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Inspection on 16/06/05 for Corbett House Nursing Home

Also see our care home review for Corbett House Nursing Home for more information

This inspection was carried out on 16th June 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.

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

What the care home does well

The original assessments of needs for new residents were comprehensive and ensured the transition from their present environment to the nursing home were as smooth as possible, this ensured aids and adaptations were in place before admission. Residents spoken to felt their privacy and dignity was respected at all times this had been noted in previous inspections as a strength in the home. The home encouraged visits from families and friends and was in the process of organising the annual fete.

What has improved since the last inspection?

Care plan documentation had improved since the last inspection. Medication records policies and procedures were followed and ensured the safe handling and delivery of medication.

What the care home could do better:

Residents or their advocate`s involvement in their care plan documentation needed to be developed. Cross-referencing of care plan documents could be improved. Environmental risks to health and safety of residents were in need of addressing urgently. Protected staff time for activities to ensure all residents were offered a stimulating programme of activities was noted as a shortfall. A more appealing menu with resident participation in the planning would improve the meal service for residents. Protection of the vulnerable adult policies and procedures were not robust enough to ensure protection. Staff needed more specific training to deal with the diseases of old age and dementia to ensure they were properly equipped to carry out the tasks involved in looking after the current resident group.

CARE HOMES FOR OLDER PEOPLE Corbett House Nursing Home 40/42 Corbett Avenue Droitwich Worcestershire WR9 7BE Lead Inspector Chrissy Presley Uannounced 16th June 2005 07:30 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. Corbett House Nursing Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Corbett House Nursing Home Address 40/42 Corbett Avenue Droitwich Worcestershire WR9 7BE 01905 770572 01905 779179 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) Corbett House Limited Miss Donna Hales Care Home 25 Category(ies) of OP Old Age - 25 registration, with number PD(E) Physical Disability (over 65) - 25 of places TI(E) Terminally Ill - 2 Corbett House Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: The home may also accommodate one named person with a physical disability who is below 65 years of age. Date of last inspection 16 November 2004 Brief Description of the Service: Corbett House is a large, detached, Victorian property which has been adapted for its present use as a care home. It is situated in a quiet residential area in Droitwich. The home is registered to provide either personal or nursing care for a total of 25 people over 65 years of age who may have a physical disability. The home may also provide care to a maximum of two people over the age of 65 years who are terminally ill and one named person with a physical disabilty who is below 65 years of age. The residents are accomodated on two floors. A vertical passenger lift is provided. The home is managed on a day to day basis by an experienced registered manager. The aim of the home is to provide a high standard of care in a safe, comfortable and homely environment in which residents are treated with dignity and respect. Corbett House Nursing Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on Thursday morning at 7.30am the inspectors left the home at 11am. The inspectors interviewed ancillary staff, care staff and residents, and time was spent with the registered manager and the operations director of the group This inspection focused on care records, the environment, health and safety issues, complaints and protection and training records. What the service does well: What has improved since the last inspection? Care plan documentation had improved since the last inspection. Medication records policies and procedures were followed and ensured the safe handling and delivery of medication. Corbett House Nursing Home Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Corbett House Nursing Home Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Corbett House Nursing Home Version 1.10 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 standard(s) 3 & 5 The information contained in the original assessment of need contained enough information to ensure new resident’s needs could be met and a care package formulated. EVIDENCE: The care file of a resident who had recently moved into the home was inspected. The information contained in the assessment document was clear and contained enough information to formulate a care plan. There was information contained in the assessment as to the reasons why the resident had not visited the home prior to admission and who had visited on their behalf. It was noted the document was not signed or dated, the registered manager said this was an oversight. Corbett House Nursing Home Version 1.10 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 standard(s) 7,8,9, &10 Care plans contained enough information for care to be delivered safely within a risk framework. Medication policies and procedures were followed. Residents were treated with respect and dignity. EVIDENCE: Four care files were inspected during the inspection. Information contained in care plans did not sometimes cross-reference into other parts of the care plan, which could lead to mistakes with regard to care delivery. Risk assessments were in place and appeared comprehensive although during this inspection the inspectors did not case track a selected number of residents to ensure the care being given was reflected in the care plan. Residents spoken to had not been involved in the drawing up of their care plan or had knowledge of the documentation. Care plans had been reviewed monthly in one care plan the document was comprehensive however in others it stated ‘no change’ which in some instances was not the case. Information was missing in one care plan on how to deal with a residents challenging behaviour. Residents said their privacy and dignity was respected and staff were kind and thoughtful. Corbett House Nursing Home Version 1.10 Page 10 Medication policies and procedures were adhered to, there was evidence in the medication charts that medication codes when a medication was omitted had not been filled in correctly, this could lead to a medication error. There were no discrepancies with regard to controlled medication noted on this visit. Corbett House Nursing Home Version 1.10 Page 11 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) There is insufficient time allowed for the development of social activities, including mealtimes for the comfort of residents within the home. EVIDENCE: The activities co-ordinator told the inspectors she did not have enough time to ensure that residents were offered a stimulating programme of activities on a regular basis. Records of activities on offer were seen and residents told the inspector they had recently planted wallflowers and were involved with the arrangements for the fete. Residents said the food offered was monotonous and the choices for lunch on the day of inspection were either gammon or sliced ham, the inspectors were unsure what the difference was between these items. When questioned the chef said residents could have a salad or baked potato. The day was quite cool and the inspectors felt a salad was not an appropriate choice. The menu on display did not reflect what was available for lunch Liquefied diets were prepared and served appropriately Fridge and food temperature records could not be found on the day of inspection, the chef had been on holiday and it appeared these had not been done during this period. Corbett House Nursing Home Version 1.10 Page 12 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) 16 & 18 The complaints policy and procedure in the home was lacking in clarity and was not user friendly. The policy and procedure for the protection of the vulnerable adult did not reflect the Worcestershire Vulnerable Adult policy and procedure. EVIDENCE: The home did not log all complaints, the complaints log seen had not been filled in since 2003. Residents said they would complain if they felt the need. The policy and procedure provided was not clear to Residents or families. The protection of vulnerable adult policies and procedures were not robust and did not contain telephone numbers of the Worcestershire Vulnerable Adult contact. The information contained in the policies and procedures was not correct and did not contain current information about best practice. Corbett House Nursing Home Version 1.10 Page 13 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) 19,21,22,23,24,25,26 The home provided a comfortable despite there being a number of areas in the home that required attention. EVIDENCE: The home was clean and warm on the day of inspection. The dining room did have a stale smell. A number of environmental issues which compromised residents’ health and safety were discussed with the manager and these are fully documented in the requirements of this report. Corbett House Nursing Home Version 1.10 Page 14 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 & 30 There were not enough staff on duty during the day to ensure that needs of residents could be met. Staff did not have enough training in the specialised need of the residents. EVIDENCE: The inspectors felt with the number of heavily dependent residents currently in the home that three care staff and one registered nurse was not enough to meet the current needs of the residents in the home during the afternoon and evening period. The day shift ended at 8pm and this left one care staff member and one trained nurse on duty to ensure residents were helped to bed when they chose and give drinks and a snack to residents before retiring. Training records seen did not provide evidence staff were equipped to cope with the needs of residents and shortfalls were noted in mandatory training. Specialised training that incorporated diseases of old age and dementia were not being addressed. The responsible individual has informed the Commission for Social Care Inspection that a risk assessment, which meets the current health and safety guidelines, is being developed with regard to Legionella. There were no facilities in the home for the safe keeping of money all residents were invoiced for ancillary items. There was evidence seen in some care plans of furniture belonging to residents. Corbett House Nursing Home Version 1.10 Page 15 Corbett House Nursing Home Version 1.10 Page 16 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) 38 Health and Safety and welfare of residents and staff in the home was not being addressed within a risk framework to ensure their safety. EVIDENCE: The registered manager told the inspectors she was the health and safety officer. She had received training in this field but the inspectors were unsure at what level. It was noted there was no first aider on duty at all times. The hazard warning sheets for spillage of hazardous waste had not been reviewed. There was no environmental risk assessment. Corbett House Nursing Home Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x 2 x x 2 Corbett House Nursing Home Version 1.10 Page 18 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. 2. Standard OP3 OP7 Regulation 14 15 Timescale for action Written assessments that are Immediate undertaken when residents move and into the home must be signed. ongoing Information collated into care Immediate plans must be cross-referenced and to ensure all parts of the care ongoing plan are up to date. Unless it is impracticable 30th august residents or their representatives 2005 must be involved in drawing up their individual plans Monthly reviews must reflect Immediate altered circumstances to ensure and staff have up to date information ongoing about events Residents who display Immediate challenging behaviour must have and a care plan which reflects how ongoing staff deal with these situations Medication codes when Immediate medication is omitted must be an ongoing recorded in the medication record There must be a stimulating Immediate programme of activities which is and appropriate for the current ongoing resident group and staff must be given time with residents. Records of activities must be up Immediate to date and contain information and about what residents preferences ongoing Version 1.10 Page 19 Requirement 3. OP7 15 4. OP7 17 5. OP7 17 6. OP9 13(2) 7. OP12 16 8. OP12 16 Corbett House Nursing Home are 9. OP15 16 Appropriate choices at mealtimes must be offered and menus must be reviewed with resident participation The menu display board must reflect what residents are going to have for lunch Fridge, freezer and food temperatures must be kept and records must be accurate Staff must receive training in the protection of the vulnerable adult Procedures for responding to suspicion or evidence of abuse must be drawn up All complaints must be logged and records kept The complaints procedure must be ammended to include time scales and referral to the CSCI during any stage of a complaint Fire doors must not be wedged open Sani wipes must be provided to ensure food probes can be cleaned after use The fire extinguisher identified during inspection must be tested and replaced if necessary The home must be kept clean and tidy The curtains in the lounge must be re-hung Locks must be fitted to toilet doors to ensure privacy and dignity Cleaning products must be stored appropriately The downstairs toilet must be fitted with a toilet roll holder The lift must be risk assessed for entrapment A key to test fire call point 1 in Version 1.10 30th August 2005 Immediate and ongoing Immediate and ongoing 30th August 2005 30th August 2005 Immediate and ongoing 30th August 2005 Immediate and ongoing Immediate and ongoing Immediate Immediate Immediate 30th August 2005 Immediate and ongoing Immediate Immediate Notice Immediate Page 20 10. 11. 12. 13. 14. 15. OP15 OP15 OP18 OP18 OP16 OP16 16 13 12,13 12,13 22 22 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. OP19 OP19 OP19 OP19 OP19 OP19 OP19 &38 OP19 OP19 OP19 23 13 23 23 23 23 13 23 13 23 Corbett House Nursing Home the home must purchased 26. 27. 28. OP19 & 27 OP19 & 38 OP24 18 13 12,13 Staff must receive mandatory training and this must be kept up to date and records kept Environmental risk assessments must be carried out Residents must be provided with keys to their bedroom doors unless a risk assessment suggests other Residents must be provided with lockable storage space for medication and valuables and a key which he or she can retain unless the reason for doing so is explained in the care plan A programme of fitting thermostatic control valves to wash hand basins in bedrooms must begin immediately Footplates must be attached to wheelchairs at all times Staff must receive dementia training and other training specific to the needs of the current residents The COSHH warning sheets must be reviewed and evidence that a review has taken place The records of residents must be kept secure at all times There must be at least one member of staff on duty at all times day and night who is trained in first aid to at least the level of an Appointed person Staffing levels must be continually monitored to ensure there are enough staff on duty at all times to meet the needs of residents. The cellar door must be closed at all times Notice 30th August 2005 30th August 2005 30th September 2005 30th September 2005 29. OP24 12,13 30. OP19 13 & 38 Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing 30th September 2005 Immediate and ongoing immediate 31. 32. OP19 OP27 13 18 33. 34. 35. OP38 OP19 OP38 13 17 13 36. OP27 18 37. OP38 13 Corbett House Nursing Home Version 1.10 Page 21 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 It is recommended the home engage a twilght shift member of staff Corbett House Nursing Home Version 1.10 Page 22 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7NW 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 Nursing Home Version 1.10 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. 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