Care Home: Corbrook Court

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What the care home does well Corbrook Court has a relaxed, friendly and welcoming atmosphere. The people who live at the home have good relationships with staff and enjoy friendly, respectful and good-humoured interactions. They told us that they always or usually receive the care they need and speak highly of the staff team commending them for their professionalism and dedication to duty. For example one person said "The quality of the care is exceptional" and another said they "believe the standard of care, professionalism & homely atmosphere to be exceptionally high standard". All the people we had contact with told us that the food is always or usually good and some people said it is excellent. Special dietary needs are catered for and menus confirm that a varied and nutritious diet is on offer so people can have a healthy diet. The accommodation is spacious, comfortable and maintained to a high standard. One person who lived at the home said the views are breathtaking and each day they count themselves lucky to be fortunate enough to be able to enjoy them.People who live at the home told us the home is always clean and fresh so it is pleasant for them to live in. Effective management and quality assurance systems ensure that the Corbrook Court is run in best interests of the people who live there. Management encourage staff members to undertake nationally recognised qualifications beyond the basic requirements, and they recognise the benefits of a skilled, trained workforce so people who live at the home are in safe and competent hands. What has improved since the last inspection? Morris & Co Limited, the company that runs the home, have effective quality assurances arrangements and work to make sure that the accommodation, services and the standards of care are continually improved so the changing needs of the people who live at the home are met. The premises have been extended to provide accommodation in 45 bedrooms all with en-suite toilet facilities and washing facilities. A programme of routine maintenance and renewal of fabric and decoration of the premises ensures that the home is maintained and decorated to a high standard. The home`s recruitment procedures have been improved and are thorough. Managers make sure that all new staff are suitable to work with the people who live at the home so they are protected from possible harm and abuse. Staff support systems have been improved since our last inspection with the introduction of regular formal supervision meetings for all staff. Staff are helped to reflect on their care practice and continue to develop their skills so they can meet the needs of the people who live at the home. What the care home could do better: Managers and staff need to make sure that care plans, assessments and risk assessments are revised and updated when the needs of the individual change so care staff always have the information they need to give care in a safe and appropriate way. Registered nurses should receive refresher training in the administration, safekeeping and recording of medication to eliminate medication errors, as far as possible. Records of the medicines given in the home including stock records must be accurate so people are safe and receive their medication as their doctor prescribed it and their health care needs are met.Where there is any doubt about a person`s capacity to make a decision an assessment of their capacity to make the decision must be made and recorded. This will ensure that care and support is provided in a way that maximises the individual`s capacity to exercise personal autonomy and choice. Managers and staff need to explore through research and training ways and means of engaging people with dementia in activities and ordinary domestic routines so they have opportunities for a fulfilling lifestyle. The home`s staff training programme needs to be developed to provide staff with the training they need to develop their skills and knowledge on equality and diversity. This will help them to understand and meet the needs of people from ethnic minorities and diverse backgrounds. Managers must make sure that all staff are familiar with the home`s policies and procedures on adult safeguarding so vulnerable people are safe from the potential for abuse. An annual report on the quality of care facilities and services provided needs to be produced and published so the people who live at the home and their relatives are kept up to date on quality issues. CARE HOMES FOR OLDER PEOPLE Corbrook Court Audlem Crewe Cheshire CW3 0HF Lead Inspector David Jones Key Unannounced Inspection 18 and 19 August 2008 10:00 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 Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Corbrook Court Address Audlem Crewe Cheshire CW3 0HF 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) 01270 812049 01270 812324 corbrook@morris-care.co.uk www.morriscare.co.uk Morris & Co Limited Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (45) of places Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The registered person may provide the following category of service only: Care home with Nursing: Code N, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Physical disability: Code PD. Old age, not falling within any other category: Code OP. The maximum number of people who can be accommodated is: 45. Date of last inspection 3 January 2007 Brief Description of the Service: Corbrook Court is a nursing home providing 24 hour nursing care, personal care and accommodation for a maximum of 45 older people requiring nursing or personal care. The home is set in eleven acres of land on the outskirts of Audlem village, which has all the essential community amenities. It is a threestorey building and there is access to the first and second floors by the passenger lift or the stairs. Accommodation is provided on the three floors of the main building in 45 rooms. All bedrooms have en-suite facilities. Separate assisted bathing facilities and toilets are also available. There are three lounges, two lounge/dining rooms, and a dining room available for communal use. Ample parking space is provided. Information about Corbrook Court including copies of the most recent inspection report is made available to each resident and can be acquired by contacting the home on the telephone number given above. Information provided by the registered manager on 3 September 2008 confirms that fees range from £662.00 to £720.00 per week for accommodation, board and care, depending on the type of the room. There are no additional charges other than hairdresser, toiletries, newspapers and other sundry items charged at cost. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 2 stars. This means that the people who use the service experience good quality outcomes. This inspection visit to the home was unannounced; it took place over two days and took 11 hours and 35 minutes in total. It started at 10:00 am on the first day. The visit was just one part of the inspection. Before the visit, the manager was asked to complete a questionnaire to provide detailed information about the home and how it is meeting the needs of the people who live there. CSCI questionnaires were made available for the people who use the service, and the staff and their views about the home have been taken into account. Records for three of the people who live at the home were checked to see the care they receive. Some people were spoken with and their views taken into account. Staff recruitment and training records were examined. Some of the home’s policies and procedures were also checked. What the service does well: Corbrook Court has a relaxed, friendly and welcoming atmosphere. The people who live at the home have good relationships with staff and enjoy friendly, respectful and good-humoured interactions. They told us that they always or usually receive the care they need and speak highly of the staff team commending them for their professionalism and dedication to duty. For example one person said “The quality of the care is exceptional” and another said they “believe the standard of care, professionalism & homely atmosphere to be exceptionally high standard”. All the people we had contact with told us that the food is always or usually good and some people said it is excellent. Special dietary needs are catered for and menus confirm that a varied and nutritious diet is on offer so people can have a healthy diet. The accommodation is spacious, comfortable and maintained to a high standard. One person who lived at the home said the views are breathtaking and each day they count themselves lucky to be fortunate enough to be able to enjoy them. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 6 People who live at the home told us the home is always clean and fresh so it is pleasant for them to live in. Effective management and quality assurance systems ensure that the Corbrook Court is run in best interests of the people who live there. Management encourage staff members to undertake nationally recognised qualifications beyond the basic requirements, and they recognise the benefits of a skilled, trained workforce so people who live at the home are in safe and competent hands. What has improved since the last inspection? What they could do better: Managers and staff need to make sure that care plans, assessments and risk assessments are revised and updated when the needs of the individual change so care staff always have the information they need to give care in a safe and appropriate way. Registered nurses should receive refresher training in the administration, safekeeping and recording of medication to eliminate medication errors, as far as possible. Records of the medicines given in the home including stock records must be accurate so people are safe and receive their medication as their doctor prescribed it and their health care needs are met. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 7 Where there is any doubt about a person’s capacity to make a decision an assessment of their capacity to make the decision must be made and recorded. This will ensure that care and support is provided in a way that maximises the individual’s capacity to exercise personal autonomy and choice. Managers and staff need to explore through research and training ways and means of engaging people with dementia in activities and ordinary domestic routines so they have opportunities for a fulfilling lifestyle. The home’s staff training programme needs to be developed to provide staff with the training they need to develop their skills and knowledge on equality and diversity. This will help them to understand and meet the needs of people from ethnic minorities and diverse backgrounds. Managers must make sure that all staff are familiar with the home’s policies and procedures on adult safeguarding so vulnerable people are safe from the potential for abuse. An annual report on the quality of care facilities and services provided needs to be produced and published so the people who live at the home and their relatives are kept up to date on quality issues. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who are interested in moving to Corbrook Court receive the information they need and can visit so they are helped to make an informed choice about the home before they move in. They have their needs assessed so they know their needs can be met at the home. EVIDENCE: People who are thinking of moving to Corbrook Court are invited to visit the home so they can find out more about it and make an informed choice about moving in. They are given are given a guide to the home, which sets out their rights, the aims and objectives of the home, details of accommodation, facilities, services and staffing provided and the complaints procedure. It also includes comments from other people who live at the home. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 10 Most of the people who responded to our survey told us they received enough information to help them with their decision-making. All people told us they have a contract so they know their rights and responsibilities. People moving into the home have an assessment before they move in and where appropriate information is gathered from relatives and other healthcare professionals involved in the care of the person. Records show that people have their needs assessed by qualified and experienced staff before they move in so they are sure that the home is suitable to meet their needs. There is a comprehensive assessment form used to record biographical details and a needs assessment based on the activities of daily living. Risk assessments are also completed so staff know what to do to make sure people are safe. However the assessment for one person who had recently moved into the home was only partially completed. The manager told us this was an oversight and took immediate action to make sure the person’s assessment confirmed all their health and personal care needs so they can be sure they will receive care and support in the way they prefer. All of the people who responded to our survey told us their care and support needs were always or usually met and some made other positive comments about the home. For example one person said, “The quality of the care is exceptional” and another told us, “Having looked at a number of nursing homes and being originally a resident at another we believe the standard of care, professionalism & homely atmosphere to be exceptionally high standard, where the individual residents dignity is respected at all times”. Corbrook Court does not provide intermediate care so standard 6 does not apply. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Arrangements for health and personal care are based on each person’s individual needs and the principles of respect, dignity and privacy are put into practice so people receive care in the way they prefer. EVIDENCE: The case records of three people who live at the home were read as part of the inspection. Relevant information was recorded in that a care plan had been drawn up for each person and daily events were recorded in the daily progress notes or on the communication sheet. All care plans seen had been kept under review but some needed further development to confirm the care that was actually being provided. For example one person had been assessed as being at risk of developing pressure sores. Staff had taken action to address this need by providing pressure-relieving equipment but this had not been recorded in their care plan. Therefore it was not clear how staff were monitoring and evaluating how this area of need was being met. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 12 Another person’s care plan identified that they had short-term memory loss and confusion but did not provide clear guidance as to how their needs were to be met. However, discussion with staff and comments from the people who live at the home, their relatives, GPs and a visiting district nurse demonstrated that a good standard of care was being provided. The manager acknowledged that there were shortfalls in the recording of care and implemented an action plan to make sure that all care plans were reviewed and where necessary revised. People living at the home told us that their health care needs were met and they were always treated with dignity and respect. They were registered with the local GP practice and were referred to other appropriate health care professionals as necessary. Records show that staff work in partnership with each person’s health care professionals so they receive the health care they need. A check of medication records showed that the people who live at the home received appropriate levels of support with their medication so their health care needs were met and their independence is promoted. However, a number of recording errors were identified and there were no stock records for loose medication. The lack of appropriate stock records makes the homes medication system potentially unsafe and makes audit difficult or almost impossible so the people who use the service are not adequately protected from possible medication errors. The manager implemented an action plan to make sure that medicines are administered in accordance with the home’s medications policy and procedures. This included refresher training for all staff involved in the administration of medicines in the home. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Suitable activities are available and people who live at the home have choice so they enjoy a good quality of life that reflects their needs and expectations. EVIDENCE: Corbrook Court has a relaxed, friendly and welcoming atmosphere. The people who live at the home have good relationships with staff and enjoy frequent, friendly, respectful and good-humoured interactions. They told us that they appreciate the way the staff always use their preferred term of address and always speak to them in courteous manner. The activities co-ordinator works five days a week offering a range of activities including board games, exercise classes and reminiscence sessions. People are consulted about what they want to do at residents’ meetings and they are provided with an activities programme so they know what is on offer. The manager told us that the home hopes to acquire a minibus so people can get out and about in the local community. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 14 All the people we spoke with during our visit to the home made positive comments about the activities co-ordinator and the activities on offer. One person said the activities co-ordinator is excellent and another said “There is something going on every day if I wish I join in”. However information from relatives indicated there were only limited opportunities for people with dementia to engage in meaningful activities. The manager told us the home intends to develop its practices regarding the care of people with dementia including staff training and developments in person centred planning. This will help to ensure that all people living at the home will receive the support they need to live a fulfilling lifestyle. It is clear that nursing and care staff help people to make decisions for themselves. They were observed to be patient with people, giving them time and the information they needed to make informed choices. People who live at the home told us that they are able to please themselves and their choices are respected. One person said, “They always make time for me and fulfil my wishes”. However, one person’s care plan indicated that staff had decided that the individual did not have capacity to make certain decisions but how they reached this conclusion had not been recorded. Where there is any doubt about a person’s capacity to make a decision, an assessment of their capacity to make the decision must be made and recorded. This is required under the provisions of the Mental Capacity Act. The purpose of the assessment is to determine the level of assistance that the individual needs to make the decision including who should be consulted and included in the decision making process. This will ensure that care and support is provided in a way that maximises the individual’s capacity to exercise personal autonomy and choice. People who live at the home can have visitors at any reasonable time and several visitors told us they are always made to feel welcome. All the people who returned survey questionnaires and all we spoke with told us the food is always or usually good. Some told us that the food is excellent. Special dietary needs are catered for and menus confirm that a varied and nutritious diet is on offer. People are asked about the quality of meals on a regular basis and menus are discussed at residents’ meetings. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There are complaints and adult safeguarding procedures for the home so the people who live there are able to express their concerns. They are listened to and are safeguarded from abuse and neglect. EVIDENCE: People who live at the home are able to express their concerns and have access to an effective complaints procedure so they are listened to and their concerns are acted upon. All people responding to the survey told us that they know how to make a complaint and staff listen to and act on what they say. One person told us, “There is a specific complaints procedure and staff are happy to listen to any concerns.” The home’s complaints records show that one complaint had been received since our last inspection. Appropriate complaints records were made including details of action taken to resolve the complaint. This shows us that complaints are welcomed and are acted upon by the management of the home. Procedures for responding to suspicion or evidence of abuse or neglect are in place including whistle blowing policies in accordance with the Public Interest Disclosure Act 1998. There have been no adult safeguarding referrals from the home since our last inspection. Some of the staff members were unfamiliar with the home’s adult safeguarding procedures and would benefit from further Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 16 training on this. Staff training records show that all staff receive basic awareness training on adult safeguarding during induction. Qualified nurses are provided with further in-depth training from the company and care assistants receive further training when they undertake an NVQ Level 2 or level 3 in Care. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who live at the home have well-equipped and well-maintained accommodation, which meets their needs and expectations so they are comfortable and feel at home. EVIDENCE: Corbrook Court is located on the outskirts of the village of Audlem in a residential semi-rural area near Crewe, Cheshire. The home is adapted to meet the needs of older people, with good access to all parts of the building. It is set within its own grounds that extend over 11 acres of rural landscape. People have access to pleasant gardens that include a large paved area with views overlooking open countryside. One person who lived at the home told us the views are breathtaking and each day they count themselves lucky to be fortunate enough to be able to enjoy them. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 18 The accommodation has been extended and refurbished since our last inspection. All bedrooms have en-suite facilities. All of the people who responded to the survey told us the home is always clean and all spoken with during the inspection told us that they are comfortable. The home meets their expectations. A programme of routine maintenance and renewal of fabric and decoration of the premises ensures that the home is maintained and decorated to a high standard. Maintenance records show that electrical and gas installations; hoists and fire prevention equipment are serviced regularly so people are safe. Potential hazards presented by heated surfaces and hot water were not sufficiently controlled so vulnerable people were at risk of being scalded. However, the manager took immediate action during our visit to make sure all people who live at the home were safe. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Staff are trained, skilled and employed in sufficient numbers to meet the changing needs of people who live at the home. Thorough staff recruitment procedures ensure that new staff are suitable to work at the home with vulnerable people. EVIDENCE: The people who live at Corbrook Court and their relatives spoke highly of the staff team and commended them for their care, professionalism and dedication to duty. All the people responding to the survey told us that staff are always or usually available when they are needed. One person said, “I always get the care required usually immediately” and another told us, “I only have to press the buzzer and there they are!”. However, staff told us that staffing levels had been reduced because the home was accommodating fewer people. Nursing staff told us that they were able to meet the day to day health and social care needs of the people who lived at the home but the reduction in nursing staff numbers meant they had less time to do paper work because they needed to work on direct care for all their shift. They said this adversely affected their ability to keep records up to date and the medication round often took too long because they were constantly interrupted to provide direct nursing care. The manager told us that she was Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 20 aware of these concerns from staff and was in the process of reviewing staffing levels. Shortly after our visit the manager confirmed that staffing levels had been increased. The home’s recruitment procedures are thorough. Managers make sure that all new staff are suitable to with the people who live at the home so they are protected from possible harm and abuse. Management encourage staff members to undertake nationally recognised qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. Information provided indicates more than 50 of the current care staff team (excluding registered nurses) have an NVQ in care at level 2 or above and five others were working toward the qualification. All staff received induction training and were initially employed for a probationary period of three months before their contract was made permanent. The home’s induction programme needs updating to reflect current “Skills for Care” training standards including training on Equality and Diversity. The home’s training strategy provides training for staff in a number of relevant training topics including manual handling, fire safety, adult safeguarding, infection control, basic food hygiene, control of substances hazardous to health and a range of other topics. However, discussion with staff and observation of their practice indicated that further training was needed in areas not covered by the home’s training programme. This included training on the care of people with dementia, the Mental Capacity Act and refresher training for registered nurses in the administration and safe recording of medicines in the home. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Effective management and quality assurance systems ensure that the Corbrook Court is run in best interests of the people who live there. EVIDENCE: There is a new manager in post who had commenced full time in the home in July. She is a registered general nurse who qualified in 1987. She has worked for Morris & Co Limited for 14 years, during which time she has obtained the Registered Managers Award. The home addresses quality assurance in a number of ways. Internal audits and quality checks are carried out on all departments - nursing and care, housekeeping, catering and maintenance. These are discussed at company Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 22 management meetings attended by heads of departments and, where necessary, action plans are developed to address any shortfalls. The people who live at the home are consulted on the quality of care, facilities and services provided on an ongoing basis at residents’ meetings and through an annual survey questionnaire. People who live at the home and their relatives have told us that they are listened to and their views are taken seriously and acted upon. However the home needs to produce a report on the findings of its quality assurance systems including details of any action taken to address issues raised. The report should be made available to the Commission and the people who live at the home and their representatives so they are kept informed of action taken to address any quality issues raised. The home has a good record for addressing requirements and recommendations. However, it was noted that there was a delay in taking appropriate action to address a requirement made by the Commission for Social Care Inspection following the short inspection of the home conducted by a CSCI pharmacist inspector on 16 July 2008. The manager received a copy of the report on the 11 August but appropriate action had not been taken to address the requirement by the 18 August 2008. However the manager acknowledge this oversight and took immediate action to meet the requirement by reinforcing the home’s medication procedures and arranging refresher training for all registered nurses involved in the administration of medication in the home. Only three people living at the home deposit money with the home for safekeeping. Balances and records were checked and found to be in order. Staff support systems have been improved since the last inspection with the introduction of regular formal supervision meetings with their line manager. Most but not all staff confirmed that they benefit from regular supervision meetings. Morris & Co Limited seeks to ensure the health and safety of all employees and people who use the service. Risk assessment and risk management is important to the management of the home. Senior mangers ensure that risk assessments are carried out for all safe working practice topics and significant findings are recorded and reviewed. However, it was noted that some potential hazards to the people who lived at the home had been overlooked. The manager took immediate action to address these issues so all people who live at the home are protected from harm. Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 23 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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 OP3 Good Practice Recommendations Assessments should be completed before a person moves into the home so managers and staff can confirm that the home is suitable to meet the individual’s needs. Where a person moves in on an emergency basis the assessment should be completed within 48 to 72 hours. Each person’s care plan should identify all their care needs and the individual arrangements made to meet their needs, so people are assured they will receive the care they need in the way they prefer. The records of the administration of medicines in the home should be accurate and completed in accordance with the home’s medication procedures, including detailed stock records for loose medication, so people are safe and safeguarded from medication errors. 2 OP7 3 OP9 Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 25 4 OP9 The registered nurses working at the home should receive refresher training in the administration, safekeeping and recording of medication to eliminate medication errors, as far as possible, so people receive their medication as prescribed and their health care needs are met. Steps should be taken, through research and training to find ways of engaging people with dementia in activities and ordinary domestic routines so they have opportunities for a fulfilling lifestyle. Where there is any doubt about a person’s capacity to make a decision, an assessment of their capacity to make the decision should be made and recorded. This is required under the provisions of the Mental Capacity Act. This will ensure that care and support is provided in a way that maximises the individual’s capacity to exercise personal autonomy and choice. All staff should be familiar with the home’s adult safeguarding procedures so they know what to do in the event of any suspicion or evidence of abuse. The training programme should be developed so staff have the training they need to develop their skills and knowledge in the care of people with dementia and equality and diversity. An annual report on the quality of care facilities and services provided should be circulated so the people who live at the home and their relatives are kept up to date on quality issues. 5 OP12 6 OP14 7 OP18 8 OP30 9 OP33 Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Region Unit 1, Level 3 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Corbrook Court DS0000053406.V370983.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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