Care Home: Comberton Nursing Home

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What the care home does well The home had a friendly atmosphere and people were encouraged to personalise their rooms to reflect preferences and tastes. Accommodation was spacious and comfortable providing people with the aids and equipment they needed. The personal appearance of people indicated that they are supported well with their needs. The staff team were responsive to people and interacted well. People told us that staff is friendly and that they enjoy the food. What has improved since the last inspection? There have been significant improvements in assessing the needs of people and developing care plans that are personal to them. The management and monitoring of health care needs and risks has improved and is more robust. Stock control of medication has improved and ensures there is no over stocking of medication making the system is safer. Medicine coming into the home is accurately recorded to ensure that the new medicine information is correct. The proprietor has replaced the disinfector on the first floor to reduce the risk of cross infection. Clinical waste bins have been replaced and locked to ensure the risk of infection is reduced. The reporting of concerns under safeguarding procedures has improved ensuring people are protected. Meetings with people who live at the home and their relatives have commenced ensuring they have a say about their care experiences. The acting manager has ensured that the improvements we asked for have been addressed ensuring positive outcomes for people who live in the home. What the care home could do better: There is a suspension of placements which means occupancy numbers at the time of our visit were eleven beds lower than the homes registration. The service must carefully consider balancing the current vacancies alongside the current staffing levels and ensure a structured admission process so that the needs of all the people can be met.We consider that the home is meeting the needs of the current people some of whom have high dependency needs. However at full occupancy there will be greater demands on staff. Staffing levels must be kept under constant review and increased in line with changing dependency levels as occupancy increases. To review the current dining arrangements so that people have a choice of social interaction during meals. Ensure that all staff receives updated training relevant to their role and responsibilities. Analyze the feedback from the quality assurance system with a view to continuous improvements. The provider must ensure the acting manager is registered with the Commission. Key inspection report Care homes for older people Name: Address: Comberton Nursing Home King William Street Amblecote Stourbridge West Midlands DY8 4EP     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Monica Heaselgrave     Date: 2 7 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Comberton Nursing Home King William Street Amblecote Stourbridge West Midlands DY8 4EP 01384262027 0138476943 comberton@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Jayantilal James Bhikhabhai Patel Name of registered manager (if applicable) Ms Mandy Coyne Type of registration: Number of places registered: care home 36 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 36 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability (PD) 36 Old age, not falling within any other category (OP) 36 Date of last inspection Brief description of the care home Comberton Nursing Home is located near to Stourbridge town centre. The home is sited in an attractive residential area. The home itself is a large detached property that has been converted and extended to its present form a 36 bedded nursing home. The Care Homes for Older People Page 4 of 34 Over 65 36 0 0 36 Brief description of the care home home comprises of three storeys. Bedrooms are located on both floors. The main living areas, kitchen, offices, laundry and a shower room are on the ground floor, further bedrooms, the bathroom, toilets and the treatment room on the first floor. The lower ground floor accommodates the office and staff room. The home has well maintained gardens to the front and rear and a good sized car park at the front. Comberton is registered to provide care to a maximum of 36 residents who have nursing needs. Please contact the home direct ly to enquire about current fees. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last Key Inspection was on 30 November 2009. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. One inspector visited the home from 10:30 - 17:45. We had discussions with the acting manager, the senior nursing staff, and care staff on duty. We also talked to people living at the home, and made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to The Commission. We looked at a number of records and documents. The previous acting manager submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to the inspection visit. We looked around the premises, looking at communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. Care Homes for Older People Page 6 of 34 As a result of the key inspection in November 2009 the service was given a zero rating. Following the key inspection in November 2009 Dudley MBC imposed a temporary suspension of purchasing approval on all Poor or zero rated services. We carried out a Random inspection in March 2010 to monitor progress and compliance. We found that the home was operating with 11 bed vacancies and there had been considerable improvements. At the time of our visit the temporary suspension was still in place. The findings of both the random and key inspections are used to inform this report. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: There is a suspension of placements which means occupancy numbers at the time of our visit were eleven beds lower than the homes registration. The service must carefully consider balancing the current vacancies alongside the current staffing levels and ensure a structured admission process so that the needs of all the people can be met. Care Homes for Older People Page 8 of 34 We consider that the home is meeting the needs of the current people some of whom have high dependency needs. However at full occupancy there will be greater demands on staff. Staffing levels must be kept under constant review and increased in line with changing dependency levels as occupancy increases. To review the current dining arrangements so that people have a choice of social interaction during meals. Ensure that all staff receives updated training relevant to their role and responsibilities. Analyze the feedback from the quality assurance system with a view to continuous improvements. The provider must ensure the acting manager is registered with the Commission. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 34 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service can ensure the needs of people are identified prior to moving into the home. However they must carefully consider balancing the current vacancies alongside the current staffing levels and ensure a structured admission process so that the needs of all the people can be met. Evidence: Following our inspection in November 2009 we were concerned that admission to the home may be agreed without any reference to a needs assessment. People may be admitted outside the registered category and the home would not be able to meet their needs. We required the service not to admit anyone outside the primary needs of old age and nursing care. We visited the service in March 2010 and carried out a Random inspection. At this time no new admissions had been made since November 2009. This was because Care Homes for Older People Page 11 of 34 Evidence: Dudley MBC had imposed a temporary suspension of purchasing approval on all Poor zero rated services. The acting care manager told us that the home was complying with this suspension. We found that improvements had been made to ensure the service had procedures in place for the pre assessment and admission of people. Pre admission documents had been improved so that all future admissions to the home would be within the registration category to ensure the needs of people can be met. We saw the pre assessment document. This was seen to be comprehensive covering all aspects of need and included information relating to other professionals that may be involved or needed such as the district nurse or occupational health. There was a process in place that identified the Acting Manager or the RGN as the responsible person for carrying out all pre admission assessments to ensure they are thorough. This will enable the service to confirm the needs of the person are within the registered category for the home. We were told that the pre assessment can take place either in the persons own home or via them visiting Comberton Nursing Home. We saw that people are advised of this process in the pre admission policy which is given to enquirers. Following the pre admission assessment a placement will be offered only if the needs assessment indicates that the home can meet those assessed needs. We saw that there is a letter to send to people following their assessment confirming the home can meet their needs and confirming their agreed placement. We were told that there have been several enquiries for placement to the home and that they have now drafted a Bed Enquiry form designed to capture initial referral information and dependency levels. This also indicates whether the enquirers dependency needs are high, medium or low and whether or not they are suited to the category for the home. We found that improvements had been made in relation to needs assessment with additional improvements seen to be in place for the admission of new people. This process is now more robust and provides a clear framework for the assessment of needs thus ensuring places will be offered to people only where the home is able to meet these needs. As there have been no admissions to the home these procedures have not yet been fully tested but we consider that the requirement we made has been met. It has only been a number of weeks since we last visited the service. The suspension on placements is still in place. The service currently has eleven vacancies. There is also a recruitment drive underway to ensure staffing levels are increased in line with the increase in occupancy levels once the suspension is lifted. We discussed with the Acting Manager the need to show that the service can Care Homes for Older People Page 12 of 34 Evidence: consistently apply these new processes. They must demonstrate that new admissions to the home will be structured in line with the increase in staffing levels. This will ensure that whilst considering the needs assessment they also consider the capacity of the service staffing to meet the needs of people. In this manner the service can demonstrate definite improved outcomes for people. Care Homes for Older People Page 13 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans contain clear information about the changing needs of individuals. Health care monitoring records show that staff has worked consistently and monitored needs to ensure individuals receive the care they need. Medication systems are sufficiently robust to ensure everyone receives medication prescribed for them. Evidence: At the key inspection in November 2009 we issued six requirements relating to care planning and health care. We carried out a Random inspection visit in March 2010 to monitor improvements in care planning. We found that significant improvements had been made. The care plans that we saw provided staff with detailed information about how they should assist people to meet their individual needs. Care plans were seen to be personal to the individual including a personal history and identifying choices and desires. For instance one stated the person enjoyed time in her own room. To meet her needs in relation to hearing she has been provided with ear phones so can listen to the TV and the home contacted Birmingham Institute for The Deaf to provide CDs so she can follow news reports. She Care Homes for Older People Page 14 of 34 Evidence: also has a newspaper from BID. It is positive to see that the home has tried to provide individuals with the aids to follow their personal interests. The care plan also reflects a personal care routine and how the individual is supported with this. The choices made in relation to personal care were recorded in the care plan and these items were evident in the bedroom. During our second inspection some weeks later we found that the care plans had been continually updated as needs had changed. For instance following bereavement the care plan for one person had been updated so that staff could understand how to support the individual. Areas of changed needs had been identified in relation to being off her food and having restless nights. Consideration had also been made concerning the bedroom and sleeping arrangements. This shows the home has a good understanding of grief and has responded to the changing needs with sensitivity. The system for updating care plans has been consistent. Care plans included evidence of appropriate strategies to reduce risks. For example strategies for managing behaviour that can challenge. There was evidence of assessment by the behaviour team. The triggers for the behaviour were known and reflected in the care plan. The peak times for such behaviour to occur were recorded and actions evident to support the person to have a quiet time away during peak times. The care plan also highlighted the medications in use. These were noted to be well documented with clear reasons for the use of PRN or as required medication in place. Staff showed a good understanding of how to meet this persons needs. During both of our visits we observed staff interacting positively and following the guidance we saw in the care plan for this person. We saw examples of good outcomes for people who have diabetes. The care plans were up to date and stated the condition clearly. The plan was comprehensive and gave guidance to staff on the optimal blood glucose range. It provided guidance to staff on what to do if the blood sugar was low. It clearly stated the frequency of monitoring blood sugar and what further steps to consider if the individual was unwell which could alter blood sugar levels. Equipment people may need to manage their diabetes was evident and recorded in the care plan. Contacts with the diabetic nurse and or clinic were evident. We found during both inspection visits that there are robust systems in place to manage the risk of developing pressure sores. Care plans identified where people were at risk from developing pressure sores. Risk assessments were seen to be in place and up to date. These identified clearly the risk and the preventative steps to minimize the risk. This included the equipment necessary to reduce the risk such as the type of pressure relieving mattress for improved pressure relief. The care plan provides staff with precise guidance in providing pressure relief to include observing for any redness Care Homes for Older People Page 15 of 34 Evidence: or discoloration of the skin or infection. This means the persons skin integrity is checked regularly. Turning charts were evident for people requiring pressure relief. These showed regular two hourly pressure relief was occurring. Turn charts showed the time staff had turned the person and onto which side. On both the Random and our second visit we observed that staff was consistent in this area ensuring they turned people two hourly and recorded this. This ensures people who need it receive consistent pressure relief. We were told 6 people have broken areas and use pressure relieving mattresses. A sample of these was included in the people we case tracked and we saw their mattress and pillows in place and turning charts. Pressure relief is known and practiced and evident in their care plans. We saw guidance for maintaining a nutritious diet. This was supported by a nutritional risk assessment which identified the risk clearly and the nutritional supplement needed. We looked at the medication records and saw the nutritional drink had been prescribed. We cross referenced this with the fluid monitoring charts which showed the vitamin supplement is actually drunk. We spoke to care and nursing staff who were able to identify those people who required support to maintain adequate fluid and food intake. We saw food and fluid monitoring charts were in place for each of these people. The charts showed what had been eaten and drank and the quantity. The entries were consistently made and dated. This means people are not at risk of inadequate nutrition or dehydration which could cause discomfort and infections. We also saw that where eating patterns had changed through for example grief staff was sensitive to this. The care plan had been updated to show the individual was off their food and how to encourage this. At the Random inspection Visit in March 2010 we found that the system in place for reviewing risk assessments in respect of bed rails had improved. Where it is deemed that a person is a risk of falling out of bed alternative options should be considered to safeguard them. We viewed three bedrooms belonging to people who require a bedrail. We saw that bedrails were in place as reflected in their care plan. Staff showed us risk assessments for each person using bedrails. These showed the reason why the person required bedrails and why other options are not safe. This ensures that controls have been considered and explored in the best interests of the individual. For example one risk assessment says the individual is unable to maintain her balance and good positioning due to a stroke. This causes her to lean to one side where she is at risk of falling from the bed. The risk assessment is signed by the assessor in this case the acting manager. It is positive to see that the resident and or their family Care Homes for Older People Page 16 of 34 Evidence: have been consulted on the use of the rails and signed agreement for this. Risk assessments are dated ensuring staff has current guidance. We spoke with the maintenance man who confirmed he and the acting manager do monthly audits on all bedrails to ensure they are in good repair and safe for use. We saw the audit book which showed where adjustments or repairs have been made to rails. The manager told us 21 people currently use bedrails and the same format is in use for all showing the controls in place to manage the risks. Risk assessments show the recommended safe measurements between the rail and mattress so that there is no risk of entrapment. During the key inspection visit we found that the management of risk in this area has been consistent. Following the Random inspection in March 2010 we considered that the six requirements relating to care planning and health care had been met. During our second inspection visit in April 2010 we found the service had continued to update their care plans ensuring they are more person centred and contain clear information about the changing needs of individuals. The care plans and health care monitoring records showed that staff have worked consistently and monitored needs to ensure individuals receive the care they need. Care Homes for Older People Page 17 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a range of activities for people to enjoy with plans for further development to expand these so that everyone can be supported to engage more fully. People are encouraged and supported to maintain important relationships and friendships. People are provided with meals they enjoy and receive support to maintain an appropriate nutritional diet. Evidence: The daily routines at the home were flexible. People we spoke with told us their preferred daily routine, such as rising, retiring, bathing, showering and food preferences are generally of their choosing. We saw that care plans reflect some preferences and guidance to staff as to individual preferred daily routine. We spoke with the activities co-ordinator who showed us a folder with a range of activities that people had engaged in. This included activities and plans for people with dementia or cared for in bed. It was positive to see that she maintained a record of whether people enjoyed activities to guide whether changes were needed. There was an activities programme displayed on the notice board and the activity worker goes round to individual people with a leaflet of planned events to inform them of what is planned. There have been regular trips, movement to music sessions, aromatherapy, Care Homes for Older People Page 18 of 34 Evidence: PAT dogs visits, bingo and craft sessions. Specialist equipment and aids such as talking books were being sourced for one individual. During the inspection visit we did observe craft activities and music. Some individual people have a varied social life outside of the home supported by their relatives. Most people we spoke with seemed satisfied that there are options if they choose to engage. There were regular church services in the home where people could participate if they chose. The home had an open visiting policy, which meant that people were able to maintain important relationships. A relative confirmed that they could visit at anytime. People told us that staff consult with them about their preferred options from the menu. They said that the meals were generally to their liking. There were food and fluids records which had been consistently filled in and showed nutrition and fluids are promoted. Observation of the meal time showed staff knows how to support some individuals and this was with discretion and sensitivity. The lounge area has dining tables but not everyone can be seated at the same time. We observed a number of people eating their meals at a small side table in their arm chair. Some of these people were able to tell us that they preferred this option. Not everyone would be able to express a preference due to their dementia. Staff need to keep this under review as sitting to the main table offers social opportunities and stimulation that some people may enjoy. Care Homes for Older People Page 19 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are effective systems in place to ensure people are protected from harm. Evidence: The service has a complaints procedure that is displayed on the notice board. Not everyone would be able to advocate for themselves. We discussed this with the acting manager. She was able to demonstrate that she had established one to one meetings with families during which they could review the care and or raise any concerns they may have. This ensures that some concerns can be managed before they become a complaint and also ensures people are listened to. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. At the previous key inspection of November 2009 the reason for the use of bedrails was not documented. A record of an incident indicated that one person had bed rails in place and they did not require them which could constitute restraint. Where it is deemed that a person is a risk of falling out of bed alternative options should be considered to safeguard them. We carried out a Random inspection in March 2010 and saw that the home has in place effective risk assessments which clearly show the reason for the use of bedrails. At this the key inspection we sampled records and saw no evidence that bedrails are used as a means of restraint. We found that people who required bedrails did so for Care Homes for Older People Page 20 of 34 Evidence: their safety and that this was clearly documented and kept under review. This means the system for the use of bedrails is risk assessed with robust review. The service had been required to ensure effective systems are implemented to ensure all safeguarding issues are referred to the Local Authority safeguarding unit. We saw at the Random inspection in March 2010 that people are effectively safeguarded. An incident at that time demonstrated that staff knows how to report concerns and that the documentation of concerns is robust. We saw that an appropriate accident report was completed with the details of the accident. We saw that body maps are completed to identify the location of injuries. Accidents and incidents had been notified appropriately to the commission via Regulation 37. We noted the accident had been appropriately referred under the safeguarding procedures. An investigation had taken place to identify the cause and records showed that the home had taken appropriate steps to protect the person from further injury. We also saw that the manual handling review sheet had been updated and the risk assessment to reflect the poorer mobility and the use of the hoist. From the records available it is clear that Comberton have improved their documentation and that there is an awareness to refer incidents under safeguarding. They have a good audit trail of the steps they have taken and these are in line with good practice. The training matrix showed that staff received training in safeguarding and discussions with staff showed they know what to do in the event of an accident or allegation of abuse. The acting manager provided evidence that care staff had been booked onto training in respect of the Mental Capacity Act and the Deprivation of Liberty safeguards. This will ensure staff knows their responsibilities in supporting people who lack capacity to make decisions. In such events decisions are made in the best interests of the individual to protect their welfare and well being. Care Homes for Older People Page 21 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a very pleasant and safe environment and have the aids and equipment to meet their needs. Evidence: Comberton Nursing Home is a detached three storey home for older people located in a residential area close to Stourbridge. The frontage of the building is well maintained with pretty garden areas and a wealth of flowers and shrubs with seating areas for people to sit out. There is ample off road parking to the front of the building. Access into the building is by a number of steps. There is level access to the rear of the building and we saw some people who use a wheelchair access this route. There was ample space for visitors to park near to the door for ease of access. The garden to the rear is well maintained and a pleasant area for people to sit out when the weather permits. A partial tour of the home was undertaken and it was found to be warm, clean and maintained to a good standard. Communal areas were looked at and a sample of some of the bedrooms and bathing facilities relevant to people we case tracked. We found the home was clean with no odour. People we spoke to said the home was comfortable and that they could access toilet and bedroom areas without difficulty. There is a small lounge where some people choose to socialise and to eat their meals. Care Homes for Older People Page 22 of 34 Evidence: To the rear of the property a larger lounge area is located with dining tables incorporated into it. We observed that people used the tables to participate in activities on a regular basis. A large screen television and music centre is available for people to enjoy. Not everyone sits to the dining tables for meals. Some people told us they prefer to have a smaller table at their arm chair. Some people we saw had their meals in their rooms. The number of dining tables would not provide opportunity for everyone to sit at the table for meals and so staff needs to keep this under review to ensure people have this opportunity should they wish. At a previous inspection visit the lounge area was described as very crowded with a lack of space to move around. At this visit the home was operating at eleven beds less than it can accommodate so it was not possible to establish if this was a difficulty. However there are systems in place for auditing the service and we are confident that the service can consider this need as the needs of more people dictates. There are twenty single bedrooms and eight double bedrooms. All are provided with wash hand basin and call bell so people can call for assistance if required. Some people told us they brought in some of their own possessions. We saw that bedrooms were personalised and reflected individual tastes and preferences. There is a bathroom on each floor with assisted bathing facilities. This means people have a choice of bathing facilities. Toilets are strategically placed around the home. We noted at this and our previous visit that cleaning chemicals had been removed from these areas and stored appropriately to minimise the risk to people living in the home. A passenger lift enables people to access all areas of the home. There is a range of equipment to assist people with reduced mobility. We saw that certificates were in place to show all such equipment such as portable hoists had been regularly serviced ensuring they are safe for use. The main kitchen was clean, well organised and adequately equipped for its purpose At our previous visit the disinfector on the first floor needed to be repaired or replaced. We saw a new disinfector had been installed which will ensure the risk of cross infection is minimised. It was noted at the previous visit that the large bins outside the home for the storage of clinical waste were not locked. At this visit we saw new bins had been purchased and were locked to ensure safe storage and reduce the risk of infection. Care Homes for Older People Page 23 of 34 Evidence: Policies and procedures for the control of infection were in place. Laundry equipment included a sluice and pre-wash cycles. Liquid soap and paper towels were evident to ensure safe hand hygiene for staff. Protective clothing such as gloves and aprons were seen in all high risk areas. Care Homes for Older People Page 24 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs of people are currently being met by the numbers of staff on duty. However there is a significant lower occupancy level and the service must ensure staff ratios increase in line with increased levels of dependency. Staff requires further training updates to ensure they have the knowledge and skills to meet peoples needs. Evidence: As a result of the key inspection in November 2009 the service was given a zero rating. We issued three requirements in the staffing outcome area. We required a review of the number and deployment of staff to ensure there is sufficient staff on duty at all times to meet the dependency needs of people. Checks are completed for newly employed staff before they commence working in the home to ensure people are safeguarded. All staff should receive updated training in respect of fire prevention to ensure staff skills remain up to date, they have knowledge of current good practice and people are safeguarded in the event of a fire. Following the key inspection in November 2009 Dudley MBC imposed a temporary suspension of purchasing approval on all Poor or zero rated services. We carried out a Random inspection in March 2010 to monitor progress and compliance. We found that the home was operating with 11 bed vacancies. The acting manager told us that they were managing the needs of twenty five people. She told us Care Homes for Older People Page 25 of 34 Evidence: that 168 nursing hours per week are needed when at full occupancy but with eleven vacancies this is manageable with her current staff compliment. She showed us a resident dependency levels chart dated 2.3.10. Each resident had been assessed by the home to identify their needs and whether they had a high medium or low dependency level. We also saw an evaluation sheet for mobility. Information from these records shows that ten of the twenty five people require hoisting. Eight of the twenty five people require a wheel chair. Seven of the twenty five people are mobile. Five people are high dependency. Two people require a peg feed. Four people have a catheter and twelve people require help with feeding. The staff ratio worked out as one staff to five people on a shift with an RGN leading the shift. A range of ancillary staff support the care staff. We saw during both visits that some people are nursed in bed. We found the arrangements for meeting their care and health needs were consistent. Staff had detailed information from care plans and health records to ensure they could identify and respond to needs. We saw that the needs of people were met consistently and that monitoring of needs was robust. Observations made showed staff to be responsive to needs. Discussion with individual residents showed that they had no concerns about the time it took for staff to assist them. The care plans showed that personal needs and routines were known and staff met these needs without difficulty. We considered that the home has met the requirement made to review the dependency levels of the people being cared for. At this visit the suspension of placements is still in place. Occupancy numbers continue to be significantly less than the service is registered for. The Acting Manager told us that they are undertaking a recruitment drive so that they can employ staff with the necessary skills and experience so that the home can meet the increased occupancy levels. The service must therefore demonstrate it has sufficient staffing to meet full occupancy levels. This means the number of and skill mix of staff is appropriate to the assessed needs of the people being cared for. We will continue to monitor this area during our next regulatory activity. We issued a requirement that the manager must ensure all checks are completed for newly employed staff before they commence working in the home to ensure people are safeguarded. At the Random visit in March 2010 one staff has been recruited since our last visit in November 2009. Inspection of this staff file showed that appropriate checks had been made to ensure the person was suitable to work with vulnerable people. The POVA Protection of Vulnerable Adults and CRB certificates were seen to verify this. Two references had been obtained from previous employers indicating the suitability of the employee. Interview notes were evident demonstrating that the home had sought to explore the applicants character Care Homes for Older People Page 26 of 34 Evidence: and responses to the care task to assist them in making a judgment regarding suitability. We talked to the acting manager who demonstrated a good knowledge of her responsibility to ensure a robust recruitment procedure. The system in place ensures an audit trail of documents sent for and returned. The management has reviewed the recruitment procedure and taken action to ensure a more robust procedure which ensures people are protected. We considered that the service had met this requirement. There had been no change at this visit. Since the Random visit in March 2010 the Acting Manager sent us an updated training programme in respect of fire prevention training for staff. This showed that staff has received fire training to ensure their skills remain up to date and that they have the knowledge of current good practice and people are safeguarded in the event of a fire. We consider this requirement has been met. The Acting manager showed us a training matrix. This identified where staff needed refreshers and updates in their mandatory training. This showed us that she has begun the process of reviewing the teams training needs. She provided a copy of the training request form to confirm that staff has been booked onto a variety of training courses. The manager is aware that there are some gaps in the training programme and plans to deal with this. Care Homes for Older People Page 27 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The acting manager is improving and developing systems to ensure a more robust monitoring of practice. The service must now consolidate this and demonstrate consistency in managing sustained improved care practices and positive outcomes for people. Evidence: The home has had a recent history of instability. The key inspection of 11th September 2008 shows they were given a two star rating. A further key inspection of 3rd November 2009 found a number of areas that required attention. As a result of those findings we gave them a zero rating. Dudley MBC imposed a temporary suspension of purchasing approval on all Poor zero rated services. A random inspection visit took place on 22nd March 2010 to check the homes compliance with the twenty five requirements issued at the key unannounced inspection on 3rd November 2009. These related to the admission process, reviewing risk assessments, risk assessments for the use of bedrails, care planning, Care Homes for Older People Page 28 of 34 Evidence: management of pressure relief, ensuring people receive an adequate diet and fluid intake and nutritional supplements, management of incidents of bruising and appropriate follow up to ensure the protection of people, and the arrangements for the safe administration of medication. Requirements were also made for improvements to the environment, the review of the staffing numbers and dependency level of the people being cared for, ensuring appropriate recruitment checks, updated staff training in respect of fire prevention, and that the proprietor ensure a manager is registered with the Commission. Following the key inspection in November 2009 the provider told us in their improvement plan that a more experienced manager had been recruited. The current acting manager commenced employment on 11th January 2010. The acting manager is not registered with the Commission. We found at the Random inspection that she had addressed the majority of the requirements made and has put in place systems for the continued auditing and monitoring of all aspects of the care practice. She demonstrates a sound knowledge of and ability to manage the home. She has worked to the homes improvement plan and to the requirements and recommendations we made at our Random visit. At this key inspection she demonstrated continued improvements. We saw that the care planning and management of risk has been completely updated. We saw that the assessment of need is thorough and care plans are updated as changes occur. Staff is well informed of their role and responsibilities via staff meetings ensuring care is consistent and the continuity of care is evident for the individual. We saw that there have been improvements in obtaining relevant staff training to target priority areas relevant to their practice. We were told that a staff recruitment drive is currently underway to increase the number of staff available alongside the proposed increase of occupancy. The acting manager has begun to re establish the quality assurance process. This involves the self auditing of practice areas. We saw that the acting manager had displayed on the notice board dates when she is available to have one to one meetings with families. This enables them to discuss their wishes and or concerns and she can obtain feedback on how the service is performing. We saw that questionnaires have been displayed in the hall so people can complete them confidentially and provide feedback to the service. A carers meeting had been organised for May 2010 which provides a platform for people to come together and discuss their experiences. We Care Homes for Older People Page 29 of 34 Evidence: consider that the acting manager has demonstrated that the quality assurance system is now re established and they are seeking feedback from people who use the service in order to create a development plan for areas of improvement. This should ensure continuous improvement. These initiatives demonstrate an inclusive and open management approach. We found that care records are clear organized and up to date and support the practices seen. The progress that has been made is visible with improved outcomes for the people who live there. The home is running smoothly with a clear structure and delegation of tasks to ensure the well being of the people living there. Health and safety maintenance checks had been undertaken in the home to ensure equipment was safe and in full working order. The acting manager inherited a number of areas that required attention. As a result of those findings we gave them a zero rating. Dudley MBC imposed a temporary suspension. Whilst much has been achieved in a relatively short time the service must now demonstrate that they can manage sustained improved practice. This will commence when the suspension of placements is lifted and there are greater demands on staffing. It is important therefore that the service has in place a management plan to address staffing and admission processes. The acting manager told us she is in the process of submitting her application to be registered with CQC. Care Homes for Older People Page 30 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 The service should make 07/05/2010 arrangements to ensure that medication administration records are accurately maintained and checked. This is to ensure that information recorded on the medicine record charts is accurate to ensure the health and welfare of people living in the service. 2 9 12 The service should make 07/05/2010 arrangements to ensure there is an effective system in place to request, obtain and retain adequate supplies of prescribed medicines so that stock levels are kept at a safe level. This is to ensure the amount of medicines stored within the service is a safe level to ensure the health and welfare of people. 3 31 8 The proprietor must ensure a 28/02/2010 manager is registered with the Commission to ensure effective leadership and management systems are implemented in the home to safeguard people. Care Homes for Older People Page 31 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 12 There must be a planned structure for the admission of people. This is to promote and make proper provision for the increase in people and their dependency levels and ensure assessed needs can be met. 16/07/2010 2 27 18 There needs to be a structured programme of staff recruitment in line with increased dependency and occupancy levels. This is to ensure the numbers of staff are appropriate to the assessed needs of the people living in the home. 17/07/2010 3 31 8 The proprietor must ensure 18/07/2010 a manager is registered with the Commission. To ensure effective leadership and management Care Homes for Older People Page 32 of 34 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action systems are implemented in the home to safeguard people. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 To continue to update care plans and health records to reflect changing needs ensuring a robust system for monitoring and meeting needs. It is recommended that a review of the activity programme is undertaken with people to ensure it meets peoples preferences and interests especially people with dementia and those cared for in bed. It is recommended that a review of where people take their meals is undertaken to ensure people have a choice in engaging in the social aspect of sitting to the table. The identified training in the proposed training plan should be completed. This will ensure that staff understand their role and responsibilities in respect of safeguarding and the Mental Capacity Act and the Deprivation of Liberty Safeguards. Consideration should be given to developing the communal areas, so people have sufficient space to move around and the opportunity to take their meals at the dining table. Staff should receive updated mandatory training as identified in the training proposal. It is recommended the feed back from the quality assurance process is drawn up indicating planned areas of improvement to ensure continuous development. 2 12 3 15 4 18 5 19 6 7 30 33 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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