Inspection on 26/04/05 for Corbrook Court

This inspection was carried out on 26th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Corbrook Court 03/01/07

Corbrook Court 04/10/05

Corbrook Court 22/11/04

Corbrook Court 11/05/04

Corbrook Court 28/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Corbrook Court Audlem Crewe Cheshire CW3 0HF Lead Inspector Gillian Matthewson Unannounced 26 April 2005 06:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Corbrook Court Address Audlem Crewe Cheshire CW3 0HF 01270 812049 01270 812324 corbrookcourt@morris-care.co.uk Morris & Co Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Julie Lyn Bristow Care Home 30 Category(ies) of Physical disability (7) registration, with number Terminally ill (3) of places Old age, not falling within any other category (20) Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for a maximum of 30 service users to include:* Up to 20 service users in the category of OP (Old age, not falling within any other category) * Up to 7 service users in the category of PD (Physical disability under the age of 65 years) * Up to 3 service users in the category of TI (Terminal illness under the age of 65 years) 2 The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 22/11/04 Brief Description of the Service: Corbrook Court is a nursing home providing 24 hour nursing care, personal care and accommodation for a maximum of 30 people. Up to 7 people may have a physical disability, up to 3 people may be terminally ill and up to 20 may be older people requiring nursing or personal care.Corbrook Court is set in eleven acres of land on the outskirts of Audlem village, which has all the essential community amenities. It is a three storey building and access can be obtained to the first and second floors via the shaft passenger lift or the stairs. Accommodation is provided on the three floors of the main building in 18 rooms, 13 of which have en-suite facilities. There is also a purpose built extension on the ground floor consisting of seven rooms, all with en-suite facilities. Separate assisted bathing facilities and toilets are also available. There are two lounges and a dining room available for service users. Ample parking space is provided. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by three inspectors of the Commission, including a pharmacist inspector. The lead inspector spent two hours planning the inspection by reviewing previous inspection reports and the service history over the last twelve months. The inspection was commenced at 6.30am because an anonymous complaint had been received that service users were being woken up very early to take medication. This was found to be unsubstantiated. The inspection took place over six hours and included a tour of the building, inspection of records and discussion with nine service users and five members of staff. Feedback was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? The home now maintains a record of valuables handed in for safekeeping. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 6 Team leader training has been provided so that a system of formal staff supervision can be implemented. 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. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Satisfactory arrangements are in place for service users to be assessed prior to admission to ensure that the home will be able to meet their needs. EVIDENCE: There was evidence in service user files that the manager or her deputy performed pre-admission assessments on prospective service users. There was a comprehensive pre-admission assessment form used to record biographical details and a needs assessment based on the activities of daily living. Risk assessments were also completed. Service users were included in the preadmission assessment and information was obtained from service users’ relatives and other healthcare professionals involved in the care of the person. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10. Service users are helped to maintain their health as far as possible by staff identifying health care needs and making referrals to other health care professionals as necessary. Although there was no evidence of service users receiving inappropriate care, there was the potential for this because care plans are not always updated as needs changed. The arrangements for storage, administration and recording of medication are unsatisfactory. Service users are treated with repect. EVIDENCE: Six service user plans were reviewed as part of the case tracking process. Individual files were maintained for each service user. All the relevant information was recorded in that a care plan had been drawn up for each service user and daily events were recorded in the daily progress notes or on the communication sheet. It took some time to obtain a full picture of the current care required for each service user because care plans had not always been updated to reflect changes in care. For example, one lady had a care plan for an exercise programme devised by the physiotherapist twelve months previously, but on reading further it became apparent that the lady was no longer able to walk. She had also had a recent visit from the dietitian and changes to her diet were recorded on the communication sheet but the care plan had not been updated to reflect this. Failure to update care plans could Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 10 result in inappropriate care being given by a member of staff who is not familiar with the service users’ current needs. See Requirement 1. There was evidence that care plans were discussed and reviewed with service users and their representatives. Service users were assessed for risk of pressure sores by registered nurses and appropriate intervention was recorded in the service user plans. One service user had been admitted with a pressure sore. An appropriate pressurerelieving mattress had been provided and the manager had sought the advice of a tissue viability nurse on the treatment of the wound. A treatment plan was recorded. Service users were registered with the local GP practice and were referred to other appropriate health care professionals as necessary. Opportunities for exercise and physical activity were provided and service users were weighed on a regular basis to assess whether they were maintaining adequate nutritional intake. Inspection of the arrangements for medicines revealed that homely remedies used to treat minor illnesses without seeing a doctor had not been checked. Two items were past their use by date, one November 2003 and another November 04. There were several bottles of prescribed eye drops being stored at room temperature even though they were labelled to be stored in a refrigerator. There was a bottle of liquid medicine in the cupboard and one in the refrigerator that were badly soiled by drips and spillage. Some glycerine suppositories that had been prescribed for residents had the labels removed and had been put with the homely remedies and some of the homely remedy painkillers had no container so it was not clear if this had been bought or taken from a prescribed supply. Some medicines, including a controlled drug had no dispensing label to identify its owner and clarify directions. During the inspection the controlled drugs were stored in a cupboard that was not to the legal standard and some were being given from the trolley, which is not secure enough. There were a number of notes in the handover book that residents had run out of prescribed medicines. The records of residents having their medicines had been missed on many occasions so it was not clear whether they had been given or not. An immediate requirement to correct these shortfalls was made during the inspection. See Requirement 2. All nursing care and personal care took place in the privacy of the service user’s room or in the privacy of the bathrooms. Staff were observed to knock on service users’ doors before entering. Service users said that they were treated courteously and with respect by all staff. It was noted that bathroom 1 on the first floor had frosted glass panels in the door, which does not afford adequate privacy for service users. See Requirement 3. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 & 14. Service users admitted to the home are able to maintain contact with family, friends and pets and make choices regarding their everyday lives. EVIDENCE: Service users confirmed they could receive visitors at any time in the lounges or in the privacy of their own room and that they were able to exercise personal autonomy and choice in their lives, for example they could get up or go to bed when they wanted, stay in or go out, remain in their room or sit in the lounge. One service user said how much she appreciated that the home allowed her husband to bring her dogs to visit her most days. Service users were also able to personalise their rooms with personal possessions and small items of furniture. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18. Service users are able to voice their concerns and appropriate action is taken to address them. Appropriate policies and procedures are in place to protect service users should there be any suspicion of abuse. EVIDENCE: The complaints procedure was available to service users in the service user guide and on the notice board. Service users said that they would inform the registered manager or one of the registered nurses of their concerns or complaints and felt confident they would be listened to and the appropriate action taken to resolve any issues. There had been two complaints since the last inspection. Both had been investigated by the registered provider and found to be unsubstantiated. The second complaint had included an allegation that service users were woken up early to be given medication, which is why the inspection was commenced at 6.30a.m. This was not the finding of this inspection. Service users who were asleep were left undisturbed and medication was given later. The home had satisfactory policies for adult protection, which included definitions of abuse, indicators of abuse (including institutional abuse), and action to be taken in the event of suspected abuse. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26. The standard of the environment within this home is good, providing service users with an attractive and pleasant place to live. EVIDENCE: The home was clean and well maintained throughout. The grounds were also well maintained. A new walk-in shower was being installed on the first floor. A fire escape led from Room 208 across a flat roof. Moss was growing on the flat roof, which could cause people to slip should they need to use that fire escape. See Requirement 4. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28. Staff morale is high, resulting in an enthusiastic workforce that works positively with service users to improve their quality of life. Staffing levels and staff training ensure that service users’ needs can be met. EVIDENCE: Staffing rotas demonstrated that staffing levels and skill mix were adequate to meet the needs of the service users in residence. Staff were cheerful and friendly and service users were complimentary about staff attitude and competence. Staff, when asked, said they felt supported and appreciated by their employers. Four of the care staff had achieved an NVQ Level 2 in Care, five had achieved an NVQ Level 3. Four more were working towards an NVQ Level 2 and one was working towards an NVQ Assessors Award. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 36. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of service users, staff and relatives. Service users can have confidence that their money and property are safeguarded by the home’s financial policies and procedures. Staff are supervised to ensure that they provide appropriate care for service users. EVIDENCE: Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 16 Service users and visitors spoken with confirmed that they had been involved in completing service user satisfaction surveys. One had been carried out not long before this inspection, but the report had not yet been produced. The manager carried out audits according to the registered provider’s quality assurance programme. The registered provider was intending to work towards achieving the Investors in People Award, which is a quality standard in relation to staff training. The registered provider or staff at the home did not handle service users’ financial affairs. Family or solicitors, if necessary, dealt with financial issues, including personal allowances. Relatives did leave small amounts of money for service users to pay for hairdressing and toiletries. Records and receipts were maintained. Secure facilities were provided for the safekeeping of money and valuables on behalf of the service user. All staff were supervised on a continuous day to day basis and received an annual appraisal of their work. The registered provider had provided team leader training, which included supervision of staff in the team. A policy on formal staff supervision had been devised and a system was due to be implemented. Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 2 x x Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP9 Regulation 15(2)(b&c ) 13(2) Requirement Ensure that care plans are updated as service user needs change. Ensure medicines are stored, given and recorded properly and set up a system to check medicines monthly to be sure none are kept beyond their use by date. Provide privacy screening to the door of bathroom 1 on the first floor. Remove the moss from the fire escape outside Room 208. Timescale for action 26.04.05 26.04.05 3. 4. OP10 OP19 12(4)(a) 13(4)(a) 26.06.05 26.06.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Unit D Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Corbrook Court F51 F01 S53406 Corbrook Court V222463 260405 Stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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