Inspection on 30/10/07 for Corbett House

This inspection was carried out on 30th October 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Corbett House 01/12/08

Corbett House 20/07/06

Corbett House 28/02/06

Corbett House 25/08/05

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 West Midlands DY8 4DF Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 30th October 2007 09:30 Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 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 Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 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 Adults 18-65. 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. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Corbett House Address Piper Place Amblecote Stourbridge West Midlands DY8 4DF 01384 441885 F/P01384 441885 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) Mrs Jenkins Mr Anthony Hartland Billingham Christine Ann Davies Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2006 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 1960s as nurses accommodation it was converted in the mid 1980s and has been managed by the Carlton Care Group since 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. The statement of purpose was not available and therefore fees could not be assessed. Prospective residents should discuss fees direct with the manager. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection undertaken without any prior notice by two Inspectors. The inspection was carried out between 09.30 and 18.40. The inspection included talking to people who live at the home, talking to staff and the Manager, a general tour of the home and those bedrooms which residents gave us permission to enter, a review of records including information forwarded by the Manager before the inspection and survey comment cards that were completed by people who live in the home and their relatives. Care records were reviewed as part of the “case tracking” of three people who live at the home and two staff records that have been employed since the previous inspection were also examined. Ten of the previous thirteen requirements have either been met or removed as they no longer apply.; Four new requirements were made as a result of this inspection. What the service does well: Corbett House is clean, friendly, welcoming and well maintained and provides homely environment for residents. There is a stable staff team who provide continuity of care for the homes residents. Residents say that they trust staff and have built up good relationships with them, comments received included: ‘The staff are lovely and very patient’ Residents have appropriate and timely access to healthcare and are supported in this by the staff when required. Professionals spoken to also were very positive about the homes. One Professional spoken to said “it is one of the best homes for people with mental health problems in the area”. All prospective residents are able to visit the home several times and also have overnight stays before they come to live at the home. There are no restrictions on visitors to the home within reasonable hours and visitors say that they are always made welcome. Health and safety of the staff and residents is well managed. Required checks on the fire system, emergency lighting and hot water are undertaken. It is also positive that the Manager has a programme for improving the home. There are good systems in place for the safekeeping of resident’s money. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is a need top ensure that the Statement of Purpose and Service User guide are updated. This is must be undertaken as soon as possible as they provide essential about the home including who may benefit form residents at the home. This will also provide staff with direction in the areas that they need to concentrate on for example is the home principle aim to provide rehabilitation for residents? The Manager must ensure that she has all required information available about residents such as a copy of the single care management assessment is available before the person is admitted. The homes cares plans need to reflect the single care management assessment and the residents’ aims. Plans of care need to be improved and ensure that they provide staff with instructions on resident’s needs and how they should be meet and demonstrate that people who live in the home are actively involved in the development of the plan and its review. Risks assessments need to be improved and include actions that are required to minimise the risk to the service user and other people. Staff need to have greater confidence in risk assessments and have the support of other professionals to enable them to give residents an opportunity to take greater responsibility in their life. Medication practice require improvement and crucial to this is the review and removal of the “additional” medication record which is confusing and duplicates the medication record that is supplied by the pharmacist. Current practice increases the risk of medication error. To enable staff and the residents at the home to go forward it is essential that they receive training to increase their understanding of conditions that affect people who live at the home. The Manager also must ensure that before residents that the building is suitable for the prospective residents in relation to its safety and the provision of aids and adaptations when required. The building must also be warm and Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 7 comfortable for residents. Residents should be able to adjust temperature in their individual rooms, as they require. 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. The summary of this inspection report can be made available in other formats on request. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective residents are able to visit the home and have an assessment of their needs before they come to live at the home, although the process could be improved by the availability of up to date written information about the home. EVIDENCE: The service user guide and statement of purpose were not available at the time of the inspection as the manager explained that she was currently updating it, although said that old versions were available. We did discuss the importance of the availability of a service user guide and statement of purpose to give essential information about the home both for existing and prospective residents and their relatives and advocates. It was previously stated that the home provides rehabilitation for people with mental health problems. We were not able to clarify “the aims of the home” and care records seen contained only limited information and no actual development plan on how staff should support and develop residents to become more independent. It was evident that some more able residents were not encouraged to develop skills in areas such as self-administration of medicines. Staff explained that this was due to poor medicine compliance previously but this needed to be developed as part Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 10 of their support programme with agreement with other mental health professionals. People who live at the home have an assessment of their needs before they come to live at the home; generally the composition of these assessments was basic with one word answers that needed to be expanded upon. There was evidence of a multi agency involvement in the resident’s assessment although it was evident that the Care Programme Approach and the single care plan had been not been provided prior to the residents admission to the home. Two residents did not have any Care programme documentation and although it was available for another resident it was not received until six months after the residents admission to the home. The care programme approach is a requirement for people with mental health problems and if available would provide staff with guidance and direction for developing a record of care and support that they require. People who live at the home that we spoke to all confirmed that they were able to visit the home over several occasions and also had an overnight stay before coming to live at the home. People who live at the home all had a contract that detailed the terms and conditions of their residence at the home. There was a need however for them to be more specific about who pays the residents fees as those seen just specified” Social Services”. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to more clearly identify residents needs and provide direction for staff to support residents meet their needs and make decisions about their lives safely. EVIDENCE: All service users have a plan of care. Care plans seen were found to be confusing and frequently duplicated information without providing staff with instructions on residents needs and how they should be meet, comments seen for example were “as finds moving traffic a problem” and “when out sometimes shouts at passers by”, staff were given the instruction to” Monitor the situation carefully” but not did not specify what they needed to do. It was positive that when we spoke to staff they were able to give a good account of residents needs. Although as previously highlighted as the home identifies that it provides rehabilitation there was little evidence within their Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 12 care/ support plan how residents’ skills were being developed and their goals for development. Discussions both with people who live at the home and staff demonstrated that residents are supported to make their own decisions although records need to reflect the decisions that have been made. One resident’s care records identified that she was taking full responsibility for her medicines ordering her prescriptions and giving all her own medicine. Although when we spoke to her she told us that staff give her just one tube of medicines a day and that “staff look after my medicine in a locked cupboard”. Staff also confirmed this arrangement saying that it was the resident’s choice as she felt happier just having a small amount of medicine to look after a day. Care plans did identify some risks to residents but then did not provide instructions for staff to minimise the risk or demonstrate that further risk assessments had been undertaken, for example crossing the road. Key workers do complete a monthly report but generally the records of discussions between residents and staff needs to be improved and residents more actively involved with the planning and development of their care and support and their identifications of their aspirations. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples’ rights to make their own decisions and their privacy is respected at the home. Support is provided to enable them to maintain appropriate relationships and take part in activities in the home and in the community. EVIDENCE: Residents spoken to described their own “routines” which demonstrated that they are encouraged to make independent choices. Residents were seen to and confirmed that they could come and go as they please spending the day where and how they wish, one resident said: “ I enjoy the company but also like to have quiet time in the quiet room or my bedroom “ it can be nice to be quiet”. Residents do their own food shopping and cook their own food some independently whilst others require and are give the support or assistance of Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 14 staff. People that we spoke to said that they cook their own food Monday to Saturday with staff cooking lunch on a Sunday which residents appreciatedwhen asked what the best thing about the home one person said: “Sunday lunch”. There is unrestricted access to all communal areas within the home and residents have their own keys to their bedrooms. Some residents have given written permission for their mail to be opened on their behalf by staff. Care records also asked residents permission for “vote by proxy” although the legality of this should be explored. Support is provided for people who live at the home to maintain appropriate relationships and take part in activities both in the home and in the community. All residents spoken spoke positively about ongoing contact with their family and friends. Residents are given the opportunity to pursue leisure activities both inside and outside the home one resident spoken to said that she goes to Weight Watchers on a Wednesday and sometimes goes dancing. Another resident said he spends his day “working out on his exercise bike and rowing machine”. Residents are also encouraged to maintain links with the local community including reading the local newspaper. A regular outing is planned on Wednesdays. Residents spoken to said that recently they had enjoyed visits to a local large garden centre to see all the Christmas decorations and a trip to Blackpool. One resident said: “ I like living here because of the people who live here and the things that we do”. Discussion with service users identified that they are encouraged to make independent choices and when necessary supported by staff. Several residents spoken to said that they needing to lose weight and discussed healthy eating. It was pleasing to hear that the home has had a tutor to support residents and discuss healthy eating. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to healthcare which is supported and when required facilitated by staff. The home has a flexible approach to promoting independence and encouraging service users to make informed choices. Medication practices require improvement to give assurance that the risk of medication errors is minimised and residents are safeguarded. EVIDENCE: The majority of residents require encouragement with personal care and to change their clothes. Residents spoken to said that staff support them and respect their privacy. Residents confirmed that they get up and go to bed when they wish and choice their own clothing. Residents were seen to have their hair cut in the main lounge by a member of staff. Staff said that they have good support from Community Psychiatric nurses although it was not evident from care plans how much they assisted staff in the development of care plans. Several residents receive regular injections at the local mental health clinic when their mental health is also assessed. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 16 Residents usually visit their GP at their surgery and are able to choose their own GP. People who live at the home have their health monitored and potential complications and problems are identified and dealt with at an early stage. The home does have some good medication practices although generally there is a need for improvement to give greater assurance that residents will be protected from the risk of error. The greatest risk was that staff write medication records sometimes duplicating the existing record. Whilst it is understood why this had been implemented, it is confusing for staff and represents a real risk to residents. There was no record of some medicines that residents had received. One resident has an inhaler but there were no instructions available as staff about the dosage and frequency that the resident should have it, staff had only recorded its administration on a separate hand written sheet and it was not recorded on the medication record sent to the home by the pharmacist. Another resident has an inhaler for breathlessness but when asked where it was kept said: “staff keep it” This may be a need for the safe keeping of his inhaler to risk assessed as there may be an occasion that he needed it in an emergency situation. Another resident had a hand written entry for: “diazepam ½ prn” handwritten but there was no staff signature confirming that the entry was correct and what dosage the resident needed. The secondary medication records were discussed and it was advised that all medicines that residents receive should be recorded on the medication record, there should be no duplicated records and when staff needed to add medicines to the medication record there should be two staff signatures for any handwritten entries to confirm the accuracy of the entry. Staff also need to ensure that they consistently record the amount of medicine that is received into the home. The Manager was also advised to reconsider the practice of returning all unused medication and then reordering the same medication the following month as this is waste of valuable National Health service resources. Staff us the “separate and additional medication record” as a was of recording the running balance of medicine that is given on an “as required basis”. The Manager was advised to look at other ways of doing this as current practice is confusing. Care records do detail what assistance residents need with their medication although when we spoke to residents records did not reflect current practice. Some of the homes residents do administer their own medication but have no separate lockable place apart from the general medication other good practice initiatives implemented n cupboard to store and take responsibility for their own medicines which appropriate care staff can also access with the residents permission. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place to ensure the views of service users are listened to and acted upon giving assurance that residents at the home are protected. EVIDENCE: The home specifies that it operates a zero tolerance in relation to abuse of any kind. A complaints procedure is displayed on the notice board in the reception area and will also be included in the updated service user guide providing residents and family members with information on how to raise concerns if they wish to. The home has received two complaints since the previous inspection, records available demonstrated that an appropriate investigation had taken place and a response was made within the required timescale. Staff spoken to were aware of what constituted abuse and what were signs of abuse. Staff were clear on actions that they would make if any allegations of abuse were made. Inspectors raised concern that one resident was known to frequently ask other residents for cigarettes or money. Staff did not feel that residents were threatened by this and said that if there were concerns other residents would make concerns known on behalf of others. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building is clean but there is a need to ensure that its warm for residents and that it provide aids and adaptations to provide assistance to residents when required. EVIDENCE: The home is clean and comfortable and generally found to be well maintained. The Home Manager confirmed that there is a refurbishment plan for the home. The home has residents bedrooms on each of the three floors with each floor having its own kitchen/dining area, lounge, shower/bath and toilet facilities. On the ground floor there is also a large communal lounge and kitchenette that was continually in use throughout the inspection. The home was found to cold on the day of the inspection and with the heating turned down to the minimum setting. The manager said that was her, as she is usually hot and immediately turned the heating back up. The home must meets residents needs and preferences and not those of the staff. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 19 The home is aimed towards providing semi dependent accommodation for residents who have a mental health problem. The building has little in the way of aids and adaptations which due to the needs of residents is not normally a problem. One resident does have some mobility difficulties and can be unsteady at times, this resident’s room is on the first floor and can only be accessed by two flights of stairs with only a banister on one side for support. There are no grab rails in toilets or showers that might provide assistance to steady this person if required. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. Staffing levels meet residents’ needs whilst they are within the home but there is a need to review this to ensure that residents are adequately supported to go out into the community. A review of training is required to assist staff to develop the support that they provide to people who live at the home. EVIDENCE: There are two staff on duty at all times. The manager works in addition to care staff numbers. The majority of residents are able to go out of the home independently without staff. The Manager confirmed that staff do go out with residents although there were insufficient records to support this and give confidence that staff support and assess residents to minimise the risk of harm to them. It is felt that current staffing numbers would not provide residents with this support or help and may need to be reconsidered. Staff say that they have good training opportunities although a staff development plan that was recommended at the previous inspection is not yet available. There is a high percentage of qualified care staff with 7 of the 9 care staff who have NVQ level 2 or above in care. Staff said that they had not had Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 21 any training about conditions that affect residents at the home. Training in conditions that affect residents is crucial for staff to understand residents needs and problems and develop effective and appropriate plans to support the homes residents and recognise risks that they may be exposed to. Two residents whose care records were reviewed identified that they can be verbally and physically aggressive. Staff said that they had not had training in the management of violence and aggression and de-escalating techniques that they could use to safeguard themselves and other residents if required. Residents spoken to said that they had a good relation with staff and comments such as “ staff are very good and patient” were typical responses received. Staff said that communication within the home is good and that there is always a handover between shifts and that they had staff meetings regularly and that records were available. Recruitment and selection of staff meets the requirements of the National Minimum standards. The Manager was advised of a need to ensure that there is a record of any discussions of employment history, potential gaps in employment and if appropriate an exploration of any criminal conviction. There is also a need for the application form to be more specific of the need to declare any criminal convictions. The manager confirmed that there was a new induction programme but had only recently commenced this and there was no record of this within staff files available on the day of the induction, although there was record of “ the first day induction”. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to monitor the service on offer with a view to continuous improvement and ensure that people who live at the home are listened to. Risk assessments that monitor residents’ health, safety and welfare must reflect risk and actions required to minimise that risk and to give assurance that residents will be safeguarded at the home. EVIDENCE: The home has a new registered manager since the previous inspection, who was previously the deputy home manager for 6 years. The manager said that she is working on a plan for developing the home and recognises the need for improvement in some areas and is working to Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 23 address this. The home has a quality assurance system that is based on the national minimum standards and seeks residents views. An annual questionnaire is due to be sent out shortly with findings of the previous years questionnaire having been shared with all interested parties. There are regular residents meetings but staff also meet with residents individually to discuss any issues or concerns that they may have. Residents are encouraged or supported by staff to handle their own finances. Residents are given £29 a week towards their food as they shop and cook their own meals six days a week. There were appropriate records of the money that had been given to residents towards their food and day to day living expenses are appropriate and are signed both by the residents and a member of staff money is all kept individually with each resident having their own plastic wallet. Records seen evidenced that staff receive supervision at the required frequency. Staff also said that they are supported by the manager. Risk assessments to highlight everyday risks to residents such as crossing the road were insufficient and generally poor. These risk assessments did not reflect the risk and actions that are required to be taken to minimise that risk. Health and safety of the staff and residents is well managed. Required checks on the fire system, emergency lighting and hot water are undertaken. Two bath temperatures were found to be a risk to residents and the manager agreed that she would address this immediately. All equipment is serviced regularly. Required risk assessments for fire and food were also available. Staff undergo health and safety, moving and handling, fire, food hygiene and first aid training on a regular basis. Policies and procedures to do with conduct and management of the home, together with all risk assessment procedures are in place. Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 1 2 1 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 2 30 3 STAFFING Standard No Score 31 x 32 1 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 1 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 x 2 x x 2 x Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 25 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 YA42 Regulation 23(4)(e) Requirement All Staff must be involved in a fire drill at least twice a year. This is an outstanding requirement from the 1st April 2006. Staff do have fire drills but there is no record of who attends just the number of staff and therefore there is no assurance that this requirement was met. A letter of immediate action has been sent to the home in relation to this matter. 2 YA1 4 The statement of purpose and service user guide must be updated and available within the home to provide essential information about the home for both existing and prospective service users. The manager must ensure service users’ care plans are amended to reflect changes in care needs. The timescale of the 7/11/06 was not met and the Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 26 Timescale for action 30/11/07 30/11/07 3. YA6 15 30/11/07 timescale has been extended. 4. YA9 12 Residents risk assessments must include actions that are to be taken to minimise the risk to the resident and must be updated regularly. The timescale of the 7/11/06 was not met and the timescale has been extended. There must be safe and robust arrangements for the recording, handling, safekeeping and safe administration of medicines that minimise the risk to residents. The home is kept warm and comfortable for residents. Aids and adaptations such as grab rails are available to both maintain residents independence and safety. 30/11/07 5 YA20 13(2) 30/11/07 6 7 YA24 YA29 23 (2)(p) 23(2)(n) 31/10/07 30/11/07 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 YA2 Good Practice Recommendations A copy of the single care management assessment that is integrated with the Care Programme Approach (CPA) should be available before agreement is made that the home is suitable to meet a prospective residents needs. The manager is advised to regularly review the details contained in each service user’s contract/statement of terms & conditions Care records should include discussions held with individual service users A review is undertaken of what medicines are being self administered by residents and how medicines that are being self administered by residents are being stored. Suitable strategies should be explored to ensure all service users are protected from abuse from other residents. DS0000025013.V354186.R01.S.doc Version 5.2 Page 27 2 YA5 3 4 5 YA7 YA20 YA23 Corbett House 6 YA32 7 YA35 Staff must receive training on conditions that affect residents who live at the home to give them greater understanding of their needs and support and assistance that they may require. All staff should have appropriate client-centred care planning training that reflects the needs of people who are mentally ill. The home should have a training and development plan. All staff should have at least 5 days paid training each year. It is also recommended that all staff have an individual training plan showing exactly what qualifications they have, when training was undertaken and when updates are required. 8 YA35 Corbett House DS0000025013.V354186.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000025013.V354186.R01.S.doc Version 5.2 Page 29 - 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. 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