensures that potential service users have sufficient information to make an informed choice. Some good examples are available demonstrating that the rehabilitation approach used does work and independent living skills are developed. The manager must ensure all relevant information is received and that care plans and risk assessments are implemented on arrival. EVIDENCE: The home has a statement of purpose and service users guide to provide perspective residents with the information needed to make a choice about whether they would like to live there. This must be made available along with a copy of the standard contact and this inspection report in a suitable format that individuals will understand. Since the last inspection there have been three new admissions. The previous residents have successfully moved onto independent living in supported accommodation. Before a formal offer of a placement is made in writing the homes procedure states that a referral form is required along with any relevant assessments and trial visits are made including an overnight stay. The managers of the home will also undertake their own assessment. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 8 Examination of two service user files contained evidence of a referral form received and assessments being undertaken. Records were made of visits to the home and a letter had been sent confirming that their needs could be met. On one file however there was no Care Programme Approach (CPA) care plan or assessment available. There were also on occasion’s gaps in the information needed including previous hospital admissions and relapse prevention plans. Both files contained a signed copy of the contract including fees payable, terms and conditions and the room to be occupied. Contact information for advocacy groups was displayed on the notice board in reception. Service users spoken to described seeing other alternative residential placements. They had visited Corbett House several times and had stayed overnight before making the decision to move in on a trial basis. Comments received included ‘all my needs are met’, ‘it is like home’, ‘I have many friends here’ and ‘I can do my own thing’. Several had stayed in other care homes and felt more opportunities were now available to them. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not fully assessed on this occasion. Please refer to previous inspection reports. EVIDENCE: Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14&15 Service users gave many examples of their involvement in the community, maintaining contact with family and friends, furthering their education and following their own intersects. The home provides many good opportunities for developing individual’s skills to enable them to return to living independently. EVIDENCE: As previously stated several service users have successfully moved into supported housing schemes since the last inspection. Discussions with service users demonstrated that they were aware of their individual needs and were receiving appropriate support from staff. They also had clear goals as to their future such as moving into their own flat or supported accommodation. Many examples were provided of community activities taking place. There are no restricts in place, unless agreed with the individual, and service users are free to come and go as they wish. Staff accompanied those who required assistance with shopping and were seen assisting with preparing meals and maintaining rooms. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 11 Opportunities are available to attend local day facilities and several had enrolled on college courses. Although no planned activities in the home or group holidays arranged, day outings are planned and encouragement is provided to follow leisure pursuits in the community. Visitors can be seen either in their own room or one of the lounge areas. Service users maintain contact with family and friends in the community and stay overnight as arranged. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The procedures for administering medication were not clear and therefore increasing the risk of an error occouring. Improvements are needed to the current practices to ensure service users receive their prescription correctly. EVIDENCE: The home maintains a record of all medication received which is checked against copies of prescriptions which are held. All returns are also entered into a book and signed be the pharmacist. The storage facility and record of administration sheets were examined. Service users can either have a sealed medic-pack from the chemist or if they are able to self medicate can make up their own pack, or take straight from the prescribed container. There were gaps identified in the records where no entry had been made. The homes policies and procedures did not reflect current practices. It was not clear when medication prescribed only as needed (PRN) should be given. Additionally practices for service users who normally do not self-administer where not clear on what happens when they stay out overnight. A record should also be made if the prescribed time is missed for example if a resident is asleep. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not fully assessed on this occasion. Please refer to previous inspection reports. EVIDENCE: Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not fully assessed on this occasion. Please refer to previous inspection reports. EVIDENCE: Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34&35 Improvements have been made to the homes recruitment and induction procedures however more work is required to ensure staff receive sufficient levels of training in order to carry out their roles safely. Similarly the manager must continue to ensure there are enough staff on duty to meet service users needs. EVIDENCE: Two staff members were interviewed and the staff rota and two personal files were examined. The rota recorded that in addition to the manager who works Monday to Friday 08:00 to 16:00hrs there were two care staff on duty during the day and two during the night, with one sleeping in. This limits the times when service users can be accompanied outside the home and must be continually reviewed to ensure their needs are being met. The risk to the health and safety of staff, service users and visitors must be monitored. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 16 Staff at Corbett House were aware of their roles in the home and had sufficient experience and knowledge of service users needs. Individual staff training programmes have not completed for all employees making it difficult to assess outstanding training needs. Where they have there were several gaps identified. It is important that mental health training is provided as part of the basic induction package for all employees. The Black County Induction programme is now being used for new employees however an example of one in use was not available at the time of the inspection. The homes policy and procedures were also out of date and did not reflect current practices. Potential employees are required to complete an application form and health questionnaire, before being short-listed and invited to attend for an interview. Appointment is subject to successful references and criminal history checks (CRB & POVA). Files examined contained all the required information however a new criminal record check had not been made in one instance. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 Although Mr Taylor demonstrates sufficient skills and experience to manage Corbett House many of the outstanding requirements remain unmet, a few for over 18 months. Action must be taken to meet these to ensure safe practices are carried out at the home. EVIDENCE: Robert Taylor has been the manager of Corbett House since February 2002. Before then he worked for MIND in Birmingham. He is a qualified Social Worker (CQSW) and has an assessor’s award. There is an outstanding requirement to obtain a management qualification. Additionally there have been delays with updating and implementing the homes policies and procedures. Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Corbett House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 19 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 2 Regulation 14,15 Requirement Timescale for action 25/08/05 2. 20 13 3. 20 13 The manager must ensure all assessment information is received including CPA documents, and that care plans and risk assessments are implemented upon arrival. The homes medication policy and 01/10/05 procedures must be updated to reflect current practice. This is an outstanding requirement from the last inspection. All staff responsible for administering medication must receive accredited training. . 25/08/05 The date must be recorded for all medications not administered from the medic-packs. Care plans must be developed for medication prescribed for only when needed (PRN). Any variation to the administration of medication must be recorded for example service users staying out overnight or missing the normal time. Staff must follow the correct procedures for administering medication and there must be Version 1.40 Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Page 20 4. 22 22 5. 24 16,23 6. 7. 34 35 19 18 8. 37 18,19 nor gaps in the records. Correct codes must also be entered. The complaints procedure must be updated and include details on how to contact the Commission. This is an outstanding requirement from the last inspection.. A planned maintenance and renewal programme needs to be introduced for the fabric, decoration, and furnishing of the property. This must prioritise the replacement of the windows. Conifer trees at the rear of the property need to be trimmed in order to allow more light into the rooms. These are outstanding requirements from the last inspection. A POVA & CRB application must be made for the staff member identified. All staff must have an individual training plan showing exactly what qualifications they have, when training was undertaken and when updates are required. The home must have a training and development plan. All staff must have 5 days paid training each year and any training needs met including food hygiene, moving and handling, health and safety, violence and aggression, fire safety, and mental ill health. These are outstanding requirements from the last inspection. A staff induction policy and procedure must be implemented. The Manager obtains NVQ level 4 in management. This is an outstanding 01/10/05 01/11/05 01/09/05 01/11/05 01/01/06 Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 21 9. 39 24 requirement from the last inspection. The home must publish the results of their quality assurance questionarries. This is an outstanding requirement from the last inspection. Policies and procedures relevant to Corbett House covering the topics set out in Appendix 3 are implemented, signed and dated by the manager, with records kept to demonstrate that they have been read and understood by staff. This is an outstanding requirement from the last inspection. 01/01/06 10. 40 12,13,18 01/01/06 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 Good Practice Recommendations Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Mucklow Office Park West Point 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. Extracts may not be used or reproduced without the express permission of CSCI Corbett House E55 S25013 Unannounced Corbett House V245440 250805 Stage 4.doc Version 1.40 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!