Inspection on 16/01/06 for Home Of Comfort Nursing Home

This inspection was carried out on 16th January 2006.

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

The inspector 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

Home Of Comfort Nursing Home 21/11/08

Home Of Comfort Nursing Home 11/01/07

Home Of Comfort Nursing Home 20/07/05

Home Of Comfort Nursing Home 14/12/04

Home Of Comfort Nursing Home 27/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Home Of Comfort Nursing Home 17 Victoria Grove Southsea Portsmouth Hants PO5 1NF Lead Inspector Jan Everitt Unannounced Inspection 16th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Home Of Comfort Nursing Home Address 17 Victoria Grove Southsea Portsmouth Hants PO5 1NF 023 92 730063 (023) 92 730063 hocomfort@aol.com 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) The Home of Comfort Charity Mrs Patricia Irene Evans Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Terminally ill (8), Terminally ill over 65 of places years of age (30) Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One male service user may be admitted to the home at any one time. This male service user must be a partner of one of the female service users. A risk assessment must be carried out prior to the admission of a male service user. A maximum of 8 service users in the TI category can be accommodated between the ages of 55-65 years of age. 20th July 2005 Date of last inspection Brief Description of the Service: Home of Comfort is a care home providing nursing and personal care for 30 ladies over the age of 65 years. The home is also registered to accommodate service users with life limiting disease with the condition that only 8 may be accommodated between the ages of 55-65 years. The registration also has a condition that one male may be accommodated at any one time, providing he is the spouse of a service user. The home is owned and administered by The Home of Comfort Charitable Trust and is represented by a management committee, one of whom is the named responsible individual stated on the certificate of registration. The home is located in the pleasant residential area of Southsea, close to Portsmouth city centre and in walking distance from the sea front and local amenities. The home is two converted Victorian houses on three floors with a purpose-built three-storey wing added in the 1960s. A newer conservatory lounge has been added in recent years. The home has a well-maintained garden that surrounds the home and is accessible to service users who make use of it in the finer weather. All rooms are single accommodation. There are two shaft lifts installed Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 16 January 2006 over a period of 5.5 hours. The deputy manager and a senior nurse assisted the inspector throughout the process. The inspector toured the building; spoke to a number of service users and two relatives that were visiting the home at the time. Comments from service users and the relatives were very positive and there is a general high degree of satisfaction with the care and services delivered in the home. The home was accommodating twenty-six residents at the time of the inspection. The inspection process assessed 13 standards, of which 8 were core standards to be assessed in the inspection year of 2005/6. The inspection found that one standard had a minor shortfall and two core standards had major shortfalls, all of which are discussed in the main body of the report. The home has a friendly welcoming atmosphere and is well maintained and has a high standard of cleanliness. What the service does well: What has improved since the last inspection? The floor covering has been replaced in the area used by the hairdresser. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 11 The service user’s health, personal and social care needs are set out in an individual plan of care, however, these care plans are not easily accessible to staff or service users and care cannot be tracked. Service users are protected by the home’s policies and procedure for dealing with their medication, but the recording of the administration is not accurate. Service users and relatives are assured that at the time of death, staff will treat them with care, sensitivity and respect. EVIDENCE: At the time of the inspection the care planning system was recorded electronically and the registered nurses on duty were the only staff able to access the information. The system was not working well. The inspector attempted to track a sample of the care planning records and was unable to, owing to either the system failing and losing information spasmodically or the information was not available or had not been recorded. The inspector viewed paper copies of the risk assessments but there appeared no care plans to follow-up any identified risks. The inspector could not evidence risk Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 10 assessments on the use of bedrails and a record of discussion and agreement with the service user for their use. The care plans that were recorded were not specific to the service user and lacked detail. The staff did not trust the system because of the failures and were not confident in using it and therefore no one person took ownership of the plans and some information was not being recorded. The inspector spoke to the nursing staff on duty at the time and they admitted they did not like the system and much preferred the handwritten care plans and records that all the staff could access to inform their practice. Further discussion will take place with the manager as to the requirement to maintain records and the nurse’s accountability for record keeping. The home has policies and procedures in place to guide practice when dealing with medication. The home has medication delivered in the monitored dosage boxes (MDS) except for the medicines that are prescribed to service users, as they need them. (PRN). The inspector viewed the cupboards and medicine trolley and observed them to be tidy and clean with no evidence of overstocking on medicines that are prescribed PRN. At the time of the inspection there were no service users needing controlled drugs. One service user was having their tablets broken up for ease of taking and this was recorded in the old paper care plans and had been agreed with the service user and the GP. The medicines administration recording sheets (MAR) were viewed. The inspector identified that the records showed that medicines were always being administered one day behind the actual date they were signed for. This was discussed with the nurse who explained the system and reported that it was because the cassettes were delivered one day but they in fact start a day later. She said that they understood the system and it had been like it for some time. The inspector viewed this as very confusing and difficult to audit and also constituted drug error and poor recording. Further discussion with the supplying pharmacist is necessary and this will be discussed with the manager and requirements made around this issue. The home is registered to provide care for those with terminal illness. Palliative care training has been provided to a number of the nurses. The nurse reported that the service users are much frailer on admission to the home and many of them are in the last stages of their lives. She reported that their wishes with regards to their care and care after death is recorded if they wish to disclose this information or if relatives wish to discuss this with the staff. The home has a Christian ethos and service users spiritual and religious needs are met. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Service users maintain contact with family, friends and the local community. EVIDENCE: The home has a policy for visiting and times are between 10am and 9pm. The nurse clarified that visitors are welcome at other times but the home would prefer if they were informed beforehand to ensure security of the home and service users. This information is given to the service user and relatives on the initial visit to the home. The visitor’s book evidenced many visitors to the home during any one day. Service users may entertain visitors in the privacy of their own room or one of the lounges. At the time of the inspection a volunteer from the community came in to collect shopping lists to do the shopping for the service users who are unable or do not wish to go out. Groups visit the home at festive times of the year. Service users may go out with relatives into the community if they are able but many of the service users are incapacitated and unable to do so. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: The complaints procedure is displayed on the wall in the hallway area. This describes the process and steps to take if a person wishes to make a complaint. It documents the CSCI contact number and address should the complainant not be satisfied with the home’s investigation. The nurse reported that no complaints had been received by the home since the last inspection. The CSCI has not received any complaints. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 22 Service users live in a safe, clean and well-maintained environment. Service users have suitable and sufficient lavatories and washing facilities. Service users have sufficient specialist equipment to maximise their independence. EVIDENCE: The home is comfortable and homely and is maintained to a good standard of cleanliness. At the time of the inspection the dining room was undergoing refurbishment and the entrance doorway to the room had been widened to accommodate wheelchairs more comfortably. The inspector visited the room and the work was nearing completion and was awaiting new floor covering. The nurse reported that service users had been consulted on the dining room being taken out of service for the duration of the alterations and they had agreed to either eating in their rooms or at tables put in the lounge area. Service users spoken with did not object to this and said they had been Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 14 informed of the temporary arrangements. The home does employ a maintenance man who was in the process of decorating a bedroom at the time of the inspection. The home has a pleasant well-maintained garden that surrounds the home and the service users report to make use of the garden during the finer weather. One service user walks in the garden every morning whenever weather permits. The floor covering has been replaced in the first floor area that is used for hairdressing. This was a requirement from the previous inspection repor The home has the required number of assisted bathing and facilities to meet the needs of the service users. There are no en-suite facilities in the service users’ rooms but washbasins are fitted in every room. Toilets are in easy access of communal areas and service users’ rooms. The home has two shaft lifts installed and a stairmatic aid to negotiate a set of three steps to access two rooms. Call bells are situated in all bedroom and communal areas. The home has had radio call bells installed in both lounges to avoid any trailing wires. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29 Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The home is committed to staff training and nine carers have achieved NVQ level 2 qualifications, five of whom have level 3 as well. A further two of the nine are undertaking the NVQ level 3. The home does not use agency staff but does use agency carers when the need arises. The home has robust recruitment practices. The inspector viewed a sample of recruitment files for two recently employed staff. All documentation required to be maintained and stated in Schedule 2 of the Care Home Regulations was present. The administrator leads the recruitment process along with the manager and interview notes are recorded. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 & 37 Service users’ financial interests are safeguarded. Service users’ rights and best interests are not safeguarded by the home’s record keeping. EVIDENCE: Service users are able to manage their own financial affairs if they are able and wish to do so. The administrator is an appointee for one service user. A sample of service users financial records was viewed. The records were maintained and all receipts were in place and the monies in place matched the balances on the records. The inspector evidenced a record of valuables held by the home for one service user. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 17 Records of care are maintained on the computer and the home is registered with the data protection act 1998. Service users would have difficulty accessing their records on the electronic system but would be able to have a printed copy of their care records if requested. The recording of incidences and accidents in the home is, at present, poor. Accidents are being recorded electronically and the systems failure has resulted in these not being accurate and no copy available for tracking. The inspector attempted to track a service user who had fallen from her bed because of the bedrail collapsed and had suffered extensive bruising to the face. There was an electronic record of this on the accident-reporting format, but the report was not detailed and the nurse did not sign it. This could not be tracked to the daily records. The reporting of incidences and accidents must be reported to the CSCI on Regulation 37 reporting forms. This had not been received by the CSCI. The service user’s son was spoken with and he reported that the home informed him of the accident the next morning. The accident reporting procedure must be reviewed and accurate records maintained with documentation of how the accident occurred and action taken following the accident. The health and safety executive must be informed via a RIDDOR form of any accidents that involve equipment failure. An immediate requirement was made with reference to the appropriate reporting of this accident. A requirement will be made around the accident reporting procedure. Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 3 3 X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 X 1 X Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15(2) Requirement The care planning system must contain accurate records of assessments and care plans and must enable staff to have information to inform their practice. The electronic care planning system must be reviewed and be assessed as to its effectiveness as a working document. Records of administration of medication must be accurately documented to reflect the correct date of administration. Records of all accidents, incidences must be recorded in individual care plans. Accidents must be recorded on a separate recording format with details of the accident and action taken. Accidents that occur and involve equipment or apparatus must be reported to the Health and Safety Executive via RIDDOR. Timescale for action 31/03/06 2. OP9 13(2)17(1 )a Sch 3 17(1)(2) Sch 4 10/03/06 3. OP37 10/03/06 Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Home Of Comfort Nursing Home DS0000011514.V254759.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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