Inspection on 28/04/08 for Cornfield House

This inspection was carried out on 28th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cornfield House 04/03/09

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Cornfield House 3 Cornfield Road Seaford East Sussex BN25 1SW Lead Inspector Mrs Sally Gill Unannounced Inspection 28th April 2008 09:30 Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 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 Cornfield House DS0000070611.V363996.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 Adults 18-65. 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. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cornfield House Address 3 Cornfield Road Seaford East Sussex BN25 1SW 01323 892973 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) cornfieldhouse@talktalk.net Jiva Healthcare Ltd Mrs Jadwiga May Carney Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia (MD) The maximum number of service users to be accommodated is nineteen (19). N/A Date of last inspection Brief Description of the Service: Cornfield House is a registered to provide accommodation for up to 19 adults with or recovering from mental health issues. The home caters for people with low dependency needs. The registered manager Mrs Jadwiga Carney has dayto-day responsibility of the home. The premise is a large detached house over three floors. There is 13 single and 3 double bedrooms on the ground, first and second floor. 3 bedrooms have ensuite facilities all others have a wash hand basin. There are 2 bathrooms (not assisted) and a shower room. The home has a large lounge, dining room and a good-sized conservatory, which is used for smoking. To the rear of the home is a large well maintained garden with lawn, established shrubs, fishpond and seating area. The home is situated in a residential area of Seaford. There is on street parking in the front of the home. The home is within walking distance of the town centre, amenities and railway station. The staff compliment consists of a manager, deputy, support staff and maintenance person. Management and staff work a rota that includes two staff on duty during the day sometimes rising to three and one waking member of staff on duty at night. Current fees range from £365.00 to £521.00 per week. Additional charges may be made for hairdressing and chiropody. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 5 Previous inspection reports are not available as this is the first inspection under the current owner. The current inspection report is available from the home or can be viewed and downloaded from www.csci.org.uk. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This first key inspection was carried out for the home under the current owners. It was carried out over a period of time and concluded with an unannounced visit to the home between 09.28am and 3.45pm. The manager assisted throughout. People that live in the home and staff were spoken to. Observations were made throughout the day. Eighteen people were living at the home on the day of the visit with one vacancy. Surveys were sent to the home for the manager to distribute to people that live there and health and social care professionals. Unfortunately some people were given the wrong type of survey to complete. Surveys were returned from people who live in the home, a relative and a professional. Most feedback was positive. The care of three people was tracked to help gain evidence as to what its like to live at Cornfield House. Various records were viewed during the inspection and a part tour of the home undertaken. People living in the home are happy and have a good lifestyle. However work is needed on strengthening systems to fully safeguard people. At the time of writing this report the Commission had not received the Annual Quality Assurance Assessment (AQAA) from the provider. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. What the service does well: Positive feedback was received from people living at Cornfield House. People confirmed they are happy and feel safe living there. One commented that care staff respect their faith and individual diet. People were happy that any concerns would be resolved and felt staff was approachable. A relative said most staff are very supportive. They are very caring to both X and myself over some very difficult times. X is very happy there and for this we are very grateful. A professional involved in the home was positive with comments including Cornfield House provides an excellent all round package of care, am confident to place service users at this placement in the knowledge that they will receive excellent support. Excellent communication with mental health teams promoting independence and social inclusion. They manage well crisis situations/deterioration in presentation. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 7 People said they are treated with respect by the staff this was evident in observing the interactions between staff and people in the home. People’s routines are flexible and they are encouraged to get out and about in the local community. Peoples health is monitored closely and referrals made appropriately. The home has forged good working relationships with professionals involved in people’s care and support. What has improved since the last inspection? What they could do better: Peoples needs and aspirations should be better identified in care plans to ensure these needs are met. People’s equality and diversity could be better reflected in documents. Limitations that are agreed should be recorded. Detail in steps to minimise risks must be recorded to ensure safety and all risks must be recorded. Minor improvements to medication administration records and instruction for as required medicines would better protect people. People’s records must be stored securely to ensure confidentiality. The complaints procedure needs updating so people have the correct information. People’s environment must be improved by addressing the highlighted concerns. Improved infection control supplies could aid better hygiene. Improvements in staff recruitment processes would fully protect people. should receive regular supervision. Staff Management must ensure appropriate incidents/accidents are reported to outside agencies to safeguard people. The provider must undertake visits to the home to ensure the required standard of care provided. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will 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. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that is right for them. People’s needs are assessed prior to admission but the recorded assessment could better inform staff. EVIDENCE: People have the information they need in order to make a decision about the home. The home has updated it statement of purpose and service user guide under the new ownership. Copies of both documents are held on each persons file. Peoples can be sure their needs will be assessed. A needs assessment is undertaken by the home prior to admission. The format for the needs assessments has been updated. The assessment identifies briefly people’s needs but there is no real detail or information about what interventions would be required in order to meet any needs. Examples were aggression was ticked but no information as to how this may displayed itself and some problems with bowels was ticked but not any detail. Information within the assessments should give a good picture of the persons needs in order that the home is able to make an informed judgment as to whether they feel they can meet all those needs. The assessment format would benefit from review in relation to Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 10 equality and diversity. Nationality, sexuality and partnerships are not included. The home obtains copies of professional assessments where involved in the persons care. They work closely with professionals both prior to admission and afterwards. People have the opportunity to visit the home prior to admission. Staff advised that people do visit the home prior to admission. At first for an hour, then usually lunch followed by an overnight stay. People are sometimes visited in their own environment. The benefits of undertaking assessments in their own environment were discussed. People are safeguarded with terms and conditions agreed with the home. The service user guide forms part of a persons terms and conditions. The room number occupied by the person should be added to the terms and conditions. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. 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. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives but do not play an active role in planning the care and support they receive. EVIDENCE: People are not involved in care planning. Three peoples files were examined. One person did not have a care plan or risk assessments undertaken by the home. The home advised they do not record a care plan until after the CPA review. The home was advised a care plan and risk assessment must be in place to inform staff from the admission which would develop as the person settled. Files have been restructured since the last visit. Work has also been achieved in developing an improved care plan format since the last visit. However care plans still lack the detail needed to inform staff. Care needs highlighted in pre-admission and other assessments have not been followed through into the care plan such as aggression and some problems with bowels. Records showed that assistance is needed but there was no detail as to what Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 12 assistance. Staff were always able to give a verbal account of care needs but this must be recorded and agreed with people. People spoken to said they were not aware of their care plans and there is no evidence they are involved in the development of their care plan. Staff advised they are involved in their CPA review and they are aware of the daily planner for personal care and household chores. Care plans and risk assessments lacked evidence of review. One care plan was last reviewed 3/7/07. There is no evidence of goal planning within care plans. The storage of daily reports by staff needs to be better organised, as some previous sheets could not be located. The manager advised she does plan to do this. Care plans must be further developed with people to ensure all care and health needs are identified and staff have clear information as to how people want to be supported in order to meet those needs. Staff advised a key worker system is in place and they have input to reviews. People spoken to say they were able to make decisions about their day-to-day lives. Service user meetings are held usually about every three months. The manager advised that any concerns or grumbles are usually discussed then as well as menus. Minutes of the meetings are available. People have agreed limitations that are in place. However not all these are recorded such as limiting the number of cigarettes at any one time and should be. Some are recorded such as personal allowance agreements. People are supported to take appropriate risks. A part from the person highlighted above everyone had risk assessments in place. However again these lack detail such as one for verbal abuse with steps to minimise the risk recorded as staff to calm situation – how? Some risks such as diabetes are not assessed. Robust risk assessments must be undertaken and recorded which include all steps staff must take to minimise the risk and for all risks. People’s records are not safeguarded. During a tour of the home it was found that confidential papers relating to people were stored in a cupboard on a landing. However the cupboard was damaged leaving the papers stored in unsecured storage. This must be addressed. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. 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. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style. Social, educational and leisure activities meet people expectations. EVIDENCE: People are encouraged to take part in a range of activities. People spoke of attending a daycentre and therapeutic daycentre with some attending five days a week. People also spoke of accessing the local community as they please such going into town, the local bookies, Eastbourne or just walking. One relative felt more support should be available when taking part in outside activities. One person goes into town to collect two daily newspapers for the home each day. In house activities are generally individual and people spoke of knitting and watching snooker on the television. Bingo is arranged for Sunday evenings as Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 14 well as film or DVD and word search evenings. The home is going to book a music man to come in a play once a month. The home has a computer with Internet access, which can be used by people. Although the manager advised no person is able at present to use this without staff assistance. One relative felt other activities other than TV should be provided and people should have the opportunity to learn how to use the computer. The manager advised that the home is also trying to arrange three special outings a year. People spoke happily of visitors to the home such as families. People have obviously forged friendships with others that live in the home as well as people in the community. People’s daily routines promote independence and choice. People talked about involvement in household chores and laundry. Development of daily living skills could be better evidenced if recorded in care plans. Usually people have an allocated day for laundry and cleaning their room although this can be flexible. People are involved in washing up and clearing away after meals and also hovering the hallways and landings. A rota is in place for these chores. Staff were observed to interact well with people throughout the day of the visit often with good humour. People confirmed that they had keys to their rooms although at times the manager advised this is not possible because of fire exits. The home could look at locks where both privacy and fire safety could be achieved. People are happy with the menus and food. The menus are planned weekly and displayed on the office door. The main meal is at lunchtime although those at daycentres have theirs at night. Tea is a light meal such as something on toast. There is no choice menu but people confirmed that alternatives are available. Lunch on the day of the visit was mince, boiled potatoes and green beans, which looked, hot and appetising. Everyone in the home spoken to confirmed that the food is good. A relative felt there is not enough salad or fresh fruit. A vegetarian diet is catered for. The manager advised that usually pudding is a yogurt and occasionally a pudding is made. Staff advised that tea and coffee is made about every two hours, which has been agreed by people. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. 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 home’s 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. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples physical and mental health needs are monitored and they are supported to remain well both physically and emotionally. Minor improvements in the medication system could better protect people. EVIDENCE: People said routines are flexible and they can get up and go to bed as they wish. One talked about shopping and how a staff member went with them to their favourite shop when buying clothes. The staff team is small and a key worker allocation is in place although dependence on this person is rightly discouraged. People’s health care is monitored closely and any concerns are referred appropriately. People receive ongoing support from the community mental health team as required. People are supported to attend outpatient’s appointments. The community psychiatric nurse offers support people and staff in the way of telephone calls and attendance at reviews and meetings if appropriate. The manager advised people have access to the dentist, optician, Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 16 and chiropodist as appropriate in the community. One relative felt more support should be available if attending appointments. Two people have a chiropodist visit the home. Records tracking people’s healthcare were discussed, as at present the information is not readily to hand. People are generally protected by a safe medication system. Staff administer people’s medication in all cases. The Medication Administration Records (MAR) charts showed medication is administered and logged in appropriately. Handwritten entries were not dated, signed and witnessed which they should be. The returns book could not be found during the visit. A local chemist undertakes a regular audit of medication systems. All staff that administers medication has received training. The home is advised to check that the training meets Skills for Care medication knowledge sets. Four staff is currently undertaking managing and safe handling of medication. There is a general written notice to staff that any ‘as required’ (PRN) medication is to be authorised by the manager or deputy but there are no individual PRN written instructions, which there should be. A recommendation is made to address the shortfalls and ensure a robust system. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People feel safe living in the home and confident any concerns will be resolved. EVIDENCE: People feel confident if they complained the manager would sort anything out. The homes complaints procedure is located in the front hallway. The address and telephone of the Commission must be updated. The manager advised no complaints have been received by the home for some considerable time. It is suggested the home has a complaints log to record and track any complaints when received. The home does not have a grumbles book the manager advised that usually these are discussed at service users meetings and minutes are recorded. People say they are happy living in the home and with the care and support they receive. People confirmed that they feel safe living in the home. There have been no safe guarding adult referrals. Some staff has received Protection of Vulnerable Adults (POVA), which also includes understanding difficult behaviour, challenging behaviour and person centred care. If monies are to be held on behalf of people robust records need to be maintained. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. 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. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home, which is bright, airy and comfortable. Some areas need attention, which would then enhance the environment. A shortfall in infection control could leave people and staff at risk. EVIDENCE: People live in a generally homely, bright, airy and comfortable environment. A part tour of the home was undertaken including toilets, bathrooms, kitchen and pantry, laundry, lounge, smoking conservatory, computer room, and dining room. A new pump has been fitted to the hot water system, which means everyone now has hot water in his or her room. One comment indicated this took too long to repair although the manager advised there were problems. Everyone spoken to said there is now plenty of hot water. Several problems were highlighted during the tour including a stack of old furniture on one landing needs removing especially as this reduces the access for the fire Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 19 exit, a rug in the lounge was a tripping hazard, a broken pane of glass in a empty bedroom, one wardrobe had its handle missing, double glazed units were blown, no blinds or curtains in some bathrooms and toilets resulting in a clinical instead of homely room and generally some carpets were worn. A requirement is made to address these shortfalls. The manager advised the home is currently obtaining quotes to replace the boilers and there are plans to redecorate the dining room shortly and provide a patio area. She said the new owner is investing in the home and there will be ongoing refurbishment/redecoration. An empty room had been redecorated and had a new carpet. Windows restrictors have now been fitted. Although the home is advised to the check the legal measurement for restrictors as some windows still appear to open quite wide and may be considered unsafe. One ensuite did not have a light and the manager advised that there had been problems with the roof above which had now been repaired and they wanted to ensure the area was properly dry before using the light again. People say they are happy with their rooms, which contained people’s possessions and reflected their personalities. One person who shares a bedroom said they are happy with this and prefer sharing, the person sharing agreed. Radiators are guarded. People live in a home, which is generally clean and tidy. However some toilets and shower/bathrooms were not sufficiently clean, some windows also appeared to need cleaning and in two toilets there was an apparent odour. In some shared toilets and bathrooms liquid soap and/or paper towels is available however there are several areas where they are not including the laundry and this compromises hygiene and must be provided. The home did send out for supplies of liquid soap during the visit. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. 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 home’s 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. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home is trained and skilled to support the people who use the service. Minor improvements are needed in recruitment processes to fully protect people. Staff could benefit from regular supervision. EVIDENCE: People receive a service from a team who are qualified. The manager advised that six staff have obtained or are undertaking National Vocational Qualification (NVQ) level 2 or above which is 66 . People would be better protected if minor improvements were made to the recruitment practices. Turnover of staff is low. Staff files were examined. All checks were in place. However one employee had a Criminal Records Bureau (CRB) undertaken by a previous employer. An immediate requirement was issued to obtain a new CRB. The application form has been updated but requires further review. It does not make clear that a full employment history is required; it should also be checked against new legislation. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 21 People are supported by staff that has received some training. Staff performance is assessed regularly using a scoring system, which is recorded. Staff undertake an induction, which is recorded. Induction training has been reviewed and a programme to Skills for Care specification is now in place. Some staff has received training in specific mental health illnesses and medications. Some training is completed with a competency questionnaire. There are shortfalls in the training of staff (see standard 38) but the manager has plans in place to address this. People do not benefit from a team, which receive supervision. The manager advised that formal supervision has not taken place for some time. Currently supervision is done informally at handover etc. The home should ensure staff receives supervision six times a year. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. 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 home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect. It has some quality systems but these need to be further developed to ensure selfassessment is highlighting shortfalls in the home, which are then addressed. EVIDENCE: People have confidence in the manager. They confirmed that she is approachable and will sort things out. The manager has considerable experience managing this home. She has an NVQ level 4 in care and has recently commenced her Registered Managers Award (RMA). She shows a commitment to improving outcomes for people that live in the home. It was apparent during the visit that people who live in the home feel confident to Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 23 approach staff with any concerns or requests. A professional confirmed the home works well in partnership with them. People are able to give feedback about the home in meetings and through a six monthly questionnaire. This questionnaire has recently been reviewed. Although completed questionnaires could not be found during the visit. Policies and procedures have been reviewed and updated under the new owners. The manager advised these are now more relevant to the home. Good work has gone into reorganising and restructuring paperwork and systems but this is not yet fully completed which was apparent during the visit as not all paperwork could be found. It may be beneficial if more of the manager’s time is surplus to the staffing requirements of the home. The manager advised the owner has yet to undertake a regulation 26 visit. These visits must be monthly and a requirement is made. The home was advised to check the Commissions website for guidance and a template. The home must have their own quality monitoring in place that will highlight any shortfalls, which can then be addressed. Systems need to be improved to ensure peoples health, safety and welfare is promoted and protected. The Environmental Health Officer has visited the home since the last inspection and made one requirement around paperwork, which the manager advised has been implemented. The fire safety logbook could not be found and although the manager advised tests are carried regularly but these are not recorded. The home is advised to contact the Fire Safety Officer to check if a record must be maintained of these tests. Fire equipment is serviced to timescales. A fire risk assessment is in place. The accident book showed a low number of accidents. However this also highlighted confusing following training of what must be reported under regulation 37. The home was advised to check the Commissions website for the latest guidance, template and report as necessary. A requirement is made. The manager advised that no staff have received manual handling training to date although plans are now in place for staff to attend this training. No staff had received training in infection control although four are now undertaking control of infection and contamination. All staff is trained in emergency first aid and fire safety, which is updated annually. Some staff is trained in food hygiene and further training is planned. The home was reminded that cleaning products must be stored inline with COSHH regulations. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA6 Regulation 15(1) Requirement The registered person must ensure that care plans be further developed with people to ensure all care and health needs are identified and staff are have clear information as to how people want to be supported in order to meet those needs. Care plans must be reviewed at least six monthly. The registered person must ensure that robust risk assessments are undertaken and recorded which include steps staff must take to minimise the risk for all risks. Risk assessments must be reviewed at least six monthly. The registered person must ensure that people’s records are stored to ensure confidentiality. The registered person must ensure that action is taken to rectify the premises concerns highlighted during the visit including the stack of old furniture, the tripping hazard in the lounge, a broken pane of DS0000070611.V363996.R01.S.doc Timescale for action 28/06/08 2 YA9 13 28/06/08 3 4 YA10 YA24 17 23(2) 28/05/08 28/06/08 Cornfield House Version 5.2 Page 26 glass, missing wardrobe handles, blown double glazed units, a lack of blinds or curtains and worn carpets. 5 YA30 16(2) The registered person must ensure that the home is kept clean and free from offensive odours and makes suitable arrangements for infection control. In particular the odour in two toilets, dirty windows, supply liquid soap and paper towels to all shared hand washing facilities. 6 YA34 19 The registered person must 28/04/08 ensure that staff are employed in line with DOH guidance and timescales The registered person must 23/05/08 ensure that the provider undertakes unannounced visits to the home in line with guidance Supply a copy of the visits report to the Commission 8 YA42 37 The registered person must ensure that the home report all incidents/accidents in line with guidance 23/05/08 23/05/08 7 YA39 26 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 YA2 Good Practice Recommendations Pre-admission assessments should contain better detail regarding needs and aspirations and take into account DS0000070611.V363996.R01.S.doc Version 5.2 Page 27 Cornfield House 2 3 4 5 6 7 YA7 YA20 YA20 YA22 YA34 YA36 equality and diversity. Any limitations in place which are agreed should be recorded Handwritten entries on the MAR charts should be dated, signed and witnessed. There should be individual written PRN instruction for staff for all medication prescribed as required. The complaints procedure should contain the correct address and telephone number of the Commission The application form should ask for a full employment history The home should ensure staff receive supervision at least six times a year. Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cornfield House DS0000070611.V363996.R01.S.doc Version 5.2 Page 29 - 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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