Inspection on 10/08/06 for Delves Court Care Home

This inspection was carried out on 10th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Delves Court Care Home 10/02/06

Delves Court Care Home 28/09/05

Delves Court Care Home 04/10/04

Delves Court Care Home 28/04/04

Delves Court Care Home 26/03/04

Delves Court Care Home 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Delves Court Care Home 2 Walstead Road Walsall West Midlands WS5 4NZ Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 10th August 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Delves Court Care Home DS0000029398.V307535.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. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delves Court Care Home Address 2 Walstead Road Walsall West Midlands WS5 4NZ 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) 01922 722722 01922 722922 Susan.Nicholls@hallmarkhealthcare.co.uk Hallmark Healthcare (Walsall) Limited Susan Nicholls Care Home 64 Category(ies) of Old age, not falling within any other category registration, with number (64) of places Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide 2 stepdown/intermediate care beds, providing all elements of N.M.S. 6 (Care Homes for Older People) are met at all times. 28th September 2005 Date of last inspection Brief Description of the Service: Delves court is a care home providing accommodation, nursing and personal care for up to sixty four older people, this includes two people who are resident for intermediate care at any one time. Owned by Hallmark Healthcare (Walsall) Ltd. the home is located in the Bescot area of Walsall, close to shops and local amenities. The home opened in March 2002 and consists of a threestorey purpose built premises with off road parking to one side and an enclosed attractively maintained patio garden area to the rear of the building. Internally each floor is self sufficient for communal rooms and toilets and bathing facilities. Nursing is provided on the first and second floors. The bedroom accommodation consists of 60 single rooms, 26 having en-suite and 2 double rooms. The ancillary services of catering, laundry housekeeping and maintenance are provided in-house. The home charges between £327.15 and £580 per week for residency. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection completed by one inspector from the Commission for Social Care Inspection. The inspection took place over two days and time spent included, viewing staff files and service users files as part of the case tracking process, talking with staff and some service users. Judgments made in this report were done so after looking at the available evidence and from information supplied to the Commission by the home and from questionnaires sent to service users and their families. Two immediate requirements were issued at this inspection as serious concerns were expressed about the excessive temperatures in the home particularly the second floor and the medication room. The inspector would like to thank all of the service users and staff for their hospitality during the inspection. What the service does well: What has improved since the last inspection? Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 6 The home has taken steps to meet all but one of the requirements from the last inspection. This was very pleasing to see. There are new locks on all of the service users bedroom doors, this enables them more privacy should they require it but also allows staff access to them in an emergency. The manager has now completed the registration process with the Commission for Social Care Inspection. All of the service users have been consulted about their likes and dislikes in relation to the food on offer at the home and adjustments have been made to the menu’s, although there are still a few grumbles about the food the majority of service users all agreed that the foods was of a good quality. Comments included “breakfast and teas are usually good but the main meals of dinner are of poor quality consisting mainly of mash”, “I am very satisfied with the food it’s lovely and tasty” What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good, this judgement has been made using available evidence including a visit to the service. Service users can generally be assured that their needs will be assessed prior to admission to the home EVIDENCE: All of the service users files seen had an assessment, this was in the most part completed. The assessment covers physical, psychological and social needs and once completed will form the basis of the care planning process. Seven service user files were seen all of them had an assessment however the two newest arrivals at the home had an incomplete assessments this means that potentially service users needs were not being met because staff were unaware of them. It was pleasing to see that the other five service user files seen each contained an assessment of their needs and that this is kept under regular review. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Service users can be assured that their health needs will be met, medicines are administered safely and that at all times they will be treated with respect and dignity. EVIDENCE: Every service user at the home has a service user plan that generally details their health, personal and social needs. These plans are reviewed on at least a monthly basis and more frequently if required. Each service user is assessed by staff for their risk of developing pressure sores, malnutrition, moving and handling and falls. Care plans do generally reflect the care needs of the service user although in some of the files seen it was noted that one service user was being treated for pressure damage and there was no care plan to address this, similarly other care plans had been started but not finished. This was discussed with the manager during the inspection and she stated that she is in the process of auditing all service users files. A report from this audit was seen and it was pleasing to note that the manager is addressing these issues. Service users have access to specialist medical services such as the colostomy care nurse, community mental health nurses, chiropody and optician, however Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 10 there have been recent difficulties with the dentistry service who will only visit the home at an extra cost to service users, the manager is currently pursuing other ways of finding this service without incurring a cost to the service user. The home has robust procedures for ensuring medicines are administered safely. There were serious concerns about the excessive temperature in the treatment room, the home cannot be assured that medicines are being stored safely at such high temperatures, an immediate requirement was issued requiring prompt action to rectify this situation. The home has a waste contract but this is only collected on a three monthly basis, during the inspection it was observed that there were nine boxes of waste medication waiting removal, this is not an ideal situation as nurses find it difficult to move around the treatment room and poses a risk due to the amount of waste medication being stored there. Prescriptions that are marked “as directed” must have administration route and frequency of administration on the MAR sheet. Controlled drugs were seen and were found to be administered safely and recorded correctly. All of the service users who completed the questionnaire stated that the staff treat them with respect and dignity most of the time. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14.15 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Service users feel that they have an active life, that they receive visitors when they wish to and generally meals are nutritious and wholesome. EVIDENCE: Some of the service user files seen did have a social interests care plan others did not. The home provides a varied activity programme throughout the year and service users appreciate this stating “full diary of engagements catering for all individuals, the home works hard to keep people happy”, “I am happy here I enjoy the entertainment”, one service user commented “the home arranges activities in the lounge I am bed ridden and confined to my room and therefore cannot take part in them”. This is something that the manager must consider in order to be able to include all service users in meaningful activity. Throughout the inspection there were many visitors, and all of the service users spoken too said that they are happy with the visiting arrangements for the home. Some of service users are unhappy with the meals stating, “breakfast and tea are usually good but the main meals of dinner are usually of poor quality Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 12 consisting of mainly mash and mincemeat or sausage or beef burgers”, “I prefer a hot meal in the evening instead of soup and a sandwich”. The provision of food was an issue at the last inspection and the manager has attempted to address this by holding service users meetings with herself and the head cook, following this meeting new menu’s were drawn up and do satisfy the majority of the service users now. “I like the food it’s very tasty” Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Service users can be assured that their concerns and complaints will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: Since the last inspection the home has received two complaints, one has been resolved and the other is still under investigation. The homes policy ensures that complainants are informed of timescales for investigations and who will be conducting the investigation. The complaints procedure is available in reception for service users and their families to view. The home only keeps a log of complaints that are “written” at present, the manager should consider recording all concerns and complaints verbal or written, this will then detail what actions were taken to resolve issues that have arisen. The home has appropriate adult protection procedures in place and the manager is aware of her role in protecting service users. Some staff have received training in adult abuse awareness and there are plans to enrol the rest of the staff group. The home is currently assisting relevant agencies in an adult protection investigation. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 Quality in this outcome area is good, this judgement has been made using available evidence including a visit to the service. Service users can be assured that they live in a well-maintained and clean environment. EVIDENCE: The home is generally well maintained throughout. There are areas of the home that need updating and redecorating as a result of general wear and tear. All of the service users bedrooms seen were pleasantly decorated and service users commented “my rooms always clean and fresh”, rooms were furnished with personal possessions and had a relaxing and cosy feel to them. There is a courtyard garden to the rear of the home and can be accessed from the ground floor there is sufficient seating for service users to be able to enjoy the garden if they choose to. Some of the service users require the use of the “Stand aid” hoist to manoeuvre them from chair to chair, at present the home only has one of these hoists in it’s possession and nursing staff are required to move the hoist Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 15 from floor to floor as required, because service users on both floors need access to this hoist at any time it is recommended that the registered provider purchase another hoist to prevent any necessary delay in care service users may experience. The home has sufficient supply of profiling beds and other pressure relieving equipment to meet service user needs. There are supplies of gloves, aprons and paper towels throughout the home to ensure that the risk of cross infection is reduced. The home has satisfactory facilities for the disposal of waste. Laundry is washed at appropriate temperatures to control risk of infection. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home provides staff in adequate numbers with the necessary skills and knowledge to perform their duties. All staff are recruited in a safe manner that safeguards service users. EVIDENCE: The home has sufficient numbers of staff on duty, this includes a trained nurse on each of the nursing floors twenty four hours a day. In addition to this kitchen, maintenance and domestic staff, all ensure that the home is well run and service users are happy. Most of the service users who completed the questionnaire indicated that they believed more staff should be available to them to meet their needs. comments included “staff are slow in responding to the call button, this would not be good enough in an emergency situation”, or “button pressing should be attended to promptly so that the reasons/action can be prioritised”, and “the care can be very patchy for instance when ringing for help to be taken to the toilet it could be a very long time before a carer can turn up giving the impression of a staff shortage” All of the care staff at the home have the opportunity to complete their NVQ level 2 currently 65 of existing care staff have completed this. This exceeds the recommended 50 by 2005 and the home should be congratulated on this achievement. Staff are recruited in a way that generally safeguards service users, all necessary PoVAfirst and CRB disclosures were available, two written references Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 17 are obtained for each employee prior to commencing employment with the company. The home has a high number of overseas nurses who are supported by the manager and the company who are currently developing a support and training package to help them adjust to the some of the changes they experience when working in the United Kingdom. All new staff are given an induction that informs staff of the aims of the home and the changing needs of the service users and meets Skills for Care specifications. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The home is managed effectively and is run in the best interests of the service users. Service users and staff health and welfare is promoted and protected. EVIDENCE: Mrs Susan Nicholls has now completed the registration process with the Commission for Social Care Inspection. She is competent and experienced and runs the home in the best interests of the service users and their families. Hallmark Healthcare provides an annual service user questionnaire where they seek the views of the people who use their services. Currently the home is awaiting the results of their quality assurance review. The manager completes regular monthly audits to ensure that the home is running in the best interests Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 19 of the service users. The manager also holds residents meetings and ensures that issues raised are addressed, for instance, there had been some complaints about the food, service users were given the opportunity to discuss what they wanted to see on the menus and this was arranged. The home currently does not complete their own individual service users survey, this is something the manager may wish to consider in the future to ensure that the home is meetings the needs of the service users living in it as well as the national picture. Policies and procedures within the home are regularly reviewed and generally in line with current good practice. At present the home does not manage any of the service users monies. The home has an ongoing training programme for all staff that includes mandatory training such as infection control, food hygiene, moving and handling and fire safety. The home is well maintained and all systems such as fire alarms, emergency lighting, gas and electricity are checked as required with certificates to evidence this. Accidents are reported appropriately and there are risk assessments for safe working practices in place. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 2 X X 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 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 Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14 Requirement The registered manager must ensure that service user assessments are fully completed at all times and kept under review The registered manager must ensure that all identified needs have a care plan to address them The registered manager must be able to demonstrate service user involvement in this process. The registered person must ensure that medicines are stored safely and appropriately at the correct temperature. Previous Timescale 31.10.05 not met. 4 OP9 13(2) Immediate Requirement The registered person must take steps to reduce the amount of waste medication accumulating in the treatment room The registered person must ensure that the temperatures on the first and second floor are not DS0000029398.V307535.R01.S.doc Timescale for action 30/11/06 2 OP7 15 30/11/06 3. OP9 13(2) 11/08/06 30/11/06 5 OP19 23 (2) (p) 11/08/06 Delves Court Care Home Version 5.2 Page 22 excessive and that service users are comfortable at all times 6 OP24 23 (2) (n) Immediate Requirement The registered person must ensure that there is adequate provision of lifting equipment on each floor. The registered manager must review staffing levels to ensure that service users are not waiting for long periods of time for care staff to attend to their needs. The registered person must ensure that unannounced visits take place at least monthly and forward a copy to the CSCI 30/11/06 7 OP27 18 (1) (a) 30/11/06 8 OP33 26 (4) (a)(b)(c ) 30/11/06 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. 2. 3. Refer to Standard OP12 OP27 OP19 Good Practice Recommendations The manager should seek to find ways to include reluctant service users in social interaction. The manager should seek ways to maintain staff visibility to visitors during peak activity periods for service users. The responsible person is recommended to consider fitting a means of protecting doors from damage by the moving of equipment. Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Delves Court Care Home DS0000029398.V307535.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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