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Inspection on 25/10/05 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 25th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 home continues to offer a high standard of nursing care to residents with a physical disability in a homely environment. Residents were heard talking to each other in the lounge and staff were seen and heard talking kindly to them. The home is clean and odour free. The registered manager is well supported by Redwood Care Homes Ltd and the responsible individual who knows the residents well. The quality assurance programme is excellent and resident views are sought, on all aspects of their care needs.

What has improved since the last inspection?

Since the last inspection the home has addressed many of the requirements. The cleanliness of the home has improved since the last inspection. The gardens have been cleared and are now accessible to residents, weather permitting. Care plans of residents now evidence monthly reviews, which reflect changing circumstances.

What the care home could do better:

There continues to be shortfalls in mandatory training for staff. The registered manager is continuing to develop supervision for all staff. Residents have been involved in planning menu`s however lunch on the day of inspection was mince or sausages and supper was soup or bacon sandwiches, these did not appear particularly nutritionally wholesome for frail residents.

CARE HOMES FOR OLDER PEOPLE Corbett House Nursing Home 40/42 Corbett Avenue Droitwich Worcestershire WR9 7BE Lead Inspector C Presley Unannounced Inspection 25th October 2005 10.30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Corbett House Nursing Home Address 40/42 Corbett Avenue Droitwich Worcestershire WR9 7BE 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) 01905 770572 01905 779179 Corbett House Limited Miss Donna Hales Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age of places (25), Terminally ill over 65 years of age (2) Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may also accommodate one named person with a physical disability who is below 65 years of age. 16th June 2005 Date of last inspection 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 disability who is below 65 years of age. The residents are accommodated on two floors. A vertical passenger lift is provided. An experienced registered manager manages the home on a day-to-day basis. 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 DS0000004105.V257664.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the morning and concentrated on standards not inspected at the last inspection and requirements from that visit. Time was spent with the registered manager and the responsible individual; care records, polices and procedures, the accident and fire log book were inspected. What the service does well: What has improved since the last inspection? Since the last inspection the home has addressed many of the requirements. The cleanliness of the home has improved since the last inspection. The gardens have been cleared and are now accessible to residents, weather permitting. Care plans of residents now evidence monthly reviews, which reflect changing circumstances. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 6 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 Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Information in the assessment of need contained enough information to ensure resident’s needs could be met and a basic care plan developed prior to admission. EVIDENCE: The assessment of need document inspected of the most recent admission to the home was filled in appropriately and there was enough information to formulate a care plan. The requirement from the last report regarding signing and dating of these documents had been addressed. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Care plans contained information which enabled care to be delivered safely within a risk framework. EVIDENCE: Care plans inspected had improved since the last inspection and monthly reviews now reflected current changes of all aspects of care. Personal care documentation did not contain enough information to enable staff to deliver care and needed further development to ensure care instructions were specific. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The meal on the day of inspection did not meet the nutritional needs of a frail elderly resident. EVIDENCE: At the last inspection it was noted food offered to residents was not appropriate. The registered manager has since held a meeting with residents and agreed a new menu. On the day of inspection lunch was mince and potatoes with vegetables or sausage and mash, for those who did not like either of these choices there was an omelette. Supper was bacon sandwiches or soup and a choice of sandwiches. This choice of food did not appear nutritionally wholesome for frail residents who may have difficulty with dentures. The registered manager is required to ensure residents receive a nutritionally satisfactory diet at all times. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints policy was readily available for all residents and families and complaints were dealt with immediately. Policies and procedures in place for the protection of the Vulnerable Adult require further development in line with Worcestershire Vulnerable Adult policy and procedure. EVIDENCE: A recent complaint to the home had been dealt with appropriately and a satisfactory outcome for all parties was achieved. The Protection of Vulnerable Adults policies and procedures were satisfactory but were noted to be unclear in the policy folder, parts of pages had been crossed out, and telephone numbers for the Worcestershire Vulnerable Adult team co-ordinator were not readily available to staff. Policies on confidentiality and staff receiving gifts were appropriate and protected vulnerable adults. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Fire records ensured equipment was tested and residents were kept safe. EVIDENCE: The fire logbook was seen and evidenced equipment was tested as necessary to ensure its safe working. The home has residents who smoke and this has been risk assessed. The fire door in the dining room did not close on its rebate. The registered manager could not find evidence of recent fire drills which staff had attended. Fire lectures and fire training for staff are held periodically. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Staff training did not ensure residents were kept safe particularly with regards to moving and handling and other mandatory training requirements. EVIDENCE: At the last inspection the inspectors were concerned about staffing levels in the evenings; the registered manager said she had worked a number of twilight shifts and felt that staff did not have to rush residents and staffing was satisfactory, she continues to review the situation. Training records evidence staff receive a thorough induction programme further developments to ensure a foundation training programme are required. Mandatory training shortfalls were noted in particular moving and handling, fire training (the registered manager said fire training was planned for that evening and she was expecting all staff to attend), food hygiene, infection control and health and safety training. There was not a first aider on duty at all times and this placed residents at risk and has been an ongoing requirement from previous inspections. The home will achieve 50 of staff trained in NVQ by 2006. Recruitment procedures were robust and all staff were only employed following a POVA first and criminal record check at enhanced level. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 & 37 The home has a quality assurance programme, which ensures residents, and other interested parties have their say in how the home is run. EVIDENCE: The home had a quality assurance programme which involved residents, relatives, visitors and professional visitors to the home, the programme looked at what it was like to live in the home and was resident focused. The information was collated into an annual report and made available to all parties including new residents to the home. During the course of the inspection a visitor to the home did not sign in, which creates a fire evacuation risk, if the registered manager is unaware of who is in the home. Information regarding items of furnishings belonging to residents are kept and were seen on the day of inspection. The home continues to work towards lockable space for all residents to keep valuables in their bedroom. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 15 The accident book was inspected and a number of incidents had not been reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 2 X Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 17 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 3 Standard OP7 OP15 OP18 Regulation 15 16 12 & 13 Requirement Personal care needs must be written specifically for each resident so staff can deliver care Meals must be nutritionally wholesome and meet the dietary needs of the frail elderly Protection of the vulnerable adult policies and procedures must be clear and contain up to date information. Fire doors must not be wedged and must be close on rebates. Evidence of fire drills must be kept and open to inspection to ensure all staff have attended fire drills periodically Residents must be provided with lockable storage space for medication, money and valuables and a key which he or she can retain unless the reason for not doing so is explained in the care plan. Staff must have moving and handling training at least once a year The registered manager must ensure staff receive as a DS0000004105.V257664.R01.S.doc Timescale for action 26/10/05 26/10/05 30/11/05 4 5 OP19 OP19 23 23 26/10/05 26/10/05 6 OP24 12, 13 31/12/05 7 OP30 18 26/10/05 8 OP30 18 26/10/05 Corbett House Nursing Home Version 5.0 Page 18 9 OP30 & 38 13 11 12 OP37 OP37 13, 23 37 13 OP30 12, 13 14 OP36 18 minimum mandatory training; infection control, food hygiene, first aid updates, health and safety There must be at least one member of staff on duty at all times of the day and night who is trained to at least. Outstanding from last inspection Visitors to the home must sign in and out of the home at all times Events under Regulation 37 of the Care Homes Regulations 2001 must be reported to the Commission All members of staff must receive foundation training to National Training Organisation specification within 6 months of appointment to their posts. Care staff must receive supervision at least 6 times a year 31/12/05 26/10/05 26/10/05 31/12/05 26/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Corbett House Nursing Home DS0000004105.V257664.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Worcester Local Office 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 DS0000004105.V257664.R01.S.doc Version 5.0 Page 20 - 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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