Care Home: Cornelius House

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What the care home does well The home has an assessment process which enables the manager to decide whether Cornelius can meet the needs of the individual. The one we saw on this occasion was completed and was used to inform the care plan. The care plans were informative and advised staff what the strengths and abilities of the individual are as well as what they need to do support individual needs. Where individuals wished to be self caring or carry out an activity, we saw that there were risk assessments to lessen any identified problems.Cornelius HouseDS0000065835.V376378.R01.S.docVersion 5.2When we spoke with people using the service they told us they were happy with the activities that are available for them. They enjoy the newsletter about the home and have contributed to it themselves. People who live at the home were generally positive about the food that the home provided and the condition of the accommodation that they occupied. The home is regularly maintained and is comfortable with pleasant furnishing. We saw that new staff had been recruited and that the home had carried out checks to protect people who use the service. New staff have begun induction training in working at the home. Staff have received updated training in many areas such as moving and handling. Whilst it was seen that the home is doing well in the areas where action was required for improvement, the areas that have improved are listed in the following section of this report. What has improved since the last inspection? The home carries out assessment visits to prospective residents to ensure that they can meet the needs of the individual. The home has care plans which describe the needs of the individual and what they are able to do independently. The plans describe the support staff have to give. The storage and administration of medication has improved with all staff have undertaken training in medication administration and with the manager having organised roles and responsibilities. Daily routines in the home are now flexible and people who use the service are being encouraged to make choices for themselves and exercise personal autonomy as far as reasonably possible. The home`s current recruitment process now protects people who use the service. Staff have undertaken training in most mandatory areas and training that helps support individual needs. The home now safeguards people`s monies with their recording and storage. A quality assurance programme is underway enabling people who use the service and their relatives to have a say about the running of the home. Mr Kellas the responsible individual for the home carries out regular visits to the home and keeps a record of these once a month. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 The challenge is for the staff at Cornelius to imbed these changes into the practice of the home and maintain them. What the care home could do better: The administration of prescribed creams and lotions need to be recorded, to ensure that all medication is given as prescribed. Whilst the manager has told us that she plans to imbed the improvements they have made to the service offered at the home, this improvement must be sustained and further planning to improve the service and its future undertaken. Key inspection report CARE HOMES FOR OLDER PEOPLE Cornelius House 114 Fishbourne Road (West) Chichester West Sussex PO19 3JR Lead Inspector Val Sevier Key Unannounced Inspection 13th July 2009 10:15a DS0000065835.V376378.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cornelius House Address 114 Fishbourne Road (West) Chichester West Sussex PO19 3JR 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) 01243 779372 01243 783237 cornelius.house@btconnect.com Cornelius House Limited Miss Pamela Annette Venus Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 20. Date of last inspection 6th March 2009 Brief Description of the Service: Cornelius House is a care home registered to provide accommodation for up to twenty residents over 65 years of age. The home’s registered providers are Cornelius House Ltd. With Mr John Kellas registered as the Responsible Individual representing the company. Ms Pamela Venus is the registered manager who oversees the day-to-day management of the establishment. Cornelius House is situated in a quiet residential area approximately a mile from the town centre of Chichester and approximately three miles from the seafront. The care home is a large, three-storey establishment with the main garden lying to the front of the property and contains a summerhouse, flower borders and large lawn. The side and rear gardens are well laid out with flower beds, bird tables and small seating areas. The accommodation is currently arranged for all people to have single occupancy with en-suite facilities there is a lift providing access between all the floors. There is a large communal lounge/dining room and a separate lounge for smaller groups. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service 2 star. This means the people that use this service experience good quality outcomes. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The visit was carried out on the 13th July 2009 between the hours of 10:15am and 2:45pm Prior to the visit to the home we reviewed, previous inspection reports and information received from the home since it was last visited in January and March 2009. The Annual Quality Assurance Assessment (AQAA) was returned to the Commission by the due date before we visited the home. The AQAA is a document that we send to a service once a year, in it they are able to comment on improvements they have made, any barriers to improvement to meeting the standards and how they feel the service is meeting the needs of people who live at the home. We met with the manager, three staff, a visitor and there were three people who use the service involved in the inspection visit. The registered provider was also at the home for a brief period whilst we were there. We looked at four pre admission assessments, four care plans, medication records, staff files and training records and fire prevention testing and training records. Several requirements were made following the last visit to the home. It was seen that the home has actioned all requirements and the AQAA for the home stated that the future improvements for the home are imbedding these actions into the running of the home and the service offered to people who live there. What the service does well: The home has an assessment process which enables the manager to decide whether Cornelius can meet the needs of the individual. The one we saw on this occasion was completed and was used to inform the care plan. The care plans were informative and advised staff what the strengths and abilities of the individual are as well as what they need to do support individual needs. Where individuals wished to be self caring or carry out an activity, we saw that there were risk assessments to lessen any identified problems. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 6 When we spoke with people using the service they told us they were happy with the activities that are available for them. They enjoy the newsletter about the home and have contributed to it themselves. People who live at the home were generally positive about the food that the home provided and the condition of the accommodation that they occupied. The home is regularly maintained and is comfortable with pleasant furnishing. We saw that new staff had been recruited and that the home had carried out checks to protect people who use the service. New staff have begun induction training in working at the home. Staff have received updated training in many areas such as moving and handling. Whilst it was seen that the home is doing well in the areas where action was required for improvement, the areas that have improved are listed in the following section of this report. What has improved since the last inspection? The home carries out assessment visits to prospective residents to ensure that they can meet the needs of the individual. The home has care plans which describe the needs of the individual and what they are able to do independently. The plans describe the support staff have to give. The storage and administration of medication has improved with all staff have undertaken training in medication administration and with the manager having organised roles and responsibilities. Daily routines in the home are now flexible and people who use the service are being encouraged to make choices for themselves and exercise personal autonomy as far as reasonably possible. The home’s current recruitment process now protects people who use the service. Staff have undertaken training in most mandatory areas and training that helps support individual needs. The home now safeguards people’s monies with their recording and storage. A quality assurance programme is underway enabling people who use the service and their relatives to have a say about the running of the home. Mr Kellas the responsible individual for the home carries out regular visits to the home and keeps a record of these once a month. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 7 The challenge is for the staff at Cornelius to imbed these changes into the practice of the home and maintain them. What they could do better: 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. Cornelius House DS0000065835.V376378.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 Cornelius House DS0000065835.V376378.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service can be assured that their needs will be assessed to ensure that the home has an understanding of their care needs. EVIDENCE: The AQAA for the home said: “Clear Statement of Purpose given to all potential residents; all residents have written contracts; new pre assessment routine for all residents; clear residents guide available to service users and relatives; trial periods encouraged; home visits are available at all times with/without appointments”. How we have improved in the last 12 months: “Introduced new Pre Assessment process”. Our plans for improvement in the next 12 months: “None – imbedding changes we have made”. There has been one new admission to the home since we last visited. We saw Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 10 that there was a personal history for the individual which they had written themselves. There was information on their first language, their family contacts, hobbies and occupation. We saw that the individual was having private physio, and they had discussed their needs and support with the manager. The assessment included a conversation with the G.P regarding suitability. The individual had been in contact with the home for several years visiting people using the service and had chosen the home for themselves. We saw that they had placed themselves on a waiting list and kept in touch with the home about their decision making process. On the day of the visit relatives were visiting the home and they were happy with the information that the home had given them Cornelius House DS0000065835.V376378.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans detail the needs of the individual and support staff are to give. However some medication records and administration within the home are not always carried out in a safe manner to protect the people who use the service. Staff working practice helped to ensure that the privacy and dignity of people who use the service is promoted. EVIDENCE: The AQAA for the home said: “Good relationship with local healthcare providers. New system of care plans and risk assessment management; end of life preferences discussed and noted. Medication Preferences catered for and respect and dignity shown to service users at all time”. How we have improved in the last 12 months: “New care plans for each individual resident, reviewed monthly by Manager; new risk assessments for all identified types of risks for Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 12 each resident have been completed; new medication system introduced; better record keeping in service user files; end of life care review completed for each service user with relatives; visit to home by optician arranged; every service user assigned key carer. Our plans for improvement in the next 12 months: “None – imbedding changes we have made”. The manager told us that one person had moved to the home since our last visit. We looked at their care plan and all documents associated with their care and support in addition we looked at the care plan for an individual who had moved to the home six months ago and one who had moved to the home two years ago. We saw that the individual who had moved to the home recently had been able to discuses their care needs with the manager at the assessment and this information had been bought into the care plan. The person has expressed to be self caring wherever possible and for as long as possible health permitting and has given preferences for bath times and days, when they want to get up and go to bed and foods. The individual has a condition which prevents them eating certain food items; we saw a plan of care that details how their nutritional diet can be met. When we spoke with the kitchen staff they were able to confirm that they knew about these dietary requirements. We saw how staff were to support the individual for example: ‘ensure mobility aids are serviced and staff are trained in use’. The individual has been seen by the incontinence advisory service and has been advised on the best products and exercises to support their needs. There were risk assessments in place which included mobility, environment, sensory deficits, profile bed use and medication. We saw that the individual had chosen not to self medicate as concerned they would forget medication. The individual has their own laptop to enable their independent contact with their family and correspondence generally, including writing their own life history and articles for the home’s newsletter. For the second care plan we saw that the home had kept records regarding the individual’s health and had followed up on GP appointments, hospital visits and recommendations. The home is being supported by the district nursing team in the care for this person, and we saw care plans relating to pressure care, relief mattresses and injections for care following an operation. This individual has difficulty communicating as they can not hear. We saw that the care plan reflected this instructing the care staff to use communication cards and writing things down. The individual also has special dietary requirements and the kitchen staff confirmed that they are aware of this and have met with the individual to establish their needs and wishes. Their diet is also supplemented with special drinks prescribed by the GP. We saw risk assessments relevant to this individual for example mobility, nutrition and fire. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 13 For the third individual we saw that they had allergies and the care plan stated the action staff should take. We saw that the individual has requested the name they wished to be known by. The person also expressed to be self caring wherever possible and for as long as possible health permitting and has given preferences for bath times and days, when they want to get up and go to bed, the linen they wish to have on their bed and foods. They told us about the residents meetings every Tuesday and they have chosen not to attend, likes the homes newsletter as it has the activities and entertainment for the month laid out. We saw risk assessments for this individual. We noted that the care plans and risk assessments have been reviewed each month since January 2009, when new care plans and risk assessments were introduced following the last by us. We looked at the medication storage and administration records. There are two medication trolleys which are secured to the wall one in the office downstairs and one on the first floor landing. The manager Miss Venus said that all staff have had training in medication administration since our last visit; however she has arranged that only one person per shift has responsibility and this individual takes on leading role for that shift. The manager has appointed a new deputy and this person has responsibility for ordering the medication and changing the stock each week. There have been concerns about the administration and recording of medication at the home, however on this occasion we could see that the records had been kept by staff. They have a sheet to sign to say that they have checked each individual entry at the time of administering the medication. We saw a photo of each individual with information on any allergies they may have. We saw that the home is using a blister pack system for most medications, where the chemist dispenses the medication into a ‘blister pack’. Staff were seen to be using a code system for reasons when they have not given a medication, we saw ‘N’ used’ offered not required’ on several occasions when the medication was not prescribed ‘as required’. We discussed this with the manager who said staff should have used a more appropriate code. We saw that staff had not signed for creams and lotions - Sudocrem and Diprobase for four people. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 who use the service participate in activities appropriate to their age, peer group and cultural beliefs as part of the local community. Dietary needs are well catered for with a balance and varied selection of food available that meets individual dietary requirements and choices. EVIDENCE: The AQAA for the home said: “Encourage Service Users to participate in activities (with limited success), encourage family and friends to visit at any time. Access to games, library, newspapers, and communion, bring and buy, birthday and Christmas parties, summer party, “Easter Parade”, Musicals, films etc Food provided of top quality with choice available”. Our evidence to show that we do it well: “Service user feed back very good through resident’s comments card – main feedback was they did not wan any more activities”. How we have improved in the last 12 months: “Introduced more activities; introduced activities log; incorporated into care plan; asked for feedback from service users; introduced more selection at meal times; staff member being Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 15 trained as activities coordinator with external training; monthly newsletter introduced”. Whilst talking with some people who use the service they told us about the newsletter with some of them having written a piece for it. They also told us about the Welsh choir that had visited and the Alpacas. An individual who lives at the home had expressed the wish to go home to visit Wales again. They are unable to do this. A member of staff had found that a Welsh choir had been performing locally and rang the local Arts centre. It transpired that the choir stopped at the home on their way to their next venue and did an impromptu concert on the front lawn which easily accommodated the fifty singers. We saw photos of the event in the newsletter and it was much appreciated by two individuals at the home. We looked at the newsletters and saw articles by the people who use the service on war time experiences, current events and gardening. There were the results of the Easter competitions, birthdays, ‘matron’s corner’, cooks pantry and quiz questions set each month. We saw a list of events taking place for the month and these included, communion, keep fit, wine and sherry at the weekend with games in the afternoon. People using the service told us that the food was lovely that they could choose from the menu or have something different. There was ample food for their ‘age’. On the day of our visit lunch was a choice between steak and ale pie or vegetable bake, we saw that one person had macaroni cheese and the cook said that another person had changed their mind at the last minute and they had had a cheese omelette. For dessert there was fresh fruit salad, meringue nest, ice cream or yoghurts or any combination the individual wished for. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure enables those people using the service to know that any complaints will be taken seriously and responded to. People living at the home are safe guarded by the homes safe guarding adult’s procedures. EVIDENCE: The AQAA for the home said: Complaints procedure well documented and informed to service users and relatives. All comments whether considered to constitute a “serious complaint” or “minor observation requiring action” are logged appropriately and action taken as necessary. Service Users regularly surveyed”. How we have improved in the last 12 months: “Introduced reporting system under Safeguarding of Adults; extended system to include logging of “minor observation requiring action” not constituting a formal complaint”. The home has complaints procedure, which are outlined in the Statement of Purpose and Service User Guide and on display in a number of places around the home including on a notice board above the visitors signing in book. It includes the timescale of response and the address of CQC. The home’s safe guarding adult’s policy was observed to have been regularly updated and included the West Sussex Multi Agency Adult Protection flow chart Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 17 on how to report suspected abuse. The manager told us that one safeguarding referral had been made to social services in the past few months. This had been resolved between the family, social services the home and the individual concerned. The manager Miss Venus attended a safeguarding update in April 2009 and she and her deputy attended a session on the Mental Capacity Act in July 2009. Miss Venus is to attend a training session on the Deprivation of Liberty guidance at the end of July; we saw that she had purchased information relating to these Acts and guidance. We saw that some staff at the home have had training in safeguarding and that training is planned for September 2009 for those that need to be updated. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 who use the service have a pleasant and homely environment to live in which also has had adaptations to meet individual needs. EVIDENCE: The AQAA for the home said: “Environment is well maintained and controlled with relevant procedures and risk assessment regularly updated. Outdoor facilities regularly maintained to high standard. En suite in all rooms. Hoists, lifts, etc available to all as required. All service users in single rooms, with own possessions where required. Maintenance is kept up do date and in process of completing Safer Cleaner Care Homes NHS Initiative”. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 19 We looked around some of the home and we were able to see communal areas such as the dining room, lounge, bedrooms and bathrooms. The garden is accessible with wheelchairs. People who live at the home are encouraged to furnish the room with personal belongings such as furniture and pictures. The home was seen to be very clean throughout, with no malodour. When we walked about the home we saw that rooms are centrally heated, all radiators and pipe work are covered. Windows are fitted with restrictors where necessary and emergency lighting is provided throughout the home. Individuals commented to us that they were happy with their accommodation they liked having ensuite facilities. They described small pieces of furniture that they had been able to bring. They liked the lounges where they could sit with others and chat, watch television, read or listen to music or just be quiet. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Current recruitment practices at the home help to protect the people who use the service. Staff have received all the mandatory training that is expected each year, and training to help them meet specific individual needs. EVIDENCE: The AQAA for the home said: “We have a loyal and caring staff complement. Low staff turnover; where we have had problems – action taken promptly e.g. new deputy manager appointed”. How we have improved in the last 12 months: “Reviewed skill mix of staff and initiated further NVQ training where required through Chichester College. Reviewed rota to ensure adequate staff at all times. Improved recruitment processes to ensure all necessary tasks completed prior to commencement of work. Reviewed Training Programme for all staff and introduced on mandatory training with IN-Care to ensure all training issues covered. Supported care manager with more training and appointment of mentor for 3 months”. We looked at the rotas for the home for the week commencing 13th July 2009 we saw that there were five care staff in the morning three in the afternoon Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 21 and two at night. We saw that the day staff are support by domestic staff and cooks to prepare both the daytime meals and supper. The manager is additional to these staff, she has administrative support and there is a handyman on site who carries out repairs and runs errands as needed. Two people have been employed to work at the home recently and we saw that there were two references, there was evidence that a CRB had been requested and that a POVA First check had been carried out and they were dated before the employee commenced work at the home. We saw that the individuals had commenced an induction process. Supervision takes place six times before the induction is completed we saw that one individual had had two supervisions so far. All staff information is kept at the home in locked cabinet in the manager’s office. There were concerns following the last visit to the home about training that had not been undertaken by staff. We saw a training plan for staff for 09/10 we could see what staff had done and what was planned. All staff have undertaken medication administration training, understanding dementia, food hygiene, fire safety and moving and handling. We saw that staff are to undertake health and safety training on 30th July 2009, safeguarding in September, infection control and challenging behaviour in November. We saw that there are identified people on each shift who have undertaken first aid awareness. The new staff undertake induction training which includes and introduction to the home for example fire procedures. The individual works through a pack with questionnaires on areas such as the home, safeguarding and their own personal development. We saw that the individual meets with the manager six times before being signed off as completing the induction. We saw that the two new staff had had one meeting and two respectively. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems and procedures monitor and maintain the quality of the service provided and which, promote the safety and welfare of those living and working in the home. EVIDENCE: The AQAA for the home said: “Care Home Manager experienced and loyal; Service User Interests are constantly being asked for feedback; New care Plans document “histories” for each service user; Residents Monies well controlled”. How we have improved in the last 12 months: “Employ qualified Care Home Manager on consultancy basis to help us update processes and Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 23 procedures and mentor Manager; New processes implemented for Service users monies etc; RI now documenting visits; Subscribed to Cromer Care Home management system”. We saw that the certificate related to the home’s registration was displayed in the hallway and displays the details of the core registration for the home. The registered manager Miss Venus has recently been to safeguarding and Mental Capacity Act training. The manager told us at the visit and in their AQAA that she plans to spend time imbedding the improvements into the care they provide and the systems they have put ion place to support that care. The registered provider for the home is Cornelius House Ltd with the responsible individual as Mr Kellas. Mr Kellas the responsible individual for the home carries out regular visits to the home and keeps a record of these once a month. We saw that the manager has undertaken staff and resident meetings. The residents commented on food, staff, activities and the homes environment. Mr Kellas told us that an external company is carrying out the home’s quality assurance and they have had an 89 response in writing. They are planning to carry out interviews at the home as well. Two requests were made in the survey responses, to have a conservatory and for a bedroom to be made bigger. We saw the policies available to staff and that new ones have been introduced as necessary for example training and medication. We looked at the records for fire safety training and monitoring of equipment we saw records that indicated that fire safety equipment has been tested regularly and that staff have received training every six months. Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement The registered person must ensure that all prescribed medications have a record of whether they have been administered this includes creams and lotions such as Sudocrem and Diprobase. This will ensure that the individual receives the correct medication and helps to monitor their health. Timescale for action 13/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cornelius House DS0000065835.V376378.R01.S.doc Version 5.2 Page 26 Care Quality Commission The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: 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. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Cornelius House DS0000065835.V376378.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. Re-publishing this information is in breach of the terms of use of that website. 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