Inspection on 02/06/04 for Corner House Nursing Home

Care Homes For Adults (18 ­ 65)Corner House Nursing Home116 Cheriton Road Folkestone Kent CT19 5HQUnannounced Inspection2nd June 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Corner House Nursing Home Address 116 Cheriton Road, Folkestone, Kent, CT19 5HQ Email address Tel No: 01303 258892 Fax No: 01303 258922Name of registered Provider(s)/company (if applicable) Mr William Puxley Name of registered Manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 19Category(ies) of registration, with (number of places) Learning disability (19), Physical disability (19) Registration number H050000210 Date first registeredDate of latest registration certificate 30th July 2002Was the Home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionyes NO 22/01/04 If Yes refer to Part CCorner House Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of Inspector Name of Inspector Name of Inspector 1 2 319th May 2004 10:00 am Julie SumnerID Code081598Name of Inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionJoss Cullum ­ Home Manager (applying for Registration)Corner House Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementCorner House Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Corner House Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service Provider must comply. Service Providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the Provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Corner House Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Corner House provides accommodation and care to adults with physical and learning disabilities, some of whom also have some health conditions and sensory impairment that need additional intervention. It is a large detached building situated in a residential area of Folkestone, near to local shops and amenities. Accommodation is on 3 floors, all of which can be reached by a passenger lift. The Home is part of a group of Homes owned by Counticare that also provide a day service in Folkestone called the Martello.Corner House Nursing HomePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the Inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Please note: The National Care Standards Commission (NCSC) has been replaced by the Commission for Social Care Inspection (CSCI). The main body of this report is to be read in conjunction with the National Minimum Standards for Younger Adults (NMSya). This unannounced inspection was carried out by Julie Sumner during one day in June. A new Manager has been employed by the company and is in the process of applying to become the Registered Manager. She has worked in the Home before and is a registered Nurse. Due to the fact that the Manager has only been in post for a few weeks the content of the inspection was modified and where appropriate timescales for requirements have been extended. Choice of Home (standards 1-5) 1 standard was assessed and had some shortfalls. The Statement of Purpose needs to be modified and designed to contain all elements listed in the care Homes regulations. The Manager has begun working on this document. Individual Needs and Choices (standards 6-10) 2 standards were assessed 1 was met and 1 was nearly met. Service User plans are currently being reorganised. Individual Service Users confidentiality is maintained and information pertaining to individuals is kept securely. Lifestyle (standards 11-17) 3 standards were assessed 1 was met and 2 were nearly met. Service Users were participating in a variety of activities on the day of the inspection. Concerns, Complaints and Protection (standards 22-23) 1 standard was assessed and was nearly met. The adult protection policy is in the process of being revised to include guidelines for staff in the event of suspected abuse. The Assistant Quality Assurance Manager visited the Home during the inspection and discussed the progress on the financial policies. Environment (standards 24-30) 6 standards were assessed, 1 was met and 5 were nearly met. The building is in keeping with the local area and is close to the town centre, the leisure centre and parks. The Manager said the Company is considering options around maximising the space and layout of the Home and grounds. Some modifications are also Corner House Nursing Home Page 6 needed to accommodate individuals and these are being organised. Privacy indicators need to be provided on toilet doors to show when the toilet is in use. Staffing (standards 31-36) 3 standards were assessed 1 was met, 1 was nearly met and 1 was not met. Training is ongoing and has been arranged. There are insufficient training courses available at present and not all staff have completed all up to date statutory training. The Manager is committed to training and said that she would endeavour to meet the timescale set. Conduct and Management of the Home (standards 37-43) 3 standards were assessed 1 was met and 2 were nearly met. Already the presence of a Manager in the Home has had a positive effect. The Manager is aware of the legislation relevant to the Home and is working with the team to ensure that Service Users are kept safe and well.Corner House Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1. 4 (1-3) YA1 To produce a Statement of Purpose containing all elements in regulation 4 and listed in Schedule 1. To produce a Service User Guide containing all elements in regulation 5 and in formats designed for individuals with learning disabilities. Ensure that all staff have the relevant training and experience to maintain the health and well being of Service Users. Introduce induction and foundation training in line with TOPSS standards. 15/03/042.5 (1-3)YA131/03/043.12, 18YA3330/07/044.18YA3530/04/04Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1. YA35 Staff to undertake Learning Disability Award Framework accredited training so that they can relate generalised training to the specific needs of this client group. Provide a written maintenance and renewal plan for the fabric and decoration of the premises.2.YA24Corner House Nursing HomePage 8 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Corner House Nursing HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1. 4 (1-3) YA1 To produce the Statement of Purpose. 15/07/042.5 (1-3)YA1To produce a core version of Service User guide and some indications of the kind of variations that could be provided dependent 15/07/04 on individual need should someone move into the Home. Ensure that all staff have the relevant training and experience to maintain the health and well being of Service Users. Introduce induction and foundation training in line with TOPSS standards. 31/08/043.12, 18YA334.18YA3515/07/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * Staff to undertake Learning Disability Award Framework accredited training so that they can relate generalised training to the specific needs of this client group. Page 101.YA35Corner House Nursing Home 2.YA24Provide a written maintenance and renewal plan for the fabric and decoration of the premises.· Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Corner House Nursing HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with Service Users Individual discussion with Service Users Group discussion with staff Individual discussion with staff Discussion with management Service User survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of Service Users spoken to at time of inspection Number of relatives/significant others the Inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding Managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) Corner House Nursing Home YES YES NO YES YES NO NO NO NO NO NO YES NO YES NO NO NO YES NO YES 2 0 0 NO NO YES YES 17 7 02/06/04 10:30 3.25 Page 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Corner House Nursing HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective Service Users have the information they need to make an informed choice about where to live. Prospective Service Users individual aspirations and needs are assessed. Prospective Service Users know that the Home they choose will meet their needs and aspirations. Prospective Service Users have an opportunity to visit and to `test drive the Home. Each Service User has an individual written contract or statement of terms and conditions with the Home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the Home, its services and facilities and terms and conditions; and provides each Service User with a Service Users guide to the Home. The statement of purpose should clearly set out the physical environmental standards met by the Home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the Service Users guide. 1060 1250 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 1 Key findings/Evidence Standard met? The new Manager had a copy of the initial draft of the Statement of Purpose and was beginning to amend it. There was a discussion about the contents and requirements and the Manager said that she would include the relevant information to complete the document. The Service User Guide also needs to be completed and this was also discussed.Standard 2 (2.1 ­ 2.8) New Service Users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective Service User, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? Not inspected at this time.Corner House Nursing HomePage 14 Standard 3 (3.1 - 3.10) The registered person can demonstrate the Homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the Home. 0 Key findings/Evidence Standard met? Not inspected at this time.Standard 4 (4.1 - 4.5) The registered Manager invites prospective Service Users to visit the Home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? Not inspected at this time.Standard 5 (5.1 - 5.5) The registered Manager develops and agrees with each prospective Service User a written and costed contract/statement of terms and conditions between the Home and the Service User. 0 Key findings/Evidence Standard met? Not inspected at this time.Corner House Nursing HomePage 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service Users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service Users make decisions about their lives with assistance as needed. Service Users are consulted on, and participate in, all aspects of life in the Home. Service Users are supported to take risks as part of an independent lifestyle. Service Users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered Manager develops and agrees with each Service User an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the Home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? Service User plans are being reorganised and information being sorted out for accessible reference. The Service User plan viewed was much clearer. An archiving system is being implemented for past information.Standard 7 (7.1 ­ 7.7) Staff respect Service Users right to make decisions, and that right is limited only through the assessment process, involving the Service User, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not inspected at this time. This was discussed with the Manager who is aware of the need to determine meaningful methods of offering choice to the Service Users.Corner House Nursing HomePage 16 Standard 8 (8.1 ­ 8.5) The registered Manager ensures that Service Users are offered opportunities to participate in the day to day running of the Home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Not inspected at this time.Standard 9 (9.1 ­ 9.4) Staff enable Service Users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the Service Users individual Plan and of the Homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? Not inspected at this time.Standard 10 (10.1 ­ 10.6). Staff respect information given by Service Users in confidence, and handle information about Service Users in accordance with the Homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the Service User. 3 Key findings/Evidence Standard met? Information pertaining to individuals is kept securely in individual folders where appropriate. The staff are using the updated accident logbook and keeping all completed forms in either individual staff or Service User folders. Individual Service Users confidentiality is maintained in the communal message book.Corner House Nursing HomePage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service Users have opportunities for personal development. Service Users are able to take part in age, peer and culturally appropriate activities. Service Users are part of the local community. Service Users engage in appropriate leisure activities. Service Users have appropriate, personal, family and sexual relationships. Service Users rights are respected and responsibilities recognised in their daily lives. Service Users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable Service Users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Not inspected at this time.Standard 12 (12.1 ­ 12.6) Staff help Service Users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Not inspected at this time.Corner House Nursing HomePage 18 Standard 13 (13.1 ­ 13.5) Staff support Service Users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 2 Key findings/Evidence Standard met? The Home is situated near to the town centre of Folkestone and close to the leisure centre. Staff organise activities using the local facilities. Community based activities are being planned and participation/interest is to be recorded on the newly designed activity recording form.Standard 14 (14.1 ­ 14.6) Staff ensure that Service Users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Activities are being planned through the individual Service User planning process. Some new forms have been designed to record activities and how individuals responded. The Martello Centre is up and running now and the staff team are supporting individuals to access it at arranged times. Some activities are planned for the week ends and evenings.Standard 15 (15.1 ­ 15.5) Staff support Service Users to maintain family links and friendships inside and outside the Home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not inspected at this time.Corner House Nursing HomePage 19 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? Staff were observed to show consideration for Service Users privacy. Ensuite bathrooms are used exclusively for individuals who occupy the adjoining bedroom. This practice does not respect individual choice and privacy and does not meet NMS. A privacy indicator needs to be provided in a form that is appropriate for the Service Users to ensure their privacy when using the bathroom/toilets. Service Users preferred form of address is documented in their Service User plan. Staff were observed interacting and talking to Service Users in a positive way.Standard 17 (17.1 ­ 17.9) The registered person promotes Service Users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not inspected at this time.Corner House Nursing HomePage 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service Users receive personal support in the way they prefer and require. Service Users physical and emotional health needs are met. Service Users retain, administer and control their own medication where appropriate, and are protected by the Homes policies and procedures for dealing with medicines. The ageing, illness and death of a Service User are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise Service Users privacy, dignity, independence and control over their lives. 2 Key findings/Evidence Standard met? There is a key worker system in the Home. Personal care is provided in private. Times for getting up / going to bed, baths, mealtimes and activities are routine based, with limited flexibility, due to the high number of Service Users who need full support with personal care. The Manager said that discussion is taking place in staff meetings around ways to provide more autonomy and choice to Service Users. This is forming part of the Service User planning process.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of Service Users are assessed and recognised and that procedures are in place to address them. No. of incidents where Service Users have been taken to Accident & Emergency during last 12 months No. of Service Users with pressure sores at the time of inspection (from information taken from care notes) 403 Key findings/Evidence Standard met? The Manager is in discussion with the GP services about the general health monitoring needed for Service Users in the Home. The Nurses carry out some health care treatments and guide the staff to support healthcare needs. When Service Users attend health care appointments these are recorded in the Service User plan. Physiotherapy aides carry out physiotherapy on a daily basis, and more frequently if indicated and for Service Users who have a tendency to chest infections. Service Users are supported to attend hospital appointments and if an emergency admission to hospital is necessary. The Manager is in discussion with the Nurses to provide an effective procedure for assessment of individual health problems when they occur. This is partly to avoid unnecessary hospital visits.Corner House Nursing HomePage 21 Standard 20 (20.1 ­ 20.14) The registered Manager and staff encourage and support Service Users to retain, administer and control their own medication, within a risk management framework, and comply with the Homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Medication records were viewed and had been completed accurately. There was some discussion about using codes when medication is not given. A laminated photo of each Service User acts as a divider, making checking and recording much clearer and safer. The Nurses on duty administer the medication. No Service Users are able to self-medicate. The Manager said that prescriptions for medication still needs to be reviewed by the GP and that arrangements are being discussed with the surgery. The medication is stored neatly and the clinical room was clean. Standard 21 (21.1 ­ 21.8) The registered Manager and staff deal with the ageing, illness and death of a Service User with sensitivity and respect. 0 Key findings/Evidence Standard met? Not inspected at this time.Corner House Nursing HomePage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service Users feel their views are listened to and acted on. Service Users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that Service Users know how and to whom to complain. No. of complaints made to the Home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Not inspected at this time. X X X X X X X Standard met? 0Corner House Nursing HomePage 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that Service Users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The Home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists NO02 Key findings/Evidence Standard met? The adult protection policy is in the process of being revised to include guidelines for staff in the event of suspected abuse. The Assistant Quality Assurance Manager visited the Home during the inspection and discussed the progress on the financial policies. Financial policies are being revised. An account has been set up for staff costs when taking Service Users on outings. Individual accounts are being set up for Service Users but there have been some difficulties and this is currently being resolved with the Company and the relevant Bank.Corner House Nursing HomePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service Users live in a homely, comfortable and safe environment. Service Users bedrooms suit their needs and lifestyles. Service Users bedrooms promote their independence. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement Service Users individual rooms. Service Users have the specialist equipment they require to maximise their independence. The Home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The Homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet Service Users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? This is a large Home providing accommodation for 18 Service Users and has one bedroom used for respite. The building is in keeping with the local area and is close to the town centre, the leisure centre and parks. The Manager said the Company is considering options around maximising the space and layout of the Home and grounds. Consideration is also being given to organising the Home into clusters of up to ten people as indicated in 24.3 of this standard. A planned maintenance and renewal plan needs to be written and available in the Home.Corner House Nursing HomePage 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each Service User with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing Homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO NO YES 9 0 5 2 9 09 0 5 02 Key findings/Evidence Standard met? Room sizes vary and are generally spacious. One of the shared rooms is an awkward shape and with all furniture and belongings does not have sufficient useable floor space. Service Users sharing a room have mostly lived at the same premises for several years. The Company needs to review its provision in shared rooms with reference to 25.5 of this standard.Corner House Nursing HomePage 26 Standard 26 (26.1 ­ 26.4) The registered person provides each Service User with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Not inspected at this time. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides Service Users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 2 Key findings/Evidence Standard met? There are sufficient toilets and bathrooms but some of the facilities need modifying to accommodate individuals living in the Home. The Manager has identified where changes need to be made and what equipment is required. Privacy indicators need to be provided on toilet doors to show when the toilet is in use.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 2 Key findings/Evidence Standard met? There have been no changes to the provision of communal space as yet although the Company are considering various options. The lounge and dining room looked clean. Some new dining room chairs had been purchased and were probably practical in that they were stackable but they were not very attractive.Corner House Nursing HomePage 27 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the Homes stated purpose and the individually assessed needs of all Service Users. 2 Key findings/Evidence Standard met? There have been no recent changes to the provision of adaptations and equipment since the last inspection. The Manager was assessing the individual needs of Service Users and said that some modifications needed to be made in bathroom/toilet areas.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the Home. 3 Key findings/Evidence Standard met? A housekeeper and domestic staff are employed to clean the Home and do the laundry. Care staff assist with some of these tasks with regard to Service Users. Overall the Home was clean and the problem areas were not evident at this inspection. There was only a faint smell of urine in the lounge which may be due to the age of some of the armchairs. There is a laundry room with a large commercial washing machine, and a commercial tumble-dryer, which are sufficient to carry out laundry in the Home. A sluice disinfector is in place, and hand-washing facilities were in place for aiding infection control.Corner House Nursing HomePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service Users benefit from clarity of staff roles and responsibilities. Service Users are supported by competent and qualified staff. Service Users are supported by an effective staff team. Service Users are supported and protected by the Homes recruitment policy and practices. Service Users individual and joint needs are met by appropriately trained staff. Service Users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered Manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Not inspected at this time.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet Service Users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 2 Key findings/Evidence Standard met? Staff continue to demonstrate good attitudes towards Service Users. The Manager has spoken to the staff about training and three staff are planning to study NVQ at the next available course. Four staff have achieved NVQ level 2 or above.Corner House Nursing HomePage 29 Standard 33 (33.1 ­ 33.11) The Home has an effective staff team with sufficient numbers and complementary skills to support Service Users assessed needs at all times. Staff numbers/hours relating to the needs of Service Users are based on guidance recommended by the Department of Health. Personal Care No. Service Users High needs No. Service Users Medium needs No. Service Users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X 4 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X073 Key findings/Evidence Standard met? There were four care staff on duty, a nurse/team leader, the Manager, the cook and the housekeeper. Two physiotherapy assistants were carrying out the individual planned programmes in the Home. One Service User was out at the Martello centre. There were sufficient staff on duty to meet the identified needs of the Service Users. The Manager has reintroduced team meetings to discuss issues. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. 3 Key findings/Evidence Standard met? Recruitment was discussed and the process/procedure has been reviewed. The Managers CRB disclosure has been requested although she already has one that was completed previously. There are some vacancies in the team and the Manager said that the posts had been advertised.Corner House Nursing HomePage 30 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the Home and meet the changing needs of Service Users. 1 Key findings/Evidence Standard met? This was discussed. Training is ongoing and has been arranged. There are insufficient training courses available at present and not all staff have completed all up to date statutory training. The Manager is committed to training and said that she would endeavour to meet the timescale set.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? Not inspected at this time.0Corner House Nursing HomePage 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service Users benefit from a well run Home. Service Users benefit from the ethos, leadership and management approach of the Home. Service Users are confident their views underpin all self- monitoring, review and development by the Home. Service Users rights and best interests are safeguarded by the Homes policies and procedures. Service Users rights and best interests are safeguarded by the Homes record keeping policies and procedures. The health, safety and welfare of Service Users are promoted and protected. Service Users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered Manager is qualified, competent and experienced to run the Home and meet its stated purpose, aims and objectives. Registered Manager qualified to level 4 NVQ in Management and care [by 2005]. YES2 Key findings/Evidence Standard met? A Manager has been employed who is a qualified nurse. She has worked in the Home before and is familiar to some of the staff and Service Users. She is in the process of applying to become the Registered Manager. Already the presence of a Manager in the Home has had a positive effect on the Home.Standard 38 (38.1 ­ 38.6) The management approach of the Home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Manager explained how she has approached her role. There was evidence of good communication systems in the Home.Corner House Nursing HomePage 32 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of Service Users, are in place to measure success in achieving the aims, objectives and statement of purpose of the Home. 0 Key findings/Evidence Standard met? Not inspected at this time.Standards 40 (40.1 ­ 40.6) The Homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? Not inspected at this time.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of Service Users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? Not inspected at this time.Corner House Nursing HomePage 33 Standard 42 (42.1 ­ 42.9) The registered Manager ensures so far as is reasonably practicable the health, safety and welfare of Service Users and staff. 2 Key findings/Evidence Standard met? The Manager has prioritised outstanding training and has requested additional course provision to ensure that all staff have up to date statutory training. Fire training has been attended or booked for all staff in the team. The Manager is reviewing training required in the Home generally. The Manager is aware of the legislation relevant to the Home and is working with the team to ensure that Service Users are kept safe and well.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the Home) ensures the effectiveness, financial viability and accountability of the Home. 0 Key findings/Evidence Standard met ? Not inspected at this time.Corner House Nursing HomePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorJulie SumnerSignature Signature SignatureRegulation Manager Brian Wintle-Smith DateCorner House Nursing HomePage 35 Public reports It should be noted that all CSCI inspection reports are public documents.Corner House Nursing HomePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 2nd June 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCorner House Nursing HomePage 37 Action taken by the CSCI in response to Provider comments: Amendments to the report were necessary NOComments were received from the Provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The Inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 14/07/04, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Corner House Nursing HomePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Joss Cullen of Corner House Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Corner House Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Joss Cullen J Cullen Manager 28.06.04Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Corner House Nursing HomePage 39 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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