Inspection on 09/03/04 for Delves Court Care Home

Care Home For Older PeopleDelves Court Care Home2 Walstead Road Walsall West Midlands WS5 4NZAnnounced Inspection9th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. AI Delves Court ­ 09.03.04ESTABLISHMENT INFORMATION Name of establishment Delves Court Care Home Address 2 Walstead Road, Walsall, West Midlands, WS5 4NZ Email Address Name of registered provider(s)/Company (if applicable) Hallmark Healthcare (Walsall) Limited Name of registered manager (if applicable) Mrs Susan Purchase Type of registration Care Home No. of places registered (if applicable) 64 Tel No: 01922 722722 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (64) Registration number E080000148 Date First registered 20th May 2002 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 28th January 2004 YES NO 11/02/02 If Yes Refer to Part CDelves Court Care HomePage 1 AI Delves Court ­ 09.03.04 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 3 9th March 2004 08:30 Ms Joy Hoelzel 073480 ID CodeName of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different Na perspective to the inspection process Name of Specialist (e.g. Na Interpreter/Signer) (if applicable) Name of Establishment Representative at Su Purchase Registered Manager the time of inspectionDelves Court Care HomePage 2 AI Delves Court ­ 09.03.04 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementDelves Court Care HomePage 3 AI Delves Court ­ 09.03.04 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Delves Court Care Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Delves Court Care HomePage 4 AI Delves Court ­ 09.03.04 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Delves court is a care home providing accommodation, nursing and personal care to sixty four older people, this includes two people who need help with intermediate care. It is owned by Hallmark Healthcare (Walsall) Ltd. The home is located in Walsall, close to shops and local amenities. The home opened in March 2002 and consists of a three-storey purpose built building. Nursing care is provided on the first and second floors. The home is currently undergoing redecoration with some refurbishment planned.Delves Court Care HomePage 5 AI Delves Court ­ 09.03.04PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The announced inspection took place in March 2004 and found that many of the National Minimum Standards are met or partially met. The overall quality of the care is good and there are support systems in place from the organisation. Service users and staff were in all parts of the building, in a variety of activities of daily living. Service users spoken with at the time of the inspection were generally satisfied with the care offered, however, one service user expressed dissatisfaction with his life at the home. Staff stated that the home was a lovely place to work but the could be extremely busy at prime activity times. Nine service user comment cards have been received some of which have been completed by staff or relatives on the service users behalf. Eight of the responses indicated that service users felt well cared for and that staff treated them well. 50 indicated that they liked the food with 25 stating that at times the food was acceptable. Twelve relatives/visitors comment cards have been received. 80 of the replies indicated that staff welcome them when they visit the home with 100 indicating that they are able to see their friends and relatives in private if they wished. 80 indicated that in their opinion there is not always sufficient numbers of staff on duty. Four people made additional comments ` very happy at the home, well cared for, `food is not very good, `never enough staff, ` carers very good, `all ok. Choice of Home (Standards 1-6) 6 of the 6 standards assessed were met The home has a current statement of purpose and service user guide that is readily available to prospective and existing service users. Health and Personal Care (Standards 7-11) 1 of the 5 standards assessed were met Arrangements are in place for meeting the health and personal care needs of service users. The plans are currently being updated. Further development of care plans has been recommended to ensure that all care needs are addressed. Daily Life and Social Activities (Standards 12-15) 4 of the 4 standards assessed were met Selections of activities are arranged on a regular basis, all service users are offered the opportunity to take part. Complaints and Protection (Standards 16-18) 3 of the 3 standards assessed were met Delves Court Care Home Page 6 AI Delves Court ­ 09.03.04 The home has a complaints procedure in place, it is included in the statement of purpose and a copy is placed on the notice boards around the home. Environment (Standards 19-26) 4 of the 8 standards assessed were met The home is suitable for the service user group. Redecoration and some refurbishment is currently being undertaken. Staffing (Standards 27-30) 4 of the 4 standards assessed were met The home is adequately staffed with registered nurses and an experienced care staff group National Vocational Qualification training is available and further development in all training is arranged. Management and Administration (Standards 31-38) 3 of the 8 standards assessed were met The registered manger is experienced and skilled to manage the home successfully; adequate systems are in place for organisational support.Delves Court Care HomePage 7 AI Delves Court ­ 09.03.04 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Delves Court Care HomePage 8 AI Delves Court ­ 09.03.04 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The service user care plan must detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service users are met. 15.1 All assessments used for generating the plan Completed 1 OP7 of care must be relevant for the service 15.2 category. The plan must be reviewed at least monthly or more often as the care needs of the individual change 2 12.1 OP8 The care plan must indicate the interventions, screening and review that is required to ensure that all health care needs are fully met. The medicine trolleys must be securely fastened to the wall when not in use Tubs and tubes of creams and lotions must be dated when opened and discarded within the recommended time scales. Hypodermic needles and syringes must not be re-sheathed after use but discarded safely in the sharps container All medications must be safely stored in the medicine trolley when not required. Completed313.2OP9Completed413.2OP9Completed513.2OP9Completed613.2OP9Completed Page 9Delves Court Care Home AI Delves Court ­ 09.03.04 7 12.2 OP11 Service users wishes concerning terminal care and arrangements after death are discussed, recorded and carried out. Door wedges must not be used for keeping doors open. If a door is required to be kept open the registered manager must ensure that a suitable door closure is fitted to meet the relevant standard. The registered manager must ensure that the bathrooms and assisted baths are fully suitable for the assessed needs of service users. A suitably qualified person must carry out an assessment of the premises and the equipment used at the home. In the absence of service users own possessions, the home must provide · Comfortable seating for two people · A table to sit at and a bedside table. 30th September 2004Implemented823.4OP19Completed914.1 No equivalent regulationOP22Completed10OP22Completed1123.2OP24Completed1212.4OP24Service users must be provided with keys with keys to their private accommodation unless their risk assessment indicates otherwise. Adequate hand washing facilities must be provided in all staff working areas, to include liquid soap, paper towels/ hot air dryers and a lidded disposal bin. A business and financial plan for the establishment must be made available for inspection and reviewed annually.1316.2OP26Completed1425.1OP34Completed1517.2 Schedule 4OP35Receipts must be given and obtained for each financial transaction on behalf of service users personal money. Completed Two signatures must be obtained for each transaction.Delves Court Care HomePage 10 AI Delves Court ­ 09.03.04 All care staff must receive formal recorded supervision with their line manager at least six times a year. Supervision must include · All aspects of practice · Philosophy of care in the home 16 18.2 OP36 · Career development needsImplemented17 18Schedule 3 OP37 &4 13.3 OP38All staff must receive an annual appraisal to review their work performance with their job description, and agree training and development needs The registered manager must ensure that all records outlined in Schedule 3 & 4 of the Care Homes Regulations 2001. The food chopping boards and frame in the main kitchen must be replaced, as they are very scored and marked.30th April 2004 CompletedRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Delves Court Care HomePage 11 AI Delves Court ­ 09.03.04PART BINSPECTION METHODS & FINDINGSYES YES YES YES YES YES YES NO YES NO YES NO YES YES YES YES NO YES NO YES 12 1 0 NO YES YES YES 28 11 09/03/04 08:30 7The following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs)Delves Court Care HomePage 12 AI Delves Court ­ 09.03.04 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Delves Court Care HomePage 13 AI Delves Court ­ 09.03.04Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 292.22 To (£) 475.00Any charges for extrasYESIf yes, please state what the extras are: hairdressing, chiropody, newspapers 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. The home has a current statement of purpose and service user guide. Both documents are readily available.Delves Court Care HomePage 14 AI Delves Court ­ 09.03.04 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking Each service user has a written contract/statement of terms and conditions with the home.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking A full assessment of need is carried out prior to offering the prospective service user a place at the home.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Discussion with the manager, Standard met? staff and service users. Observation of documents. Case tracking Staff individually and collectively have the experience and skills to deliver the service, which the home offers to provide.Delves Court Care HomePage 15 AI Delves Court ­ 09.03.04 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking Prospective service users and their representatives have the opportunity to visit the home prior to making the decision to move in.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking The home provides an intermediate care service for two people and delivers short-term intensive rehabilitation to enable service users to return home.Delves Court Care HomePage 16 AI Delves Court ­ 09.03.04Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking Care plans for all service users are currently being updated. The plan must detail the action, which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service users are met. All assessments used for generating the plan of care must be relevant for the service category. The plan must be reviewed at least monthly or more often as the care needs of the individual changeDelves Court Care HomePage 17 AI Delves Court ­ 09.03.04 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)11 42 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking The care plan must indicate the interventions, screening and review that is required to ensure that all health care needs are fully met.Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Discussion with the manager Standard Met? and staff. Observation of documents and staff working practice. Case tracking The home operates a twenty-eight day cycle of medication administration using a monitored dose system with some bottles and boxes. Staff demonstrated a good knowledge in this area. The medicine trolleys must be securely fastened to the wall when not in use. Tubs and tubes of creams and lotions must be dated when opened Hypodermic needles and syringes must not be re-sheathed after use but discarded safely in the sharps container. All medications must be safely stored in the medicine trolley when not required.Delves Court Care HomePage 18 AI Delves Court ­ 09.03.04 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Discussion with the manager Standard met? and service users. Observation of documents and staff working practice. Case tracking Service users confirm that staff treat them with respect and dignity. Staff were observed to be maintaining privacy when offering care.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 2 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking Service users wishes concerning terminal care and arrangements after death are discussed, recorded and carried out.Delves Court Care HomePage 19 AI Delves Court ­ 09.03.04Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Discussion with the manager, Standard met? staff and service users. Observation of documents and staff working practice. The social activities organiser arranges leisure and recreational activities in and out side of the home. A daily programme of activities is arranged and placed on the notice boards of all three floors. Service users are given the opportunities to discuss their social preferences at the monthly coffee mornings. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Discussion with the manager, Standard met? visitors and service users. Case tracking The home operates an open visiting policy suited to the service users. Visitors confirm that they are able to visit the home at times arranged with service users.Delves Court Care HomePage 20 AI Delves Court ­ 09.03.04 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents and staff working practice. Case tracking Service users are encouraged to exercise choice and control over their lives within the capacity of the individual.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Discussion with the manager, Standard met? staff and service users. Observation of documents and staff working practice. Case tracking The home operates a four weekly rotational menu, which is nutritious and wholesome. Staff were observed to be assisting service users with their midday meal in an unhurried and relaxed manner. The cook at the time of the inspection demonstrated a good knowledge of the menu on offer and the special diets that are required.Delves Court Care HomePage 21 AI Delves Court ­ 09.03.04Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 13 6 7 0 0 2 100 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. The home has a complaints policy and procedure, it is included in the statement of purpose and a copy is placed on each of the notice boards around the home.Delves Court Care HomePage 22 AI Delves Court ­ 09.03.04 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Discussion with the manager. Standard met? Case tracking All service users are on the electoral roll with postal and proxy votes arranged for the people who wish to vote but are unable to go to the polling station.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X3 Key findings/Evidence Discussion with the manager Standard met? and staff. Observation of documents. The home has an adult protection procedure. Staff demonstrated a good knowledge of how they would respond to suspicion or evidence of abuse.Delves Court Care HomePage 23 AI Delves Court ­ 09.03.04EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Tour of the premises Standard met? The home is currently being redecorated. The registered person must ensure full compliance with the fire officers report 05/08/02. Door wedges must not be used for keeping doors open. If a door is required to be kept open the registered manager must ensure that a suitable door closure is fitted to meet the relevant standard. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Tour of the premises Standard met? Service users have access to safe and comfortable indoor and outdoor communal facilities.Delves Court Care HomePage 24 AI Delves Court ­ 09.03.04 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Tour of the premises Pre Standard met? inspection questionnaire. The home has a sufficient number of toilets and bathrooms for service user use.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Tour of the premises Standard met? A suitably qualified person must carry out an assessment of the premises and the equipment used at the home. The registered manager must ensure that the bathrooms and assisted baths are fully suitable for the assessed needs of service users.Delves Court Care HomePage 25 AI Delves Court ­ 09.03.04 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 60 20 2 0 3 60 00 0 2 0Key findings/Evidence Tour of the premises. Standard met? Discussions with service users Service users confirm that the bedrooms are suitable for the purpose.Delves Court Care HomePage 26 AI Delves Court ­ 09.03.04 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 2 Key findings/Evidence Tour of the premises Standard met? In the absence of service users own possessions, the home must provide · Comfortable seating for two people · A table to sit at and a bedside table. The reason for not doing so is explained in the service users plan of care. The registered manager has planned for the installation of suitable door locks to be fitted to all bedroom doors. Service users must be provided with keys unless their risk assessment indicates otherwise.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Tour of the premises Standard met? Service users live in safe comfortable surroundings.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Tour of the premises Standard met? Adequate hand washing facilities must be provided in all staff working areas, to include liquid soap, paper towels/ hot air dryers and a lidded disposal bin.Delves Court Care HomePage 27 AI Delves Court ­ 09.03.04StaffingThe intended outcomes for the following set of standards are: · · · 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 homes recruitment policy and practices. · Staff are trained and competent to do their jobs. Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 6 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 39 16 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X12 29 143 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking The manager confirms the following staffing levels Daytime - two registered nurses, ten care staff Night time- two registered nurses, four care staff Management support, domestic, catering and ancillary staff and activities coordinator are additional.Delves Court Care HomePage 28 AI Delves Court ­ 09.03.04 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 6 20 3Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Pre inspection questionnaire National Vocational Qualification level 2 & 3 are continuing.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. Key findings/Evidence Discussion with the manager. Standard met? 3 Observation of documents. The home has a robust recruitment procedure with the necessary checks carried out. Criminal record bureau checks are continuing for all new and existing staff. Staff are required to pay the appropriate fee.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. All staff have had their training and development needs identified, courses and updates are arranged through out the year.Delves Court Care HomePage 29 AI Delves Court ­ 09.03.04Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. The registered manager is a registered nurse and has the necessary skills and experience to successfully manage the home. The registered manager must demonstrate that she undertakes periodic training to update her knowledge and skill base. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Discussion with staff, service Standard met? users and visitors. Observation of documents. Visitors, service users and staff stated that the home is well managed and although is very busy at times it is a `lovely place to live and work in.Delves Court Care HomePage 30 AI Delves Court ­ 09.03.04 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. There is an effective quality assurance and monitoring system in place, this is based on the Kings Fund model. An annual development plan is produced from the internal audits.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 2 Key findings/Evidence Observation of documents. Standard met? A business and financial plan for the establishment must be made available for inspection and reviewed annually.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 3 0 12 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking Secure facilities are available for the safe keeping of personal money and valuables on behalf of service users. Receipts and two signatures for each transaction must be given and obtained.Delves Court Care HomePage 31 AI Delves Court ­ 09.03.04 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. All care staff must receive formal recorded supervision with their line manager at least six times a year. Supervision must include · All aspects of practice · Philosophy of care in the home · Career development needs All other staff must receive formal supervision as part of the normal management process. All staff must receive an annual appraisal to review their work performance with their job description, and agree training and development needsStandard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking The registered manager must ensure that all records outlined in Schedule 3 & 4 of the Care Homes Regulations 2001.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Discussion with the manager. Standard met? Observation of documents. Case tracking The food chopping boards and frame in the main kitchen must be replaced, as they are very scored and marked.Delves Court Care HomePage 32 AI Delves Court ­ 09.03.04PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateJoy HoelzelSignature Signature SignatureDelves Court Care HomePage 33 AI Delves Court ­ 09.03.04PART D(where applicable) N/aLAY ASSESSORS SUMMARYLay Assessor Date Public reportsN/aSignatureIt should be noted that all NCSC inspection reports are public documents.Delves Court Care HomePage 34 AI Delves Court ­ 09.03.04PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleDelves Court Care HomePage 35 AI Delves Court ­ 09.03.04 Action taken by the NCSC in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was requiredAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Delves Court Care HomePage 36 AI Delves Court ­ 09.03.04 E.3 PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies. E.3.1 I of Delves Court confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Delves Court Care HomePage 37 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!