Inspection on 07/04/05 for Corrina Lodge Nursing Home

This inspection was carried out on 7th 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

Corrina Lodge Nursing Home 30/05/06

Corrina Lodge Nursing Home 22/09/05

Corrina Lodge Nursing Home 03/11/04

Corrina Lodge Nursing Home 27/07/04

Corrina Lodge Nursing Home 25/02/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Corrina Lodge 79 The Avenue Camberley Surrey GU15 3NQ Lead Inspector Mary Williamson Unannounced 7 April 2005 10:00 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. Corrina Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Corrina Lodge Nursing Home Address 79 The Avenue, Camberley, Surrey, GU15 3NQ 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) 0207 3522224 Barchester Healthcare Homes Ltd Margaret Hughes CRH N 51 Category(ies) of OP Old Age - 51 registration, with number PD Physical Disability - 10 of places PD(E) Physical Disability - over 65 - 10 Corrina Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1) In respect of this service, persons accommodated falling within the category OP may be admitted from the age of 60 years and over. 2) Up to ten persons accommodated within the PD category may be admitted from the age of 50 years and over. 3) Up to ten persons may be accommodated in the PD(E) category 65 years and over. 4) One named service user under the age of fifty may be accommodated. Date of last inspection 3 November 2004 Brief Description of the Service: Corrina Lodge is a purpose built home providing accommodation and nursing care for fifty-one service users. The home is located on the outskirts of Camberly in a residential area. The town centre, railway,and amenities are within easy walking distance. Accommodation is provided on two floors, with a stairs and passenger lift access to the first floor. There are fifty-one single rooms, forty-seven of which have en-suite facilities including either a bath or shower. There is an atttractive communal lounge and dining room on each floor. The home stands in secluded well-maintained gardens that have sheltered terraced areas and raised flowerbeds. There is on- site parking available at the side and front of the building. Corrina Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the first in the inspection programme for the inspection year 2005/2006. The inspection took place over five hours and was undertaken by Mary Williamson Lead Inspector for the service. Mrs. Sheila Poulter was the nurse in charge and the acting manager Carolyn Whitfield was also present for part of the inspection. At least twenty service users were spoken to and three relatives also expressed their views. The overall view of the care provided was positive. There was a relaxed and happy atmosphere in the home. The inspector would like to thank the service users, the staff and relatives for their time and input with the inspection. A tour of the premises took place and the home was well maintained, clean and bright. The bedrooms are comfortable and personalised, reflecting individual personalities. Several service users praised the standard and the variety of the food available. Two service users had complained about some dishes but this was resolved during the inspection. Everyone spoken to knew how to use the complaints procedure and there was only one complaint since the last inspection. Some shortfalls were identified in the standard of record keeping and staff recruitment, which have been elaborated on throughout the report. What the service does well: The home provides a good standard of accommodation, which is offered in single rooms. The standard of cleanliness is excellent with all rooms and communal areas cleaned daily. Care is provided to service users in a kind and sensitive manner. Care staff respect individual preferences and wishes. The meals are varied and the menus cater for a wide range of needs and choice. Several of the service users spoke highly of the food available. One service user stated that she enjoys her bingo sessions twice a week. There is a wide and varied programme of activities available and there was a church service-taking place during the afternoon of the inspection, which was well attended. Corrina Lodge Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or Corrina Lodge Version 1.10 Page 7 by contacting your local CSCI office. Corrina Lodge Version 1.10 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Corrina Lodge Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3, and 4. There are shortfalls in the admission procedure as two of the pre- admission needs assessments were not in place. Therefore it was difficult to establish if these specific care needs were being met. Written contracts of occupancy are in place. EVIDENCE: Six care plans were sampled and two of these did not have a pre- admission needs assessment to support the care needs outlined in the care plans. One service user stated that his care plan had been discussed with him but there was no evidence recorded which indicated his dietary preferences. Four of the six care plans seen were not signed by the service user, or a representative. Records kept on a service user who required fluid balance monitoring had not been completed since 18.00 hrs the previous evening. Fluid balance charts are part of individual care plans and necessary to monitor the care provided. Failure to maintain these correctly may put the service user at risk of dehydration and is not good care practice. Corrina Lodge Version 1.10 Page 10 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,and 10 Most of the care needs identified in service users care plans were being net. Care is provided in privacy in a respectful and dignifed manner. There were however shortfalls in fluid balance and oral hygiene which is not good practice. The administration of medication is in line with the homes medication policy. EVIDENCE: Personal care is provided in a caring and dignified manner, which was confirmed by several service users who were spoken to. Individual care plans are in the process of being updated. These need to be compiled with and signed by the service users or their representatives. One service user who was being nursed in bed required fluid balance monitoring to be recorded, and oral hygiene administered. It was observed that his mouth and lips were very dry. There was evidence of pressure relieving equipment in use in the home and there is one service user in the home with a pressure sore. Discussion with service users confirmed access to specialist services for example chiropody, dental care, and regular eye tests. The GP visits the home on a regular basis and details of visits are recorded in individual care plans. Medication is managed and administered in line with the homes medication policy and The Nursing and Midwifery Councils Code of professional conduct. Corrina Lodge Version 1.10 Page 11 The required documentation was in place and all medication records are well maintained. There are no service users who self medicate. Corrina Lodge Version 1.10 Page 12 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) 12,13,14 and 15. The social and recreational activities are varied and appropriate. The catering arrangements and facilities are satisfactory and well managed. EVIDENCE: There is a leisure activities co-ordinator in post who compiles a full and varied programme of events with the help of the service users who wish to contribute to this. One service user stated that she liked the bingo sessions twice a week. Several service users stated that the organised musical events were very good. One service user preferred his own company and his daily newspaper. The church service taking place on the afternoon of the inspection was well attended. There are a number of service users considerably younger living in Corrina Lodge and activities for example action films are shown in an allocated lounge. Family links are maintained and several service users stated that they regularly go out with family. The acting manager also stated that relatives are actively encouraged in the care planning process. Two chefs oversee the catering arrangements and the choice of food offered on the menu is varied and nutritious. Several service users spoke very highly about the food and choice available to them. Two service users complained about the texture of the meat and how they had difficulty in chewing this. A Corrina Lodge Version 1.10 Page 13 discussion took place with the acting manager who confirmed that alternative arrangements are in place for these service users. Corrina Lodge Version 1.10 Page 14 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) 16,17 and 18. Service users and relatives generally felt satisified with the complaints process, and more training has taken place in abuse awareness since the last inspection. EVIDENCE: There has been one complaint since the last inspection and the acting manage followed the homes complaints procedure to manage the complaint efficiently, with a satisfactory outcome. Several service users and relatives spoken to during the inspection were aware of the complaints procedure and felt confident about using this process. Since the last inspection further training has taken place on the Protection of Vulnerable Adults. This was following on from an adult protection issues in the home last year when the procedures were not followed correctly. Several service users were making arrangements to vote in the forthcoming general election and the postal voting system is also in place. Corrina Lodge Version 1.10 Page 15 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 ,20, 21, 22, 23, 24, 25, and 26. Service users individual and communal accommodation is of a high standard which is comfortable and well maintained. Ample toilet and bathroom facilities are provided some of which have been adapted to meet mobility needs. EVIDENCE: The standard of accommodation is very good offering all service users single en-suite facilities, arranged over two floors. All service users spoken to stated that the standard of accommodation was very comfortable. There was evidence to indicate that rooms are personalised some service users stated that they liked the idea of having their own furniture and belongings with them. The home provides a comfortable lounge and dining room on each floor with an extra lounge area on the second floor for some of the younger service users who have different social needs. Facilities are in place to support the less mobile service user and the acting manager stated that specialist advice for example from a physiotherapist or an occupational therapist is available to promote independence. Corrina Lodge Version 1.10 Page 16 The standard of cleanliness is good and one cleaner spoken to was trained in, and familiar with the homes infection control policies and procedures. There is an isolated incident of MRSA infection in the home and this is being managed in line with the homes policies and procedures. Corrina Lodge Version 1.10 Page 17 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 and 29. The number of staff on duty during the inspection was sufficient to meet the physical needs of the service users. The recruitment procedure in the home is not being followed in full. EVIDENCE: The home provides adequate staff to meet the care needs of the service users living in the home. There were three registered nurses on duty eleven care staff. However three service uses stated that they experienced communication difficulties with some care staff. The acting manager stated that this problem had been identified and English classes are being arranged to support two staff members. There were also two cleaners, a housekeeper, laundry assistant, dining room assistant, a chef and kitchen assistant on duty during the inspection The employment records for two new staff members were inspected. Criminal Records Bureau checks were in place but there was only one written reference available in one file. All staff spoken to stated that they all had a job description and contract of employment. All staff spoken to confirmed that they all received induction training. Corrina Lodge Version 1.10 Page 18 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) 31 ,32, 33, 37, and 38. The leadership of the home is being provided by an acting manager who needs to apply to The Commission for Social Care Inspection for registration. The standard of record keeping is generally good but the shortfalls in maintaining fluid balance charts and not having some needs assessments available does not promote good practice. EVIDENCE: The home has an acting manager in place since the last inspection, but has not as yet made application to The Commission for Social Care Inspection to become the Registered Manager. It was clear from discussion with the acting manager that although she is managing the home well, the management structure of the home needs to be organised. This should enable responsibilities to be delegated and adequate time off made available for the acting manager. Corrina Lodge Version 1.10 Page 19 There were no negative comments from service users or relatives regarding the management of the home. There are shortfalls in the standard of record keeping. These have been identified in pre admission needs assessments, fluid balance records, and staff employment records. Fire records examined indicated that the fire alarms were not being checked regularly and there are very large gaps between entries in the fire log. This practice puts the health and safety of the service users and the staff at risk and must be addressed immediately. Records for the monitoring of hot water outlets were not available. Corrina Lodge Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 3 x x x 2 2 Corrina Lodge Version 1.10 Page 21 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. Standard 3 and 4 Regulation 14 Timescale for action A full needs assessment needs to 31/05/05 be undertaken on all prospective service users prior to admission to the home, to enable care care staff to deliver the care required. Service users care plans must be 31/05/05 signed by them or a representative following discussuon Care staff must maintain oral 31/05/05 hygiene of service users, and maintain fluid balance records The service must ensure that 31/05/05 staff employed in the home have the communication skills necessary to understand service users and be understood Two written references must be 31/05/05 obtained for all new staff prior to commencement of employment. A manager must be appointed 31/05/05 and seek registrarion with The Commission for Social Care Inspection. Records must be maintained and 31/05/05 documentation inproved to include assessments, fluid balance records, fire records, and employment records. The fire alarms must be tested 31/05/05 weekly and records maintained. Version 1.10 Page 22 Requirement 2. 7 15 3. 4. 8 27 12(1)(b) and 17(1)a) 18(1)(a) 5. 6. 29 31 19 8 7. 37 17 8. 38 23 Corrina Lodge 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 Corrina Lodge Version 1.10 Page 23 Commission for Social Care Inspection The Wharf Abbey Mills Business Park Eashing Surrey GU7 2QN 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 Corrina Lodge Version 1.10 Page 24 - 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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