Inspection on 10/02/06 for Delves Court Care Home

This inspection was carried out on 10th February 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 10/08/06

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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Maple Lodge

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Ravenhurst

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Inspirations

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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 Richard Eaves Announced Inspection 10th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 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 debbie.harris@hallmarkhealthcare.co.uk Hallmark Healthcare (Walsall) Limited 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.V275506.R01.S.doc Version 5.1 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 Bescott 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, 20 having en-suite and 2 double rooms. The ancillary services of catering, laundry housekeeping and maintenance are provided in-house. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the unannounced inspection during September 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire, comment card responses from service users and relatives and records held at the home. The inspection involved a full tour of the property including, bedrooms, communal rooms and service areas and provided an opportunity to speak with most of the service users. What the service does well: What has improved since the last inspection? The process of care planning has been improved to include separate plans for each individual problem identified and equipment as required identified in the plan. Carers involved in the administration of medicines have received accredited training. The process of formally supervising staff has been introduced. The programme of decoration has been completed and new disabled assisted baths fitted, a shower room has also been refitted and made more accessible. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–6 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home, this is confirmed by contract. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home. Designated staff provide skilled intermediate care maximising the opportunities for rehabilitation. EVIDENCE: Copies of the statement of purpose and service user guide were available in reception and the guide is available in each bedroom and issued to persons making enquiries. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 9 The case files for each of the three floors of the home were inspected and found to include a pre-admission assessment and further in depth assessments at the time of admission using an activities of daily living model and including individual risks such as falls, pressure sores, nutrition and continence. The home uses the Walsall single assessment raised by the hospital for intermediate care service users, this is received pre arrival at the home and a confirmation is returned that confirms the unit can meet the assessed needs. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. Rehabilitation therapies are provided by hospital out reach staff. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 10 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 – 11 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Administration of medication practice is robust and ensures service users medication needs will be safely met. Service users are treated with respect and their privacy upheld. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: A sample of three care plans were randomly inspected on each floor they were derived from extensive assessments of needs and individually assessed risks, these were completed well and provided good direction for the delivery of care. Evaluations were undertaken monthly and included reassessments. All service users are registered with a GP of their choice and other allied health care providers attend on a regular basis. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 11 The home has a good range of pressure relieving equipment and these were for the most part observed to be in use and where a mattress was in use an equivalent cushion was used on chairs. Arrangements for medication management are robust and undertaken by the nursing staff on the nursing floors and carers on the personal care area, all use a monitored dosage system for most medicines. Carers involved in medication administration have attended an accredited training course. The processes are audited weekly by the manager and quarterly by the pharmacist. Over the period of the inspection staff were observed to interact in a kindly way with respect and thoughtfulness that is sensitive to protecting service users dignity. The topic of respect for service users is included in the induction programme for new staff. While the 18 comment cards returned by service users were almost entirely positive about the home although 9 chose not to complete the response to the question, is your privacy respected? While no one would be drawn on this in conversation, such ambivalence requires to be examined and corrective action taken. A limited programme of training of care of the dying is included in the NVQ units and the Nursing staff have experience in care of the dying. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 12 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 - 15 The home provides a well-organised and varied social and recreational activity programme that provides interest and pleasure for the residents with efforts to meet individual and minority needs. An open visiting policy assists service users to maintain contact with their family and friends. Many aspects of care evidences that service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste and catering for special dietary needs. EVIDENCE: The Home employs a social activities organiser who arranges leisure and recreational activities in and out of the home. The programme of activities is displayed on the notice boards of all three floors. Service users participate in planning events at the regular coffee mornings. One service user was not happy with the suitability of the activities arranged but provided no comment. The home operates an open visiting policy suited to the service users and visitors were observed to come and go across the day. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 13 Service users are encouraged to exercise choice and control of their lives to the extent of their capacity, this can be observed in the individual bedrooms that were seen to have items of personal property such as display case, favourite chair and most were decorated with pictures and photographs and other decorative memorabilia. Other choices encouraged include choosing clothes to be worn that day, meals from the menu and times of rising and settling. The Home has a 4-week rotating menu that includes choices with an option of hot food at each meal. The make up of the menus suggest that the meals are nutritious, wholesome and well received by those service users that responded in conversation. Hot and cold drinks and snacks are available outside of meal times. Of the 18 comment cards received from service users 8 liked the food, 9 sometimes and 1 did not. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 14 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 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The complaints procedure is well promoted in the service user guide and in notices displayed in numerous places about the home. Records demonstrate that concerns raised are acted on and that the staff are receptive to personal wishes. Advocacy services are also displayed in the main reception area. The manager identified that the electoral roll is completed each year and confirmed that postal votes had been arranged for the coming year. The home has a robust adult protection policy and all staff have undertaken adult protection training. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 15 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 & 26 The home provides a good standard of décor, furnishings and managed services providing a safe, disabled accessible environment and an attractive, and homely place to live. The bedrooms have bathrooms in close proximity for the convenience of service users. The home is clean, free from odours and hygienic. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 16 EVIDENCE: Delves Court is a purpose built Home providing accommodation for up to 64 residents in 60 single, including 26 en-suite and 2 double rooms , the design incorporates requirements to meet the needs of the disabled. The premises are well maintained and decorated. Since the previous inspection 2 new disabled assisted baths have been fitted on the first and second floors and a shower room refitted. Arrangements are in place for monitoring and regular servicing of equipment and utilities. The building is subject to safety monitoring and complies with fire and environmental requirements. The grounds provide an attractive, safe and accessible area for service users and appeared neat and tidy and appropriate for season on the day of inspection. A separate parking area is available for visitors and staff to the side of the building. The home was found to be clean, hygienic and free from odours, each floor has its own sluice disinfection facility and the modern laundry is fitted with washing machines with sluicing and disinfection programmes and all surfaces are washable. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 17 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 – 30 The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: An inspection of the staffing rotas demonstrates that the home maintains satisfactory staffing levels. Of 7 comment cards returned by relatives 3 answered no to the question are sufficient staff always on duty. The manager is recommended to find means of raising the visibility of staff at peak times. Since the previous inspection the homes’ staff have achieved NVQ level 2 in excess of the 50 standard. An inspection of training records shows that mandatory training is up to date. Recruitment and selection are completed to a good standard and includes all necessary checks such as CRB, POVA and nursing registration. Staff files also show that two references are obtained and a record kept of the interview. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 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 – 37 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance which includes consultation and seeking the views of service users and their families and evidenced that it is acted upon. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 19 EVIDENCE: The manager is well experienced and is progressing an application for registration. All levels of staff consider themselves to be valued and respected for their input into the team as a whole. On the day of the inspection it was apparent that there was a very good atmosphere amongst the staff. The manager holds frequent staff meetings and maintains a record and actions taken in response to staff inputs. Service users views are canvassed regularly using a range of questionnaires that between them cover all aspects of service. The area manager undertakes monthly regulation 26 visits completing a report of each inspection. The home does not act as appointee for service users arrangements with full accounting procedures, are in place for personal allowances held for safekeeping. A sample of supervision records were inspected and these show that supervision session topics are relevant and the process is on target to achieve at least 6 sessions a year for all staff. Records required by regulation and the schedules are maintained and kept up to date. Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 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 2 3 3 X 3 3 3 X Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 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 op24 Regulation 12(4)(a) Requirement The responsible person must ensure doors to service users accommodation are fitted with locks accessible to staff in emergency. Timescale 31.3.05 not met. The registered person must ensure that medicines are stored safely and appropriately at the correct temperature. Timescale 31.10.05 not met. The registered person must seek to improve the perception of respecting privacy of service users. The registered person must seek service users views on what they believe would improve their satisfaction with the meals provided. The manager must demonstrate fitness by completion of the registration process. Timescale for action 31/05/06 2. OP9 13(2) 31/05/06 3. OP10 12(4)(a) 31/05/06 4. OP15 16(2)(i) 31/05/06 5. OP31 9(1) 31/05/06 Delves Court Care Home DS0000029398.V275506.R01.S.doc Version 5.1 Page 22 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.V275506.R01.S.doc Version 5.1 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.V275506.R01.S.doc Version 5.1 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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