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Inspection on 05/09/07 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 5th September 2007.

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 is very well presented to prospective clients both in general appearance and in the excellent sources of information provided. The home provides very person centred personal care in a friendly, homely atmosphere and a very pleasantly maintained environment. Assessment of need and care planning is thorough and relevant to delivering a good standard of care. Staff were observed attending to residents with sensitivity and demonstrated due respect to privacy and dignity. Visitors to the home say that they are always made welcome. Service users that were able spoke well of the meals served, responses on the comment cards mostly said always to liking the meals, one said sometimes.

What has improved since the last inspection?

The organisation has reviewed terms and conditions and now issues an individual copy to both private and funded service users. Care planning and documentation is thorough and involves the service users at all stages of assessment, planning and review. Medication documentation has been improved to ensure all medication can be audit trailed. Staffing numbers across the 24 hours have been reviewed and while this has not changed the allocation aspects of work have been revised to prioritise activity to ensure meeting needs is the first priority. Generally the home has been proactive in addressing previous requirements and recommendations particularly to address issues in regard to the environment.

CARE HOMES FOR OLDER PEOPLE Corbett House Nursing Home 40/42 Corbett Avenue Droitwich Worcestershire WR9 7BE Lead Inspector Mr Richard Eaves Key Unannounced Inspection 5th September 2007 08:30 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.V342748.R02.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 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.V342748.R02.S.doc Version 5.2 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 chris.bradley@redwoodcare.co.uk 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.V342748.R02.S.doc Version 5.2 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. 6th November 2006 Date of last inspection Brief Description of the Service: Corbett House is a large, detached, Victorian property, which has been extended and 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-today 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. The fees at Corbett House currently range from £460.00 to £492.00. Fees do not include hairdressing, chiropody (private) or for items such a newspapers, dry-cleaning and taxis. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information the pre-inspection questionnaire, comment card responses from service users and relatives, records held at the home, including care records reviewed as part of the ‘case tracking’ of three service users and reports from the organisation relating to the conduct of the home. The inspection involved a full tour of the property including, a number of bedrooms, the communal rooms and service areas and provided an opportunity to speak with many of the service users as they were able. Good progress has been achieved in addressing previous requirements. What the service does well: What has improved since the last inspection? The organisation has reviewed terms and conditions and now issues an individual copy to both private and funded service users. Care planning and documentation is thorough and involves the service users at all stages of assessment, planning and review. Medication documentation has been improved to ensure all medication can be audit trailed. Staffing numbers across the 24 hours have been reviewed and while this has not changed the allocation aspects of work have been revised to prioritise activity to ensure meeting needs is the first priority. Generally the home has been proactive in addressing previous requirements and recommendations particularly to address issues in regard to the environment. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 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. The summary of this inspection report can Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 7 be made available in other formats on request. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 8 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.V342748.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5 Quality in this outcome area is good. The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. The most experienced staff undertakes pre-admission assessments and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission. Service users are invited to visit and trial the home before committing themselves to staying at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes statement of purpose and service user guide/brochure are a good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. The service user guide has been reviewed and amended to include terms and conditions fees and room to be occupied. Since the previous inspection the registered manager confirms in writing that the home is able to meet identified care needs following assessment. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 10 A sample of three case files were selected for case tracking these show that a pre-admission assessment is undertaken by the most experienced staff records show that staff liaise with medical staff and relatives to ensure the assessment of need is comprehensive. A further in depth assessment is undertaken at the time of admission and each of these were seen to be completed thoroughly using an activities of daily living approach and clearly identified needs to be developed as care plans. A range of risk assessments were seen and these include a risk reduction plan and were seen to be subject to regular review. Provision for preadmission visits is provided for and evidence was seen that this is taken up where time allows but many admissions from hospital allow little opportunity although most show that families have visited. Corbett House does not provide intermediate care and has no plans to provide such a service in the foreseeable future. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10 Quality in this outcome area is good. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Health care needs of service users are fully met. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of case files were selected at random to be inspected and case tracked. The care plans were drawn from the assessed needs process and were relevant and maintained to a good standard. The care plans reflect actual care requirements detail the actions required of staff. Plans are subject to monthly review and a daily record maintained by each shift. A number of omissions are noted, such as a person assessed with some stress incontinence supported with pads had no care plan therefore was not reviewed to establish improvement or deteriating position. Another receives regular pain relief but Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 12 no care plan and as required medications such as laxatives and analgesia were not supported with care plans. A service user was risk assessed for pressure damage as at high risk requiring intervention to protect the skin, the equipment provided, while proving successful over an extended period, was of low dependency standard without documentation to justify it. The home has a supply of pressure relieving equipment for a range of dependency needs. Continence is promoted with the involvement of professional advice and needs met, other professional advisors are utilised to ensure needs are met such as nutritional advice, tissue viability, speech and language, dental, sight and hearing tests with aids as appropriate. All receive chiropody care and register with a GP of their choice. A previous inspection report noted that care plans had both improved in content and that monthly reviews were taking place, overall good progress continues to be made and a good standard is achieved. A monitored dosage system is used for the administration of medicines provided by a local chemist who also audits the service on a quarterly basis. An inspection of the administration of medication procedure identified that it is administered to a satisfactory level. Medications are stored in locked cupboards records are maintained of medicines received and a contract is in place for disposal of unused medications. Monitoring of room and refrigerator temperatures are undertaken, the medicine refrigerator was in need of defrosting. The current medicine administration record (MAR) provided evidence of drugs being booked into the home and double signing taking place to verify handwritten amendments. The medication trolley was in good order with the date of opening recorded on items not included within the monitored dosage system. The receipt, administration and disposal of Controlled Drugs are recorded in a Controlled Drugs register. Qualified Nursing Staff undertake the administration of medicines. The previous requirement has been met, arising from this inspection used hypodermic needles were seen in the sharps boxes that had been re-sheathed. The induction programme includes a section on treating service users with respect and their privacy is upheld, locks are fitted to all bedroom doors, staff were observed to knock before entering bedrooms and interact in a friendly and open way using the service users choice of name. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15 Quality in this outcome area is good. The home provides varied social and recreational activities that provide interest and pleasure for the residents, suiting their preferences and capabilities. Visitors are welcome and help to keep service users informed about the wider community Many aspects of care evidences that service users exercise choice and control over their lives. Food served is nutritious and well balanced and offers a healthy and varied diet for residents, the menus do not demonstrate the choices available and so deprive some of opportunity.. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two members of staff take a lead in providing activities on a daily basis while the manager and deputy continue to organise trips and visiting entertainers. A list of daily activities was on display in the entrance hall and recorded in a diary completed following events, the manager advises that the programme is flexible to accommodate the wishes of service users on a day by day basis. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 14 The activities notice stated that residents could take Holy Communion within the home in addition to attending a local church on a monthly basis. The records held confirmed that these events took place on a regular basis as advertised. Service users spoken with consider that sufficient social activities are in place within the main lounge. Notices were displayed advertising future entertainments arranged including a singer during the following week. The home has an open visiting approach for any reasonable time and visitors were seen to visit across the day. Visitors are able to use communal areas such as the lounge or dining room as well as resident’s own rooms as they wish. Information regarding a local advocacy service and access to records was on display in the entrance hall. Rooms visited show that service users have their personal possessions with them and in conversation it was clear that service users could decorate and furnish their room as they wished. The home has a four-week menu providing a balanced and nutritious food but the cooks copy seen did not include a choice of meals, supper is included on the daily menu. Special diets such as pureed, soft and diabetic diets are catered for. The manager advised that a choice is always available but on the first day of inspection the meals served were of the menu main or the soft diet option, on the second day an alternative was provided. A liquefied meal seen being fed was not attractively presented but staff giving assistance provided this unhurried and sensitively. No fresh fruit was seen to be offered. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Training regarding safeguarding adults requires to be given to ancillary staff in addition to carers in order to fully safeguard vulnerable persons. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A clear and concise Complaints Procedure is displayed in the entrance hall and included in the service user guide and which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details, one complaint has been received over the year and resolved locally to the complainants satisfaction. Service users spoken with were confident that they would be able to complain if the need arose and would be comfortable to do it. Survey responses asking do you know how to complain, one service user said no and three relatives said no. One relative who answered no said they were “quite sure the staff would be most helpful should we need to complain about anything”. Policies relating to the protection of Residents from abuse were observed to be in place and readily accessible, these included, ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. A flow chart was available to staff in the nursing office. Staff training files indicated that care staff receive training in respect of these Policies, however it was clear that ancillary staff were not Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 16 included in training other than at induction or a risk assessment specifically identified a need. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21,23, 24, 25 & 26 Quality in this outcome area is good. The Home provides a comfortable, attractive, safe and ‘homely’ place to live. Specialist equipment, consistent with the needs of the Residents and the demands of tasks carried out by care staff, is available to facilitate the provision of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Corbett House is a large, detached, Victorian property, which has been extended and adapted for its present use as a care home. It is situated in a quiet residential area in Droitwich and has bedroom accommodation on the ground and first floors consisting of single and double rooms, a small number having en-suite. A vertical passenger lift is provided. Set in pleasant grounds there is a limited amount of parking at the rear. The main outside service user accessible areas are at the rear with a low level patio and a higher garden with gazebo approached by a recently tarmac path that has improved accessibility. The exterior is maintained neatly, on the first day of inspection the clinical Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 18 waste bags were overflowing due to a missed collection, this was resolved the same day at the instigation of management. Internally the home is entered through an alarmed front door into a hallway where the certificate of registration is displayed as is insurance details, the complaints procedure and a notice board with information such as activities and advocacy schemes. A visitors book is also provided and copies of the statement of purpose, service users guide, recent quality audit and the last inspection report. The hallway was pleasantly decorated and had a new carpet. The main lounge was decorated earlier this year with new carpet and continues to appear bright and fresh. The carpet décor and furnishings within the smoking area remains in need of improvement. The ground floor corridor is clean and in good decorative order, however it was observed that lifting and hoisting equipment is provided to assist residents with limited or reduced mobility to be stored in there presenting a potential trip hazard and obstruction of the fire escape route. During the tour of the building it was observed that there are adequate bathing and toilet facilities. Bedrooms are personalised and have been redecorated, each is furnished appropriately although some seemed old and battered one was noted to not have a hot water mixing valve fitted (Room 15) a number had no bedside lights possibly as a matter of choice but this needs to be documented, one example was seen of a bedrail used as a single item, one room had only one double electric socket and doors either had no lock or were fitted with a non approved type. Rooms were seen to have the requisite fittings such as safe radiators and natural secure window ventilation. The sluice is fitted with a sluice disinfector, however the hand wash hot water supply is uncontrolled delivering very hot water preventing the washing of hands under running water. The laundry has a washer with sluice and disinfection cycles, a second washer is domestic and was previously used for personal clothing but is no longer required for this purpose. One dryer is provided, the manager says that the organisation has capacity in other homes to provide a contingency arrangement. Hand wash is within the Belfast sink, which is no longer used for sluice purposes so can be adapted for hand wash but should have a controlled source of hot water. Overall the premises are kept clean, hygienic and free from malodour. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30 Quality in this outcome area is good. Staff are clear as to their individual roles and responsibilities and are sufficient in numbers, well trained, supportive and committed to maximising the service users quality of life. The recruitment practices, staff training and supervision all contribute to ensuring service users benefit from the skills and knowledge of the staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix is sufficient to enable a good service provision meeting the care needs of the Service Users. The Home Manager is in addition to care staff numbers and a full complement of domestic, catering, maintenance and laundry staff are also available through out the day. The number of care staff with a National Vocational Qualification (NVQ) level two or equivalent is now at 64 . A sample of two staff files were inspected, including the most recent appointee and show that recruitment procedures are completed to a good standard with appropriate checks of Personal Identification Number and Criminal Record Bureau in place, it is recommended that where a risk assessment becomes relevant in the process this should be available at the home and shared with Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 20 the Commission. Job descriptions appeared satisfactory for roles and support the underlying values of the home. Staff are subject to a thorough, and relevant, orientation/induction programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘infection control’. In addition, the Home provides for the continuing development of staff, and support staff in undertaking appropriate training based assessed individual training needs. As previously identified in this report ancillary staff do not receive adult protection training Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38 Quality in this outcome area is good. Leadership at the home is good while benefit to the service would be gained by the manager undertaking periodic management training. The home regularly reviews its performance including seeking the views of service users families. Service users financial interests are safeguarded and good record keeping protects the interests of service users. The health safety and welfare of residents and staff is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a first level nurse who has been the manager since 2001, she requires to undertake formal management training either the NVQ level 4, Registered Managers Award or equivalent and demonstrate periodic updating of skills and knowledge. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 22 The home uses the RNHA quality assurance system and undertook a full audit during June of this year. The action plan derived is currently underway and expected to be complete by the end of September. Items included in the plan include fitting privacy locks to bedroom doors, this has commenced but with locks no of an approved type, involve service users in care planning and reviews, evidence was seen of this having been implemented. Service user and staff meetings to be introduced to improve communications, some progress has been made including a Nurses minuted meeting, and a coffee morning arranged for service users, a news letter is being produced. Service users survey and relatives survey have been undertaken and have been included within the quality assurance results. It was reported that the home does not routinely hold money in safe keeping for residents preferring relatives to carry out this function. Expenditure occurred for items such as hairdressing is therefore invoiced to residents representatives Supervision is fully implemented and the content relevant to the continued development of the service. A sample of records required by regulation were viewed and found to be up to date and well maintained. Documentation was seen of a full range of servicing, maintenance and regular monitoring of services and equipment undertaken, staff receive training in health and safety and first aid. Monitoring of hot water is good and records show that the standard of 43°c is achieved consistently. Fire safety including tests, staff training and equipment maintenance were seen to be up to date. Records of all accidents are recorded, using data protection compliant documentation and reported as necessary. The accident reports are not currently subject to audit and filing under individual files. The lack of audit shows that five staff reports while all minor failed to pick up that they all involved the use of hoist equipment. Induction and foundation training is provided to Skills for Care standards that includes health and safety as a topic. Overall the premises were observed to be well managed to meet safety requirements. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 23 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person must ensure that staff stop resheathing of used hypodermic needles. The medicine refrigerator requires to be defrosted to ensure it functions adequately. The registered person must take action to demonstrate that service users receive choice of menu for each meal. Fresh fruit should be made available each day and a means devised to demonstrate this happening. When bedrails are required and following a documented risk assessment the rails must be used in pairs and subject to frequent safety checks. The registered person must take action to confirm that service users and their relatives know how to complain. The registered person must ensure that all staff including ancillary staff receive adult protection training. The responsible person must when appointing staff on the basis of DS0000004105.V342748.R02.S.doc Timescale for action 31/10/07 2. OP15 16 (2) (i) 31/10/07 3. OP8 13 (4) (c) 31/10/07 4. OP16 22(1) 31/10/07 5. OP18 19 31/10/07 Corbett House Nursing Home Version 5.2 Page 25 6. OP19 23 7. OP24 23 8. OP31 9(2) 9. OP38 13 fitness established by risk assessment, notify the commission of the findings. The registered person must remove the hazard of storing hoist equipment in the corridor. The carpet in the smoking room should be replaced with alternative appropriate floor covering. The registered person must ensure that each bedroom is fitted with approved privacy door locks, that each has two accessible double electric sockets and has have a safe supply of hot water. The manager must undertake a relevant management qualification and demonstrate that periodic training is undertaken. 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 This requirement was not met. The previous timescale of 25/04/07 remains. 31/10/07 31/10/07 30/06/08 31/03/08 10. OP38 13 The registered person must audit 31/10/07 accident reports and take action to reduce risk and ensure accident reports are file correctly. 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 Good Practice Recommendations DS0000004105.V342748.R02.S.doc Version 5.2 Page 26 Corbett House Nursing Home 1. 2. Standard OP8 OP26 Nursing staff choosing pressure relief equipment outside the guidance of the assessment tool should document the justification for this. It is recommended that hot water at staff hand wash outlets be controlled to a safe temperature to promote good hand washing practice. Corbett House Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office The Coach House, John Comyn Drive, Perdiswell Park, Droitwich Road, Worcester, WR3 7NW 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 Nursing Home DS0000004105.V342748.R02.S.doc Version 5.2 Page 28 - 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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