Inspection on 16/06/05 for Drake Court

This inspection was carried out on 16th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Drake Court 20/04/09

Drake Court 23/10/08

Drake Court 29/04/08

Drake Court 22/11/07

Drake Court 18/05/07

Drake Court 27/11/06

Drake Court 19/07/06

Drake Court 28/01/06

Drake Court 10/01/05

Drake Court 13/08/04

Drake Court 10/03/04

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

CARE HOMES FOR OLDER PEOPLE Drake Court Drake Close Bloxwich, Walsall West Midlands WS3 3LW Lead Inspector Chris Fuller Announced 16 June 2005 th 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 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. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Drake Court Address Drake Close, Bloxwich, Walsall, West Midlands, WS3 3LW Telephone number Fax number Email 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 476060 01922 407555 Drake Court Health Care Limited Miss Gillian Rosemary Edwards Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2005 Brief Description of the Service: Drake Court is a two-storey purpose built home which provides accommodation for twenty-nine elderly service users. The home is situated close to Bloxwich town centre and local amenities. The home is maintained to a high standard with adequate parking to the front and side of the property. There are twentyseven single rooms and one double room, all with a toilet and washbasin. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This year the Commission for Social Care Inspection is making a proportional inspection based inspection against a selected number of the National Minimum Standards. The focus remains on assessing the quality of care provided through the experience and outcomes for service users, a review of progress on meeting National Minimum Standards from last years inspections and focusing on aspects of service provision that require further development, or pose the most significant risk to service users. Some standards have not been inspected on this occasion. The Announced inspection of Drake Court residential home was made on Thursday morning 16th June 2005. The registered person and the accounts manager did not attend the inspection. The pre inspection questionnaire was provided prior to the inspection by the Registered Manager, Gillian Edwards who assisted the Inspector throughout the process. The staff and service users spoke with the inspector as individuals and groups and were helpful in their contributions, co-operating fully with the process of the inspection. Only two feedback questionnaires were returned from relatives of the residents and none from the residents themselves. The records were inspected and a tour of the premises made. The administration of medication was observed. There continues to be progress with some outstanding statutory requirements from previous inspections. The Inspector is concerned to find some basic statutory requirements have not yet been met. The minimum staffing levels remain a serious issue which impact on the Registered Manager and staff time and capacity for meeting the national minimum standards. An immediate requirement was issued in respect of a Health and Safety issue. What the service does well: There is a core group of staff working at the home that have knowledge, experience and are competent in their duties. They demonstrate a commitment to providing personal care services to the residents living at the home. One of the relatives stated “my parent has really changed for the better since being in Drake Court”. The friendly and helpful manner of staff provides a welcome to relatives and visitors. Staff are able to develop a good working relationship with other agencies. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 6 The premises and environment is generally well maintained internally and externally. It provides homely and comfortable surroundings with all areas decorated with traditional colours, design and furnishing. What has improved since the last inspection? 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. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 standard(s) 1,2,3,4 and 5 Some progress has been made with the revision of the statement of purpose and issuing to prospective residents and their relatives. An assessment of need format has been provided and letter of confirmation that service users needs can be met. Contracts hold details of room numbers and fees. All of these formats and procedures must be implemented to provide assurance that the care needs of residents will be met and to ensure appropriate placements are being made at the home. EVIDENCE: Standard 6 was not assessed as the home does not provide intermediate care. There were 28 residents accommodated at the time of the inspection; one was in hospital and one of these was on a respite stay. The home does provide respite care for residents however this is not included in the statement of purpose or registration. Seven residents were admitted for a period of respite during the past inspection year. Ten residents were admitted and remain at the home. A further ten were admitted, six who subsequently moved on to Nursing home care and four who were admitted to hospital and did not return. The home is busy with a considerable amount of change throughout the year. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 9 The statement of purpose has been revised and is available in the home and will be issued to residents, relatives, placing authority staff and new enquirers. Some of the files seen, hold copies of letters and assessments by the home (or by social services and health) confirming a placement at the home, ensuring the needs of service users can be met. The contracts are held on file with details of room number and fees to be paid however these have not been signed by either party and there is no letter of evidence that this has been issued to the resident or their relative. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 standard(s) 7,8,9 and 11 There has been some progress to restructure the framework for maintaining files and recording resident’s details. Reviews must be completed on a regular basis with the involvement of residents to ensure their health care needs are being identified and met. EVIDENCE: The management is restructuring the format of the resident’s files and a sample was seen of the old and new records. The latter hold formats for risk assessments of falls, pressure sores and nutrition. The information seen was current, with basic details recorded, signed and dated. Records hold an individual plan of care where details of health, personal and social care needs are recorded. Health care needs such as optician, chiropody, dental care etc. are monitored by the key worker and relevant health care agencies accessed and appointments and treatments obtained. The restructuring of files and information recording should assist and develop preventative health care practice in this area. The care staff engaged the residents in a short chair exercise session for muscle tone and fitness. District Nurse support was provided to one resident with successful treatment of a minor ankle / leg pressure sore. The resident was awaiting change from a pressure mattress to a standard mattress. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 11 The review of care plans is irregular and the care plans are not signed by the resident or relative. These matters must be addressed to ensure the care plan reflects the residents current needs and wishes and demonstrate their involvement in care planning. As noted earlier a third of the residents were admitted to hospital or transferred to a nursing home during the last twelvemonths. This would indicate improvements are needed in the initial assessment and to enable staff to identify and address health care needs at an early stage. The administration of medication was observed at lunchtime of the inspection day. The care staff demonstrated knowledge and competence in the process of administration and recording. Staff have received accredited medication training. Residents were observed to receive and take the medication. One resident has skin cream medication in her own room and has a lockable storage facility in the bedside cabinet. The home has a medication storage room with a medication fridge. There were homely remedies/unprescribed medication stored inappropriately in the fridge and cupboard. The Registered Manager stated these belonged to staff and were stored without her knowledge. The heat from the fridge warms medication stored in the cupboard directly above it, potentially making it unsuitable for use. The formats for assessment and care plans have headings for details of residents wishes at time of death however these remained incomplete. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 standard(s) 12,13 and 15 Insufficient staffing levels have a negative impact on the service delivery in respect of daily life and social activities. The management team address shortfalls as they arise to the best of their abilities and resources. There was a lively, busy atmosphere in the home and residents and relatives appreciated the efforts made by staff to provide personal care attention. EVIDENCE: The pre inspection information listed the following as activities provided by the home: Bingo, games, keep fit, music, social evenings and pub lunch. The records seen held details of the personal interests and hobbies of residents. The inspector noted several people knitting, crocheting, reading and watching TV during the afternoon. A seated exercise class was led by care staff in the morning. Feedback from relatives was mixed with several commenting on their satisfaction with the services provided but others who said “there are not enough activities or outings due to the limited time and number of staff it would take to escort people on outings”. There are a lot of visitors to the home both from visiting professionals and agencies and also from relatives and friends of the residents. The residents enjoy the visits from family and may go out on outings with them or for walks and shopping trips. Relatives were satisfied with the contact from the home and are kept informed of any changes to the well being of their relative. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 standard(s) 16 The registered person has not been co-operative with a request to investigate a complaint in previous inspection year. The complaints procedure has short timescales and the registered person and Registered Manager must ensure complaints are listened to, accepted and taken seriously and acted upon to give residents and others confidence to report issues of concern. EVIDENCE: Few formal complaints have been received by the home. Staff are expected to address issues as they arise. The complaints procedure had been issued to all service users and displayed on the doors of their individual rooms. The home’s complaints policy and procedure must be updated to provide current details of the Commission For Social Care Inspection. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 standard(s) 19,20,21,23,24, and 26 The home appears to be reasonably well maintained and in good repair internally and externally. There are still some basic requirements to be met to provide a safe and secure surroundings. Insufficient staffing levels for cleaning and ancillary staff is having an impact on maintenance of standards in the home. Residents rooms seen were found to be in good order, reasonable decoration, fabric and furnishings and personalised with their own belongings. The communal areas were comfortably furnished and provided a pleasant environment with good use of the space available. EVIDENCE: During a tour of the premises the inspector noted there was a stained damaged chair and broken weight scales in bathroom 1. Bin lids were missing in several areas of the home i.e. kitchen, bathroom and toilets. Door locks in the original part of the building are unsuitable for the safety of the resident and must be changed as a priority to meet health and safety standards. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 15 The equipment in the kitchen was in good order with new plate covers for the food taken to the bottom lounge, new whisks, tongs and toaster. The storage containers in the store cupboard need to be refreshed or replaced. Surface cleaning is satisfactory however several areas require an annual deep cleanse for floor surfaces, carpets and wall tiles. A washing machine had been out of order for over a week and the maintenance person was making the repair at the time of the visit. With no one specifically employed to cover laundry and only part time hours allocated to a night care worker to cover the duties it places a considerable strain on care staff to withdraw from care duties to attend to the laundry. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The home has operated with minimum staffing levels for a number of years at times falling below these levels due to long term sickness, staff vacancies and periods of leave. The staff support systems are not in place or fully implemented. Staff are expected to multitask covering care and ancillary duties. The number and deployment of staff is insufficient and leaves staff and thereby residents vulnerable in terms of health and safety in the home. EVIDENCE: There were a sufficient number of staff on duty on the day of the inspection. Staff duty rotas were confusing because they did not reflect the staff on duty. Tippex had been used on the records so it was not possible to track or identify the changes that had been made. The pre inspection questionnaire provided conflicting information regarding the staffing details. The Registered Manager explained that staff choose to provide cover for vacancies and sickness leave etc and staff from other homes within the group will be used to provide cover rather than contract agency staff. This does mean that some staff will work double shifts. The Registered Manager confirmed that on one occasion a senior had worked 24 hrs to cover a night shift. Information provided also identifies there are insufficient hours for ancillary staff with additional staff needed to cover duties for laundry staff, domestic staff and an assistant cook. The Registered Manager stated the laundry staff was due to return in one week from long term sick leave. A domestic staff member was due to be employed once references are cleared; to cover weekend cleaning duties having successfully been appointed through advertising and interview process. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 17 The on call rota, which does not include the Registered Manager, has three seniors who are expected to deal with on call queries and cover shifts if care staff are not able to provide cover. The senior care staff have not been given the authority to engage agency staff. As a consequence some staff are working double shifts and on one occasion a member of staff had to cover 24hrs. These are unacceptable arrangements for staff working conditions. There was no evidence of staff meetings being held in the last six months. There has been some improvement with the structure and content of staff recruitment files and records. The Registered Manager confirmed that all staff employed at the home have the required satisfactory reference checks and clearances. The Registered Manager is developing a staff training profile and was advised to add dates to the matrix of courses completed. Staff confirmed training received in all safe working practice topics through J & S Consultants. Four staff have now completed their NVQ level 2. One trainee from Age Concern received news of successful completion with an excellent portfolio. Others in the staff group have enrolled. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36 and 38 The registered person does not fulfil the duties and responsibilities in a timely and constructive manner. The Registered Manager operates within the limitations of the authority delegated and has made some effort to delegate care and some operational duties to a newly designated post of deputy manager and senior staff. However this change in structure has proved a difficult period for the new management team and staff group as a whole due to staffing shortfalls and lack of staff support and quality assurance systems. This leaves the staff group demoralised and vulnerable as individuals. EVIDENCE: The registered person has delegated the duty of the once a month unannounced visit to the home and a comprehensive written report to be provided to the Registered Manager of the home and the Commission for Social Care Inspection, to the Accounts manager Mr Wardle. Only one such report was available in the home. At the end of the inspection a further three Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 19 were faxed to the office with a statement these had been completed quarterly but would be done monthly in future. There was no evidence in the home of a quality assurance system or an annual quality assurance and development plan for the home. The Registered Manager has begun to maintain some basic information on income and outgoings in the home. This does not meet the requirement for a business and financial plan for the home, open to inspection and reviewed annually. There has been some progress with supervision arrangements. Senior care staff have recently been delegated some supervisory duties. Two different supervision formats have been utilised. In the past month a small number of supervision sessions have taken place. The Registered Manager and other staff providing supervision sessions would benefit from training in Supervision Skills. A significant number of care and ancillary / domestic staff had not received formal supervision. The Registered Manager had been asked at the last inspection to provide the Commission for Social Care Inspection with a yearly plan of six supervision sessions for each member of staff identifying the supervisors and the staff they supervise and the weeks in which the supervision will take place. This was still not available and given the few supervisions that have taken place this should be presented. The registered person was still unable to provide a certificate of the five year electrical service by a competent electrician. There were some hygiene issues that were identified during the inspection and these are as follows: the ventilation shaft for the cooker, the tiles and flooring in the kitchen, laundry, toilets and bathrooms. Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 2 x 3 2 x 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x 1 1 x 2 x 2 Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 21 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 &5 Requirement The Registered Person must ensure that the Statement of Purpose for the home and the Service Users’ Guide are issued to the service users and their representatives. 1.1 & 1.2 Ensure all relevant parties sign the Contract/ terms and conditions. Ensure care plans are reviewed on a regular basis and signed by the resident or relative. Ensure improvements to the initial assessment procedure are implemented to enable staff to identify and address health care needs at an early stage. Ensure suitable location of the medication fridge. Ensure suitable separate safe storage of staff medication. Ensure appropriate records are kept of the purchase administering and disposing of non prescription medication. Ensure the residents wishes concerning terminal care and arrangements after death are discussed, recorded and carried out. Timescale for action 31/07/05 2. 3. 4. 2.1 7.4 8.1 5 15(2) 12(1) 31/07/05 31/07/05 30/06/05 5. 6. 7. 9.4 9.4 9.4 13(2) 13(2) 13(2) 30/06/05 30/06/05 immediate 8. 11.3 12(2) 31/07/05 Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 22 9. 16.4 22(7) 10. 19 23 11. 21.1 23(2) 12. 24.5 12(4) 13. 14. 26.1 26.1 12(1) 12(1) 15. 26.1 12(1) 16. 27.1 18(1)(a) 17. 27.1 18(1)(a) Update the complaints information to provide the correct contact details for the Commission for Social Care Inspection The following matters require attention: 1.Toilet 2 Paint work. 2.Room 5 redecorate. The Registered Manager must ensure the stained damaged chair and broken weight scales are removed from bathroom 1. Door locks in the original part of the building are unsuitable for the safety of the resident and must be changed as a priority to meet health and safety standards. The storage containers in the store cupboard need to be refreshed or replaced. The registered manager must ensure bin lids are provided to all bins throughout areas in the home ie kitchen, bathroom and toilets. The registered person must ensure that the washing machines are repaired in a timely manner. Provide a sufficient number of domestic staff to ensure that standards relating to food, meals and nutrition are fully met, and that the home is maintained in a clean and hygienic state, free from dirt and unpleasant odours The registered person and the registered manager must ensure there the staffing numbers and skill mix of qualified / unqualified staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home, at all times. 31/07/05 31/07/05 immediate 30/09/05 30/06/05 30/06/05 30/06/05 30/06/05 immediate Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 23 18. 28 18(1) 19. 30.1 12(1) 20. 21. 30 33.1 12 & 18 26(5) 22. 33.2 24 23. 34.5 25 24. 36.1 18(1)(a) 25. 36.2 18(2)(b) The registered person must ensure there is a minimum ration of 50 trained members of care staff (NVQ level 2 or equivalent). 28.1 The registered person must ensure the registered manager and other staff providing supervision sessions receive training in Supervision Skills. Provide staff training in the following topic: Dementia Care. The registered person must ensure that at least once a month an unannounced visit is made to the home and a comprehensive written report is provided to the registered manager of the home and the Commission for Social Care Inspection. 33.1 Timescale of 31/05/05 not met. The Registered Manager must produce an annual Quality Assurance development plan for the home, based on a systematic cycle of planning, action, review, aims and objectives and outcomes for service users. 33.2 The Registered Provider must ensure that there is a business and financial plan for the home, open to inspection and reviewed annually. 34.5 Provide the Commission for Social Care Inspection with a yearly plan of six supervision sessions for each member of staff identifying the supervisors and the staff they supervise and the weeks in which the supervision will take place. 36.1 The timescale of 31/05/05 was not met. The Registered Manager must ensure that all staff receive formal supervision six times a year. 36.2 31/09/05 31/09/05 31/09/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 24 26. 38.3 23(2)(b) 27. 38.3 13(3) 28. 38.3 & 26.1 13(3) The registered person must provide within two weeks, by 30th June 2005, a certificate of the five year electrical service by a competent electrician. The registered person must ensure the ventilation shaft for the cooker is deep cleansed by a competent contractor at least once a year and as necessary. The registered person must ensure the tiles and flooring in the kitchen, laundry, toilets and bathrooms receive at least an annual deep cleanse and as necessary. 30/06/05 30/09/05 30/09/05 29. 30. 31. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 3 Good Practice Recommendations The registered manager should monitor admissions and discharges to identify the level and nature of need of service users upon admission and the period of time and reason for discharge. 3.1 Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 25 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8BR 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 Drake Court E55 S20809 Drake Court V227293 160605 Stg4 .doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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