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Inspection on 06/11/06 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 6th November 2006.

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 general atmosphere within the home was welcoming throughout this inspection. Open visiting is in place to encourage contact with family and friends. Information is available regarding the services offered within the home. Pre admission assessments are taking place as required. Staff were observed attending to residents kindly and demonstrated due respect to privacy and dignity. Residents spoke highly of all staff members. Activities are provided for residents although the recording of such was somewhat limited. The registered persons have a good understanding in relation to the reporting of any concerns regarding poor or abusive practice to the necessary agencies including the CSCI. The complaints procedure is displayed. The grounds to the front of the home are well maintained. The registered manager continues to be well supported by Redwood Care Homes Limited; it was evident that both the responsible individual and the quality assurance manager know the home and the residents well. A well developed quality assurance tool is in place whereby the standards are assessed for compliance.

What has improved since the last inspection?

Following the last inspection the number of requirements from the inspection prior to that had reduced. Evidence that some of other requirements are now either met or partly met was seen during this inspection.

What the care home could do better:

Information available to residents regarding fees and the nursing contribution needs to be available to current and prospective residents. Care planning and associated risk assessments lacked sufficient detail or updating, and therefore are in need of attention to fully ensure that care needs can be meet in a consistent manner. Risk assessments need to be reviewed following any incidents involve individual residents such as following a fall. Bumpers need to be fitted to bedsides to prevent the risk of entrapment.Although the majority of medication administration sheets were completed satisfactorily some concerns were noted and needed attention regarding recording and practices around the communal use of some medication. The auditing procedures were in need of improvement. The proposed review of menus and dietary provision should take place especially in relation to the current tea menu. The provision of early morning drinks and staff availability also needs reviewing. A further review is necessary regarding evening staff and the preparation of residents tea. Shortfalls were discussed in relation to the recruitment procedures within the home. Any complaints received need to be recorded along with the investigation and the findings. Some staff need to attend training in relation to safeguarding vulnerable adults. Some improvements to the overall environment are needed in particular some carpets, a fire door and lighting. In addition a review of issues regarding the smoking area needs to take place. Some risk assessments regarding environmental issues are required. The quality assurance manager was aware of some shortfalls in training in relation to moving and handling, infection control and first aid.

CARE HOMES FOR OLDER PEOPLE Corbett House Nursing Home 40/42 Corbett Avenue Droitwich Worcestershire WR9 7BE Lead Inspector Andrew Spearing-Brown Unannounced Inspection 08:40 6 and 9 November 2006 th th 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.V304697.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 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.V304697.R01.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 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.V304697.R01.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. 25th October 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-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 pre inspection information received by the Commission during August 2006 stated that fees at Corbett House currently range from £458.00 to £473.00; the Registered Manager at the start of this inspection confirmed these figures. Charges / fees do not include hairdressing, chiropody (private) which are charged by the hairdresser / chiropodist or for items such a newspapers, dry cleaning and taxis. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of any inspection carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at Corbett House two visits to the home were undertaken. The visits to the home were unannounced and lasted a total of 13 hours commencing at 8.40 a.m on the first visit and 8.00 on the second visit. The last statutory visit to the home, which was also unannounced, took place during October 2005. This inspection takes into account information received by the CSCI since the previous inspection as well as the visit to the home. Prior to the visit a pre inspection questionnaire was posted to the manager requesting certain information. The inspector received the completed document prior to the inspection. In addition to the pre-inspection questionnaire a number of questionnaires were also sent to the home for residents, relatives and other persons to complete. A total of 3 residents questionnaires, which appeared to be completed on behalf of residents by either staff or their family were returned to the CSCI prior to the inspection. None of these questionnaires were signed by neither the resident or included their name. In addition a small number (2) comment cards were returned from relatives / visitors. No comments were received from any others persons. At the time of the visits to Corbett House the home had 3 vacancies. A partial look around the home took place concentrating primarily on communal areas and facilities. The care documents of a sample number of residents were viewed including care plans, daily notes, risk assessments and accident records. Other documents seen included medication records, some service records and some staffing records. Due to personal reasons the registered manager needed to return home during the morning of the first visit and was taking leave during the second visit. The responsible person attended for part of the first visit and the organisations quality manager was present throughout a sizeable part of the visit. In addition to the persons mentioned above discussions took place with two trained nurses, two carers and the cook. Discussions took place with a number of residents throughout the inspection and one relative. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Information available to residents regarding fees and the nursing contribution needs to be available to current and prospective residents. Care planning and associated risk assessments lacked sufficient detail or updating, and therefore are in need of attention to fully ensure that care needs can be meet in a consistent manner. Risk assessments need to be reviewed following any incidents involve individual residents such as following a fall. Bumpers need to be fitted to bedsides to prevent the risk of entrapment. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 7 Although the majority of medication administration sheets were completed satisfactorily some concerns were noted and needed attention regarding recording and practices around the communal use of some medication. The auditing procedures were in need of improvement. The proposed review of menus and dietary provision should take place especially in relation to the current tea menu. The provision of early morning drinks and staff availability also needs reviewing. A further review is necessary regarding evening staff and the preparation of residents tea. Shortfalls were discussed in relation to the recruitment procedures within the home. Any complaints received need to be recorded along with the investigation and the findings. Some staff need to attend training in relation to safeguarding vulnerable adults. Some improvements to the overall environment are needed in particular some carpets, a fire door and lighting. In addition a review of issues regarding the smoking area needs to take place. Some risk assessments regarding environmental issues are required. The quality assurance manager was aware of some shortfalls in training in relation to moving and handling, infection control and first aid. 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.V304697.R01.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.V304697.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 4. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The documentation supplied to residents and or their representatives regarding fees and the nursing contribution needs to be improved in line with recent changes in regulations. An assessment of care needs is carried out prior to admission although written confirmation of the homes ability to meet identified care needs is lacking. EVIDENCE: A copy of the service users guide was available near to the visitors signing in book. Neither the service users guide nor the statement of purpose was viewed in any detail during this inspection; any amendments to these documents need to be forwarded to the commission. In addition to the service users guide a document was on display giving the results of the most recent survey of residents, relatives and GP questionnaires. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 10 A copy of the homes terms and conditions is included within the service users guide. This document needs to be reviewed due to changes made to the Care Homes Regulations, which came into force on the 1st September 2006. As a result of the changes to regulations further information now has to be supplied to residents including matters regarding the nursing contribution payment. The file of a recently admitted resident contained an initial assessment as well as a document entitled residents record. The residents record comprised of more details following the initial assessment document, together these documents are able to encapsulate sufficient information providing they are used to their entirety. The initial assessment seen was completed prior to the admission while the residents record was completed on the day of admission. The inspector saw no evidence that the registered manager confirms in writing that the home is able to meet identified care needs following assessment. 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.V304697.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and associated risk assessments lacked sufficient detail or updating, which can potentially place individuals at risk. The provision of full and accurate documentation can assist in ensuring that care needs are met in a consistent manner. The management of medication was insufficient in some areas and in need of improvement. EVIDENCE: The previous inspection report stated that care plans had improved and noted that monthly reviews were taking place, which reflected the changing care needs of residents. The report did however state that documentation failed to contain enough information to enable staff to deliver care and therefore meet identified care needs. As part of this inspection a representative sample of care plans, risk assessments, daily notes and associated documents were viewed. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 12 Each file contained a range of documents, all of which were easy to read as well as a photograph of the resident concerned to afford easy recognition should it be needed. The files contained a sheet entitled ‘Daily Routine’ – which gave a brief pen picture of each resident; those seen needed further details adding in places. The daily records seen were generally sufficient in their detail to demonstrate either how care needs were met or events which had occurred during each shift. On a number of occasions no entries were evident within the daily notes; on one particular event this omission prevented a trail of events being explored. The accident records of a number of residents were viewed in detail. It was noted that the fall risk assessments were not reviewed following incidents. The auditing of accidents was not taking place and therefore no systems were in place to establish any patterns or common themes in accidents. As a result of the shortfalls in auditing of falls no preventative measures were evident to reduce further incidents. Accident forms were used to record bruising however the records were insufficient to demonstrate that reasons were suitably investigated and preventative measure put into place. A lack of bumpers on bedrails was a cause for concern and brought to the attention of the quality manager due to the potential entrapment hazard to residents. As part of the inspection the management of medication was assessed. In order to carry out this assessment the storage and recording of medication was examined including the current months Medication Administration Record (MAR) sheets. The majority of MAR sheets were found to be satisfactory. On one MAR sheet checked the number of signatures against a course of antibiotics balanced with the number of tablets prescribed. Each of the MAR sheets viewed showed any known allergies; where none were known this information was recorded. Amendments to the MAR sheets were double signed as needed. A photograph of each resident preceded their medication record to ensure recognition if needed. The storage of medication including controlled medication was in line with the required standard. A small stock of medication is held elsewhere, no over stocking was evident. The controlled drugs book was completed satisfactorily and the balance recorded was found to match the amount of medication held. The keys to the medication trolley were held with the trained member of staff working the shift. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 13 Concern was however noted regarding some elements of recording and administration of medication, which were discussed at the time of the inspection with the quality manager and the trained nurse on duty. On two occasions medication was recorded as ‘O’ – out of stock. This was of concern as not only did it appear that medication was not administered as prescribed but a box of medication within the trolley was dated prior to when this recording took place indicating that the medication was available. On occasions the code ‘O’ was used without any definition as to why the code was used and why the medication was omitted. It was evident that a liquid medication was used communally rather than using each residents own prescribed supply – this practise was of serious concern and required immediate action to address. The practise in place would make an audit of medication held difficult to undertake. The majority of medication was booked into the home however on occasions this was not the case. Staff were not recording the date when boxed medication (not included within the monitored dosage system) was opened therefore making a full drug audit difficult. When medication was prescribed on a variable dosage the actual dose given was not always recorded. A list of specimen signatures of those authorised to administer medication was not in place. The quality assurance manager is aware of a shortfall in relation to staff training upon medication management. Verbal assurance of improvement as required was given at the time of the inspection by the quality manager in order to fully safeguard residents against potential medication errors. Observations throughout the visits to the home demonstrated that staff treat residents with respect and give due consideration to the upholding of residents dignity while delivering personal care tasks. Reference to the time residents wake and get up each morning is included elsewhere within this report. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 14 The home does not have a payphone for residents use; however the use of the office phone is permitted. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records available evidenced that activities are provided. Improvements and further reviewing of the menus needs to continue to ensure that residents have a fully balanced and nutritious diet. EVIDENCE: A list of daily activities was on display in the entrance hall. This was crossreferenced against a diary completed following events, which had taken place and found not to match. 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. One resident consulted made reference to the input from local churches. Two members of staff have a few hours per week dedicated to the providing of activities within the home. Residents and the majority of staff consulted believed that sufficient social activities are in place for residents residing within the main lounge. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 16 Records viewed demonstrated that 11 events took place during October 2006 including board games, quizzes and an entertainer visiting the home. Prior to the last inspection a new menu was introduced into the home. Some concern was noted regarding the nutritional value of the menu and the home was required to provide meals, which are nutritionally wholesome. The inspector was informed that the cook from another home was currently devising some new menus and suitable recipes to be used across the company. On the first day of this inspection the mid day meal was either sausage and mash or poached fish. The vegetables used were frozen as the intended fresh item had gone off. No fresh fruit was available. The inspector was informed that fresh vegetables were used and roasted as part of the main meal on the day of the second visit. Positive feedback was received regarding the meals provided although the planned review of provision needs to continue especially in relation to the teatime menu. One relative joined a resident while having a meal. Staff were briefly seen assisting residents with their meals in their bedrooms; this seemed to be carried out appropriately. Residents reported that drinks are available throughout the day. Jugs of squash were in the lounge. The quality assurance manager undertook to review the availability of hot drinks upon residents waking in the morning. Reference to the time residents wake and get up each morning is included elsewhere within this report. Visitors are able to visit at any reasonable time. 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. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 17 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): Standards 16, 17and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered persons need to ensure that residents representatives are aware of the homes complaints procedure and that staff who have not undertaken training regarding safeguarding adults attend in the near future in order to fully safeguard vulnerable persons. EVIDENCE: Corbett House has a complaints procedure, which was displayed in the hallway. The procedure is clear and included the address of the Worcester office of the commission should anybody wish to raise any matters of concern with the regulator. In addition a notice close to the front door states that should persons have any concerns then they should ‘ see the person in charge.’ In response to a question upon the quality assurance questionnaire forwarded to a sample number of relatives ‘ Do you know how to complain? ’ 30 stated ‘Yes’ while 70 stated ‘No’. The commission has received no complaints in relation to Corbett House. The quality manager was aware of one complaint since the last inspection regarding the laundry. No record regarding the complaint, the investigation or the outcome reached was included within the complaints log. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 18 The quality manager was aware that residents have in the past received voting cards or postal votes. One resident confirmed that she would be able to vote in an election if she desired. The home has a procedure regarding the reporting of adult abuse. This was discussed at the time of the inspection and found to be in order with the exception of one minor area. A copy of a recently issued booklet issued by the local authority was held with the procedure. The name and contact details of the adult protection coordinator employed by Worcestershire Adult Service was displayed within the hallway. In discussion with the quality manager it was evident that the registered persons would take any allegations of abuse seriously and would refer any concerns to suitable agencies such as the commission, adult protection, the police and the Department of Health’s Protection of Vulnerable Adult (PoVA) list. A number of staff including trained staff were consulted about the action they would take regarding actual or alleged abuse. The responses were generally satisfactory. Some staff have not attended training regarding the safeguarding of vulnerable adults. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 19 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): Standards 19, 20, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements regarding the environment need to continue in order to provide residents with a comfortable place to reside where care needs can be met. EVIDENCE: Residents accommodation is located on both the ground and first floor; a passenger lift is provided to afford accessibility to these areas. The home has a total of 14 single bedrooms (2 with en-suite facilities) and 4 double bedrooms. Lifting and hoisting equipment is provided to assist residents with limited or reduced mobility; the lack of storage is however a concern and means that equipment is ‘parked’ in a corridor, which could be a potential trip hazard. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 20 The carpet in the smoking room / lounge is dirty and stained and requires either a considerable deep clean (which may not bring about the desired outcome) or replacing. The carpet in the main lounge is showing signs of fading. The ‘smoking room’ area appeared untidy. A trolley storing residents mugs and tea / coffee making provisions had a vinyl covering which was dirty, stained and split. It was noted that the trolley had a new vinyl covering in place by the time of the second visit. The furniture within the smoking room is older than the seating within the main lounge. The smell of cigarettes drifts from this area into the corridor. As the hatch to the kitchen has no covers smoke is likely to drift into this area where food is prepared and staff are working. The main lounge was adequately furnished however some items such as pressure relieving cushions and tables, which can be placed over chairs, were damaged. A dining room is provided although it is not large enough to cater for all residents should this eventuality be needed. One bathroom (reported not to be used) contained items such as a wheelchair, a walking frame and a carpet shampooer making the area appeared cluttered and unwelcoming as a bathing area. Future use of this room needs to be reviewed to improve the bathing facilities within the home. A recently decorated bathroom near to the managers office had the blind / curtain missing from the window which potentially compromised residents privacy and dignity. It was noted that due to the use of low energy bulbs the lighting within communal facilities was initially dull until maximum illumination was reached. Although some of the downstairs bedrooms had a lockable devise fitted to the door they were not suitable in that access could be gained via means of a coin. Upstairs bedrooms do not have locks fitted. Care plans do contain reference to door locks indicating that individuals either do not want a lock or were assessed as incapable of using such a facility. The lack of a door lock does however remove the right of residents to privacy and dignity within the home and the current stance of providing only if requested should be reconsidered. A number of bedrooms seen contained a range of personal belongings. As Corbett House was an ‘existing home’ prior to the introduction of the National Minimum Standards some of the standards are not applicable such as the size of single bedrooms. It was reported that all radiators that are in use are covered to prevent accidental scalding. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 21 No offensive odours were noted during this inspection (other than the smell of cigarette smoke apparent in the area around the smoking lounge). One relative stated upon a comment card received in advance of this inspection ‘The home is kept clean’ The laundry is located in the basement of the home; a coded locking devise is fitted to the door to prevent unauthorised people accessing this area. It was reported that only one washing machine (which has a sluice facility) was currently working, as a domestic style machine was out of order. No risk assessment was in place regarding the sluicing of commodes. Although this inspection took place during the earlier part of the winter the grounds to the front of the house were well maintained. A lawned area is provided at the rear of the home however this area is raised and can only be reached by either steps or a slope, which is both uneven and unsuitable for older persons. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures were found to have a short falling, which can potentially place residents at risk. A review of staffing levels needs to take place to ensure that suitable and sufficient numbers are on duty at all times in order that care needs are able to be met. EVIDENCE: It was evident from a number of sources that the morning shift is covered by five carers and one trained member of staff while the afternoon shift has three carers and one trained. Other staff are employed during the morning including a floor domestic, laundry assistant and a cook. The last inspection report stated that the registered manager had worked a number of evenings and that she believed staffing levels to be satisfactory. As the registered manager was unable to be present during the majority of this inspection it was not possible to check this opinion out following any subsequent review. Carers working on the afternoon shift need to finish off the preparation of the residents tea. This brings about a couple of concerns and therefore needs to be reviewed: Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 23 A reduction in care staff available to care for residents while a carer is deployed in the kitchen Infection control and cross infection concerns if persons carrying out personal care tasks also carry out tasks within the kitchen. The night shift commence work at 8.00 pm working until 8.00 am the following morning. A previous inspection report highlighted some concern regarding the number of staff on duty at night as staffing levels are reduced to one trained and one carer. The inspector was informed that staff start getting residents up from 6.00 am onwards should they be awake and wish to be up. Due to the dependency levels of residents a further review of staffing levels is needed. The daily routine documentation held in relation to each resident failed to give sufficient detail of residents preferred bedtime and time of getting up. The registered persons must be confident that getting residents up from 6.00 am onwards is in line with residents wishes and best practice and not for the connivance of staff. The use of agency staff was reported to be rare. Four carers, hold an NVQ (National Vocational Qualification) level 2 with one of these persons also holding a level 3. The organisation is aware that this level of trained staff falls short of the expectation that 50 of carers would have achieved a level 2 by the end of 2005. Therefore accounting for 33 of the carers. Additional carers have recently registered for this training and will be commencing in the near future. A new induction training programme was recently introduced which is believed to be in line with the standards set by Skills for Care. As this programme has not yet commenced with any employee it will need to be assessed as part of future inspection visits. The staff records of two recently appointed employees were looked at. Areas of good practice in relation to recruitment were noted such as the taking up of a PoVA (Protection of Vulnerable Adults) first check and a CRB (Criminal Records Bureau) disclosure. Application forms and contracts of employment were held on file. A number of areas of some concern were discussed at the time of the inspection as follows: An employee who is viewed as a minor (under the age of 18 years) had no risk assessments in place in relation to the job held. Although evidence of telephone references was in place written references were not in place prior to the commencement of employment. One person did not have a second written reference in place until 4 months after the start of employment. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 24 A training matrix was on display within the manager’s office. A number of shortfalls in training were identified although the majority of staff have attended mandatory training. References to the shortfalls in training identified are included elsewhere within this report. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 25 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): Standards 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has extensive experience although lacks the required management qualification. Staff supervision systems although in place need to be improved. The quality systems in place are good. Some health and safety matters need addressing, to safeguard residents. EVIDENCE: Due to personal circumstances the registered manager needed to return home during the morning of the first visit of this inspection. As a result the standards associated to the manager will be fully assessed as part of forthcoming inspections at Corbett House. Registered managers were expected of have two qualifications prior to 31st December 2005 relevant to the care they are responsible for. In the case of Corbett House these qualifications would be a registered nursing qualification with a live registration and a Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 26 qualification in managing care services. There is a specific National Vocational Qualification (NVQ) level 4 to cover the management requirement – Registered Managers Award. Although the registered manager is a qualified nurse she does not hold the management award. The certificate of registration was displayed in the hallway. The single condition of registration regarding one named resident remains current. The need to remove the category of registration ‘Terminal illness’ was discussed, as this category no longer exists following confirmation from the Department of Health that the category is not required in order to admitted residents with palliative and or end of life care needs. The quality assurance manager confirmed that both a business and financial plan are held at head office, which would be open to the commission, should they be required. A certificate of public liability insurance was on display. Residents personal belongings are insured up to the sum of £500.00. 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. The National Minimum Standards state that care staff receive formal supervision at least 6 times a year. These sessions should cover: all aspects of practice philosophy of care in the home career development needs Although it was evident that supervision is taking place this was not as frequent for some staff as it was for others and needs to be improved. The quality manager present during the inspection believed that this standard will be achieved in the near future as a trained nurse takes on the role of supervising staff in addition to the registered manager. The quality manager has carried out an extensive review of the service offered at Corbett House responding as to whether the home is compliant or part compliant. The document seen showed that the quality manager had found most areas to be ‘compliant’. The document shows identified shortfalls and the action taken to address these shortfalls. The organisation regularly carries out surveys amongst residents, relatives / representatives and GP’s to gain feedback regarding the level of service offered within the home. The results of these questionnaires are made available and were on display. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 27 The responsible individual is required to visit the home on at least a monthly basis and prepare a written report to the manager. These reports must be available on request to the commission; although these visits are taking place the reports from the last three months were not on file. Staff and resident meetings are currently not taking place and therefore no minutes were available. The commission has received notification regarding events within the care home as required under Regulation 37. As reported elsewhere within this report it was evident that some records are not sufficiently detailed to ensure effective and efficient care planning takes place. No policies and procedures were viewed during this inspection; these will form part of future inspections at Corbett House. The majority of staff have received mandatory training including moving and handling and fire training. The quality manager is aware of shortfalls in relation to the training attended by some staff and stated that action is in hand to ensure the required training takes place. Some staff need to undertake infection control training and basic food hygiene up date training. Refresher training for moving and handling is required for some staff. Although the majority of trained and care staff have attended a basic first aid course nobody holds a full first aid certificate. The fire records were viewed and demonstrated that fire drills and fire simulations to form part of staff training have not taken place as needed. The majority of staff received fire safety training during October 2006. The fire log was generally satisfactory it was however noted that a list detailing the locations of fire extinguishers was not in place. The quality manager informed the inspector that a review of the homes fire risk assessment has recently taken place. The newly completed document was available on the second day of this visit. It contained instructions in relation to the practice of wedging open fire doors, which was in direct conflict with actual practice within the care home. The inspector advised that the responsible persons review current fire procedures, practices and risk assessments in light of the recently introduced Fire Safety Order. It was noted that some bedrooms doors do not have intumescent seals furthermore the door leading into the dining room is free swinging and therefore not linked to the fire alarm system, these matters need either referring to the fire officer or including within the fire risk assessment. The dining room door was not closing into its rebate sufficiently and in need of attention. At the start of this inspection a plastic bucket containing cleaning materials including bleach, toilet cleaner and washroom sanitizer was left unattended within the smoking room / lounge. At least one bottle contained a warning Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 28 that the product was ‘irritating to eyes and skin’. This bucket was later removed however it was of concern that these items were left insecure for a period of time in any area where residents could of accessed them. An Environmental Health Officer (EHO) from Wychavon District Council visited Corbett House recently. A number of shortfalls were noted primarily around mainly regarding areas that needed to be cleaned such as some louver doors, tiles and the floor. These areas were reported to have been cleaned following the EHO visit. Other areas highlighted included the need for fly screens and replacement of shelving in a ‘fridge. The temperature records regarding ‘fridge and freezers and hot food were satisfactory. The records regarding the calibration of the food probe were not available for inspection. The majority of records regarding the safe maintenance of equipment and services were not viewed on this occasion. On the door of each bedroom a checklist is displayed which shows water temperatures and whether the window restrictor is in order. The safe storage of water was discussed and although chlorination of water tanks has not taken place water samples are reported to be sent off and found to be satisfactory. Environmental risk assessments are in place one was needed in relation to a potential trip hazard in a bedroom. A current gas landlord safety certificate was not available as the servicing was overdue. The quality assurance manager undertook to ensure that the necessary action took place and agreed to forward a copy of the certificate once available to the commission. The quality manager believes that all pipe work and functioning radiators are suitably boxed in to prevent accidental scalding. Accidents are recorded on appropriate forms in line with Data Protection legislation although concerns regarding the auditing and monitoring of accidents are referred to earlier within this report. The quality assurance manager is aware of the circumstances / events that have to be reported to the commission under Regulation 37 of the Care Homes Regulations. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 29 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 2 2 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 2 X X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 3 2 2 2 Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 30 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 OP1 OP2 2 OP4 14(1)(d) Regulation 5A 5B Requirement The Service users guide and the homes terms and conditions / contract must be amended in line with recent changes to the Regulations A letter confirming the homes assessment and the ability to meet care needs must be sent to potential residents or their representative. Timescale for action 31/01/07 31/12/06 3 OP7 15 (1) Residents care plans and daily 31/12/06 notes must contain sufficient up to date detail to ensure that carers are able to meet identified care needs. Residents records must be maintained to ensure that an accurate account of events is in place and that these are able to be cross referenced against other records. These events include falls and fall prevention. 31/12/06 4 OP7 OP8 15 (2) Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 31 5 OP8 12(1) Risk assessments regarding 31/12/06 residents care must be in place and reviewed following events/ incidents, concerns or changes in circumstances. 6 OP8OP38 13 (4) (c) When bedrails are in place (following suitable and sufficient risk assessments) bumpers must be in place to prevent entrapment. Medication must be administered to residents as prescribed by a dispensing practitioner. 09/11/06 7 OP9 13 (2) 06/11/06 8 OP9 13(2) If medication is omitted details be means of a code and an explanation if necessary must be recorded in on medication record. Medication must only be administered / used for / by the named individuals for who the item was dispensed The registered manager must ensure that systems are in place to enable a full audit of medication to take place. This must include: booking in all medication recording the date of opening on all boxed / bottled medication not included within the monitored dosage system. 06/11/06 9 OP9 13 (2) 06/11/06 10 OP9 13 (2) 06/11/06 Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 32 11 OP9 13 (2) When medication is prescribed on a variable dosage the actual dose given must be recorded. The registered persons must continue with the reviewing evaluation of menus as well as ensuring that residents have access to drinks throughout the day including upon waking including upon waking. The date given is for the full review – the requirement regarding drinks is immediate from 09/11/06 06/11/06 12 OP15 16 (2) (i) 31/01/07 13 OP16 22 (1) The registered manager must record all complaints and the investigation. 09/11/06 14 OP19 23(2) The registered provider must 31/01/07 ensure that all areas of the home are kept in good repair and good order this in particular concerns some carpets and the dining room door. The registered person must assess the lighting throughout the building to ensure that it is sufficiently bright to maintain a safe environment for residents and others. The registered person must assess the areas identified for smoke escape to ensure the heath, safety and welfare of residents and others. Fire doors must not be wedged and they must close fully into their rebates. (This requirements is similar to one issued within the inspection report dated 25th October and 31/01/07 15 OP20 23(2) (p) 16 OP26 OP38 23 (5) 31/01/07 17 OP19 OP38 23 31/12/06 Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 33 16th June 2005. This requirement must be met in full) 18 OP27 18 The registered persons must reviewing and monitor staffing levels throughout the day and night to ensure that care needs are met. 31/01/07 19 OP30 OP38 18 The registered manager must ensure staff receive as a minimum mandatory training in infection control, food hygiene, health and safety. (Previous timescale of 26/10/05 not met. A new timescale is given) This must now include moving and handling 28/02/07 20 OP38 13 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 Cleaning products must be stored appropriately. 31/01/07 21 OP38 13 06/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP21 Good Practice Recommendations A review of bathing facilities should take place. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 34 2 OP24 Residents should be provided with single action locks on their bedroom doors to provide privacy and means of escape in the event of a fire. Corbett House Nursing Home DS0000004105.V304697.R01.S.doc Version 5.2 Page 35 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.V304697.R01.S.doc Version 5.2 Page 36 - 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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