Inspection on 18/05/07 for Drake Court

This inspection was carried out on 18th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 27/11/06

Drake Court 19/07/06

Drake Court 28/01/06

Drake Court 16/06/05

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 Keith Salmon Key Unannounced Inspection 18th May 2007 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 Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drake Court Address Drake Close Bloxwich Walsall West Midlands WS3 3LW 01922 476060 01922 407555 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) Drake Court Health Care Limited vacant post Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th November 2006 Brief Description of the Service: Drake Court is a two-storey purpose built home situated close to Bloxwich Town Centre and the local amenities it offers. Accommodation is provided for the 29 Residents in 27 single rooms, and 1 double room, all with en-suite toilet facilities. There is small garden, with patio to the rear, with car parking availability to the front and side aspect of the building. Charges range from £327.15 to £351.94 per week. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection of ‘Key’ Standards was undertaken over two days, Friday, 18 May and Monday, 21 May 2007. The second inspection day was necessary to enable the Inspector to hold discussions with the Acting Manager, Mrs. Harvinder Kaur, who was unavailable on the first day of inspection. Both days commenced at 9.30am, with a total inspection time of 8.5 hours. Representing the Home on the first day were Karen Bracknell, Deputy Manager, and Mr Michael Wardle, Responsible Individual. In addition to the inspection of ‘Key’ Standards, this Inspection also sought to review progress in meeting ‘Requirements’ arising from the previous Unannounced Key Inspection, held in November 2006. In view of the poor levels of performance reported, at that time, a formal ‘Management Review’ was undertaken by CSCI (also November 2006) resulting in the issue of an ‘Improvement Plan’, the response to which was also to be monitored at this Inspection. Furthermore, following a ‘Random’ Inspection undertaken in March 2007 aimed at monitoring the transfer of 10 Residents, together with the Registered Manager and other Staff from Manor Court Care Home, due to refurbishment, this Inspection was an opportunity to review how well Residents had settled in to Drake Court. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the home. The Inspector also held individual discussions, with 12 Residents and 3 Visitors, the Acting Manager, the Senior Carer in charge of the shift on day one of the Inspection, the Responsible Individual, and several other members of staff. What the service does well: All Residents appeared well groomed to a degree that suggests a very well run internal laundry system, and reflects well on Care Staff. Residents are enabled to make meaningful lifestyle decisions, e.g. a number of Residents ‘clubbing together’ to subscribe to the ‘Sky Sport’ television channel. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Past inspection reports evidenced recurring issues, and concerns, regarding the lack of action taken by the previous Responsible Individual, and the then Manager of the home, in addressing issues discussed and agreed at inspections, and subsequently highlighted in the inspection reports. On 21 November 2006 a Management Review meeting was held by CSCI, with the Responsible Individual, due to serious concerns that the home was establishing a history of failure to meet National Minimum Standards of Care, and non-compliance in meeting statutory requirements within agreed timescales. At that meeting, the Responsible Individual gave assurances every effort was being made to address shortfalls, and subsequently submitted an action plan, with timescales for completion, clarifying how the outstanding requirements would be met. However, at this Inspection, it was found that, despite some progress having been achieved (as stated in the Section above) many of the major issues in the Action Plan have either not been addressed, or remain only partly met, with some Statutory Requirements remaining outstanding with little evidence of any positive input. These include Revision of the Statement of Purpose, and provision of copies to prospective Residents and their families has not been completed. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 7 Issues relating to arrangements for the receipt and day-to-day management of Residents’ personal monies have not been satisfactorily resolved. No copies of reports following unannounced inspections by the Responsible Individual were available at the Home for the Inspector to peruse. The worn carpets, in communal areas and hallways, some of which may pose a danger to Residents - compromising the safety of Residents/Staff and Visitors - have not been replaced. There was no evidence of planning to meet this Requirement. The Acting Manager, Mrs. Harvinder Kaur, transferred from Manor Court to undertake ‘day to day’ management responsibility, at the same time as the transfer of 10 Residents. At the time of this Inspection, Drake Court does not have a Registered Manager (as required by Regulation) and, as yet, no formal appointment has been made to this post. This post must be filled as soon as possible, which should provide a more secure platform from which to address the many shortfalls remaining. 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. The summary of this inspection report can be made available in other formats on request. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective Residents, or their Representative, are not yet provided with the information they need to make an informed choice about ‘where best to live’. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: A Requirement from the previous Inspection was “The Responsible Individual must ensure that the Statement of Purpose for the home is reviewed and updated.” The Inspector was informed a draft had been prepared and is subject to further amendment, though this was not available for perusal. This Requirement will remain, with the added proviso that a copy of the revised Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 10 draft is forwarded to CSCI for their information and consideration, as soon as available. A further Requirement in this ‘Outcome Area’ was “The registered manager must ensure new residents are admitted only on the basis of a full assessment and where the home can demonstrate it is able to meet those needs.” This Requirement has been outstanding from inspections prior to November 2006. At this Inspection evidence was observed which confirmed The Acting Manager now completes a full care needs assessment prior to any admission. The care needs of those Residents recently admitted appear to be within the care provision capabilities of the Home. Therefore, the Inspector considers this Requirement to be met. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan utilised by the Home sets out Resident’s health, personal and social care needs, and enables assessed care needs to be met. The care provided is delivered considerately and effectively. The reception, storage, disposal, and record keeping relating to medicine administration are generally in accordance with accepted ‘good practice.’ Residents’ privacy and dignity is respected. EVIDENCE: Review of care planning documents, relating to six Residents selected at random for ‘case tracking’, demonstrated the Home uses an ‘in-house’ design of care plan, which is sufficiently comprehensive to meet Residents’ individual care needs, and is reliably maintained by Care Staff. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 12 Evidence was observed of regular review/up-dating of care plans having been carried out by one of the four Senior Care Staff (each operating as ‘key worker for nine Residents) and overseen by the Acting Manager. Areas of care addressed by the care plan include; full range of risk assessment based on ‘activities of daily living’, pressure sore risk assessment, nutritional state (including daily food and fluid intake), regular weighing (frequency determined by assessed need), and records of visits by clinical/social care professionals, e.g. GP, Community Nurse, Social Worker, Optometrist. Residents’ interests, hobbies, and preferences are now also recorded. Three Requirements, relating to the management and administration of medicines, were issued at the previous Key Inspection. Specifically: Monitoring administration of medicines to ensure Staff actually observe Residents taking their medication. Ensuring all Staff administering medication have completed the accredited training in the safe handling and administration of medication. The establishment of a central record showing the names of those Staff who have completed accredited medication training and the date of completion. This record to be held with the MAR Sheets. Staff were observed administering medicines, and were seen to ensure Residents took the medicine(s) administered. Residents confirmed the usual practice was for Staff to remain at their side until the process had been completed. The Deputy Manager informed the Inspector that when Residents where unable/unwilling to take their prescribed medication this was entered in the MAR Sheet, and, where appropriate, Staff would retry later. Examination of MAR Sheet Records confirmed the relevant entries had been made. Evidence was also observed in staff files confirming Staff who undertake administration of medicines, e.g. Acting Manager, Deputy Manager, plus two nominated Senior Carers, have all completed the relevant training, and their names are maintained in a ‘central record’ as required. These ‘medicine’ related Requirements are now met. In addition, a review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicine refrigerator temperatures). All were found to be generally in accordance with current ‘good practice’. However, there was one exception to this, in that the digital thermometer, used to measure the internal temperature of the medicine refrigerator, does not have a ‘reset’ button. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 13 To remedy this important aspect of medicine policy it will be a Recommendation that the Home purchases a model incorporating this facility, to enable accurate sampling of the ‘24 hour’ minimum/maximum temperature cycle. Residents and visitors, with whom the Inspector held discussions, stated they and their Relatives/Visitors were always treated in a respectful and considerate manner. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure opportunities provided are consistent with Residents’ capabilities. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: Residents informed the Inspector they generally enjoy sitting in the main lounge and dining room areas where they can pursue their own interests of knitting, reading and watching TV. In addition, they have the option of relaxing in other smaller, quiet sitting/dining rooms, which are used less frequently. Residents also stated they enjoyed the musical entertainment, and the fitness exercise sessions provided once a week. In one particular section of the main Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 15 lounge, three gentleman Residents were watching the international cricket on television, and informed the Inspector they had ‘clubbed together’ and subscribed to ‘Sky Sports’, which has enabled them to enjoy a variety of sporting events. They were very enthusiastic about being able to do this, and it has facilitated continuation of their interest in following their sporting interests. In addition, the home benefits from having a twelve-seat coach used for transport to leisure/social events, and for which the manager is the named driver. Evidence was observed showing Residents’ meetings are held, at which discussion covers topics such as the type of activities the Home may arrange/provide, e.g. shopping trips, visits to garden centres. When discussing the Residents with ‘Key workers’ they were able to demonstrate a good understanding of the preferences/specific needs of the Residents in their direct care, e.g. health, emotional and social needs, and how these should be met. In relation to meals the general consensus of Residents is the range, quality, amount and choice of food provided is good. Comments included… “it is good quality food, always enough and you can always ask for more if you want it”, …“ If I don’t like what is on the menu the cook will do something different. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18. Quality in this outcome area is now good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse. EVIDENCE: An on-going Requirement arising from previous Inspections has been – “The Responsible Individual and the Registered Manager must ensure a record is kept of all complaints.” The Inspector was informed that no complaints had been made since the previous Inspection (November 2006), and the CSCI had not received any complaints relating to the home. It is not possible to judge whether the home has improved their performance in respect of recording complaints, although the Inspector is now able to report that systems are now in place which should enable such improvement if a formal complaint is raised. Also, Residents spoken with stated they had no complaints, but would feel comfortable to speak with the Manager or Staff at any time should they feel Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 17 the need to do so. In the light of these findings this Requirement will be removed. Information, from various authorities, regarding adult protection/’whistleblowing’, is displayed on the main notice board and Staff attend the Courses on Adult Protection held by the Local Authority. Accident Records were reviewed and found to be current, presenting no areas for concern. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a reasonably comfortable, generally safe, though rather worn environment, with some carpets, curtains, and dining furniture in need of replacement. Specialist equipment, consistent with meeting the assessed care needs of Service Users, and the demands of tasks carried out by Care Staff, is available, and appropriately serviced and maintained. EVIDENCE: Two Requirements, cited at the previous Inspection, relating to ‘Environment’ were - Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 19 “The Responsible Individual and the registered manager must replace the dining room chairs and tables.” “The Responsible Individual and the registered manager must replace carpets in the dining room, lounge and downstairs hallways.” Dining room chairs and tables remain worn and still in need of replacement, as are the carpets in the dining room, lounge, and downstairs hallways. At the previous Unannounced Inspection particular reference was made to the potential trip hazard of the worn carpet by Room 3, which was discussed on that occasion, and agreed this would be given priority. These issues have been outstanding through three previous Inspections and have not, as yet, been resolved. The Responsible Individual confirmed there were plans to make improvements to the fabric and furnishings in the home, e.g. all downstairs corridors have recently been painted and the Inspector was informed that new curtains are on order. To facilitate progress in respect of the state of decoration/furnishings, and to establish meaningful indicators of progress in respect of this, it is a Requirement of this Inspection that a refurbishment/redecoration/replacement programme be instigated. This programme must include proposed work with planned completion dates for each element of work. A copy of this programme is to be forwarded to the CSCI by the ‘Timescale for Action’ date. Replacement of worn and dangerous carpets should receive priority, and be installed without further delay, as they compromise the health and safety of Residents, Staff and Visitors. Domestic duties are undertaken by two domestic staff, covering every day of the week, working together on three days and singly on the remaining four. Throughout the tour of the premises the Inspector found the home to be clean, and odour free. The Laundry is covered six days per week by a designated laundry employee, with a member of Care Staff providing cover on day seven. The laundry appeared well organised with its effectiveness reflected in the tidy and immaculate appearance of all the Residents. The Inspector considers the Domestic and Laundry Staff are to be commended for their efforts despite the generally worn state of the décor, furniture, and furnishings. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty, and skill-mix, were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. Commitment of the Home in providing training for Care Staff is satisfactory, and in accordance with individual Staff Member’s learning needs. EVIDENCE: The current staffing rota, plus those from the immediately preceding weeks, were examined and compared with staff numbers on duty at the time of the Inspection. These demonstrated staffing numbers, and skill-mix, enable a service provision, which meets the care needs of the Service Users. A staff member, who transferred with Residents from The Manor, informed the Inspector that she, and other transferred staff had settled in well. A plan for staff training was reviewed which covers safe working practice topics such as; dementia care, continence management, abuse awareness, safe handling of medicines, and a course on bereavement care. Staff appear enthusiastic about their training prospects, are eager to be nominated and are supported in attaining NVQ qualifications. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 21 A Requirement from the previous Inspection was “The Responsible Individual must ensure the registered manager or acting manager remains supernumerary at all times.” The Inspector was informed that the person in charge for any specific day, be it the Acting Manager, Deputy Manager, or one of two nominated Senior Carers, is always supernumerary, and a review of duty rosters confirmed this to be so. This Requirement is met. A second Requirement in this area of care was ”The Responsible Individual and the registered manager must ensure there is a minimum ratio of 50 of care staff (NVQ Level 2) employed in the home.” At the time of this Inspection 8 members of Care Staff from a total of 21 (covering day and night shifts) had attained NVQ Level 2 – which equates to 38 . The Inspector was shown evidence that 3 members of Care Staff are currently undertaking NVQ Level 2 training, with expected completion dates in the coming months. If all are successful, with nothing to suggest otherwise, the addition of this number will take the percentage up to 52 . In expectation of this prospect, together with the fact the Home has now put into place seemingly robust systems to support Staff through their training, this Requirement will be removed. A final Requirement in this area was “The Responsible Individual and registered manager must ensure that all staff have an annual staff appraisal.” The Acting Manager has introduced an arrangement by which she, the Deputy Manager, and two nominated Senior Carers, each have responsibility for the active supervision/appraisal of a proportion of Care Staff. Review of staff personal files demonstrated the system is operational and Care Staff informed the Inspector they were happy and confident in the new system. The Inspector considers this Requirement to be met. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There has been some improvement in the management of the home. However, progress is slow and there are a number of management issues to be addressed so as to ensure the health and well being of residents is safeguarded and promoted. EVIDENCE: Following the previous Unannounced ‘Key Inspection, a number of Requirements were made in respect of ‘Management and Administration’. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 23 With several having been outstanding from previous Inspections this served to highlight the concern of the CSCI with regard to the quality of management, and the worth of input, and support, received from the Responsible Individual. Therefore, the prime focus of this Inspection was to ascertain clear evidence of Requirements having been met, or evidence that issues have been, or are being, addressed in a meaningful and effective way. The measure of progress, or otherwise, is illustrated below through the process of considering an outstanding Requirement, plus any ‘Key Standards’ not covered by those Requirements. Of the 6 outstanding Requirements in this Outcome Area, the first relates to management style, leadership, and general effectiveness, i.e. “The registered manager must ensure that the management approach of the home creates an open, positive and inclusive atmosphere.” At the time of this Inspection the Home does not have a ‘Registered Manager’. Mrs. Kaur was previously ‘Registered Manager’ at Manor Court Care Home, and accompanied the Residents who transferred from that Home in February of this year. There are some indications of improvement in the management of the home, e.g. changes to operational systems, i.e. pre-admission assessment, organisation of staff deployment, some aspects of staff training, positive comments by Residents and their Visitors. However, the current management is still going through a ‘settling in’ period, and further development may be influenced by the eventual appointment of a substantive ‘Registered Manager’, subject to approval/registration by CSCI. A second Requirement in this area was “The Responsible Individual must ensure that the registered manager is competent to run the home and meet its stated purpose, aims and objectives.” As there is currently a vacancy for the ‘Registered Manager’ post both of the above Requirements are technically redundant. However, during the period awaiting the appointment of a ‘Registered Manager’ it is important the Responsible Individual is aware of his responsibility to continue supporting the current ‘Acting Manager’, and that he holds ultimate accountability for any shortfalls in care at Drake Court. Besides being a requirement of Regulation, it is the view of the Inspector that, whilst progress to date should be recognised, the appointment of a ‘Registered Manager’, formally approved and Registered by CSCI, is imperative to ensuring continued progress and improvement in this significant ‘Outcome Area’. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 24 It is a Requirement of this Inspection that a manager be recruited and appointed as soon as possible, and the successful appointee must apply to CSCI for formal ‘Registration’ as Manager immediately following appointment to the post. The third Requirement relates to formal staff supervision, i.e. “The registered manager must ensure all staff receive regular supervision (at least every two months).” As reported, following the ‘Random Inspection’ in March 2007, the Acting Manager had recommenced supervision arrangements through sharing the task with a management team comprising the Acting Manager, Deputy Manager, and two Senior Carers. Evidence was observed that this arrangement is continuing. The Staff confirmed this process is on-going, and they are finding it helpful, both as feedback on individual performance, and as a learning experience. Staff meetings have been held to clarify line management responsibilities, expectations of staff, care service delivery and daily routines. Discussion between the Inspector and Mrs. Kaur suggested that, apart from some ‘fine-tuning’ in respect of the need to further develop record keeping, sufficient progress has been made for this Requirement to be considered met. A fourth Requirement was “The Responsible Individual and the registered manager must make suitable arrangements to receive and store resident’s fees and monies in a safe and secure manner (in the safe) providing receipts with copies held in the home.” In respect of administrative systems for the safeguarding of Residents’ personal monies, the Inspector found systems in place, which appear to be generally secure. Arrangements involve appropriate accounting records backed by signatures and audit as necessary. However, a potential flaw in the integrity of the procedure is the Manager holds the only key to the safe, which means when she is absent for any reason the person in charge cannot access funds, should Residents require them, except by temporary use of ‘petty cash’. More critically any funds left with the Home by Relatives cannot be held securely until the Manager returns to duty. Therefore, it will be a Recommendation that the Manager/Responsible Individual review and revise the current arrangement, in conjunction with Staff, to ensure secure, yet convenient, access to Residents’ monies, within the confines of the Regulation. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 25 It is further recommended that letters should be sent to Relatives/ Representatives, and to Residents for their information, advising them of the revised procedure and the names of personnel with whom money may be deposited. A fifth Requirement was “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.” Following discussion, at the previous Inspection, regarding the importance and purpose of Quality Assurance, the Responsible Individual agreed to provide an Annual Quality Assurance Development Plan, based on a systematic cycle of planning, action, review, aims/objectives and outcomes for Service Users by the end of March 2007. This is not yet forthcoming and, as such, will remain a Requirement, with the need for urgent attention, to enable this area of management responsibility to advance. In addition, with regard to ‘quality assurance’ related activities, the Inspector was informed that questionnaires designed to sample the views of Residents and Visitors are in the process of being introduced. No evidence in support of this was available for perusal – although it is accepted that development of this area is on the agenda for the Acting Manager. It will be a Recommendation the development of methods by which the Service Users’ views are sought is given some degree of priority. The final Requirement in this ‘outcome group was “The Responsible Individual 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.” With regard to the Regulation 26 Visits, the Responsible Individual informed the Inspector he was in regular attendance at the Home, on most days of the week, and that regular written reports on his unannounced visits had been submitted to the CSCI Office at Halesowen. However, although the frequency of visits to the Home were confirmed by the Acting Manager, and the Deputy Manager, there was no evidence of submitted written reports in the Service Record for CSCI, nor by way of ‘hard copy’ at the Home. To ensure tracking of future visits it will be a Requirement of this Inspection that copies of reports, from the Responsible Individual’s ‘Regulation 26’ visits to the Home, are maintained at the Home, in addition to being forwarded to the CSCI office. In summary, even allowing for some evidence of progress in terms of general management performance, and the meeting of some of the Requirements, Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 26 there is a considerable way to go before ‘Management and Administration’ can be considered for a higher rating. Therefore, this ‘Outcome Area’ will remain at the previous rating of ‘poor’ pending the addressing of outstanding Requirements, and evidence of robust and continuing improvement in management performance. The Home’s practices in the context of health, safety and welfare of Residents, Visitors, and Staff were seen to be in accordance with the Regulations, i.e. COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken, and appropriately documented. Records of regular checks on hot water temperatures at outlets accessible to Residents showed temperatures to be in accordance with the relevant Standard. Other ‘health and safety’ records examined related to fire risk management, lighting, nurse call bells, Legionella, portable electric equipment, hoists, and all were found to be satisfactory. Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 27 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 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 1 2 1 X 2 3 X 2 Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 4. 5. 23. – (2) (b)(c)(d) Requirement Work to review, revise, and update the Statement of Purpose for the home must be completed. A refurbishment/redecoration/ replacement programme must be instigated. This programme must include proposed work with planned completion dates for each element of work. This to be forwarded to CSCI. Worn carpets are to be replaced as a priority, in particular the replacement of a dangerous area by Room 3. Timescale for action 31/07/07 2. OP19 30/06/07 3. OP19 OP38 23. – (2) (b)(c)(d) 30/06/07 4. OP31 5. OP31 8. – (1) (a) (1) (b)(i) (1) (b)(iii) (2) (a)(b) 9. 8. – (1) (a) (1) (b)(i) (1) (b)(iii) (2) (a)(b) 9. – A Manager must be recruited and 31/07/07 formally appointed as soon as possible. On taking up the post of Manager that person must apply to CSCI for formal approval as ‘Registered Manager’ status. 30/09/07 Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 29 6. OP33 24. - 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 must be produced. A copy to be forwarded to CSCI. An unannounced visit by the Responsible Individual must be undertaken, at least once per month, and a written report of that visit prepared, and circulated/made available, in accordance with the Regulation. 31/07/07 7. OP33 26. – (2)(a) (3) (4) (a)(b)(c) (5) (a)(b) (c)(i) 30/06/07 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 OP9 Good Practice Recommendations It is recommended that the Home purchase a digital thermometer which incorporates a ‘reset’ facility, to enable accurate sampling of the ‘24 hour’ minimum/maximum temperature cycle. It is recommended that the development of methods by which the User’s view on service quality is sought be given some degree of priority. It is recommended that the current arrangement by which the Manager is the only person to hold the keys to the safe for Residents’ personal funds be reviewed and revised. It is further recommended that letters should be sent to Relatives/Representatives, advising them of the revised procedure and the names of personnel with whom money may be deposited. A copy should also be sent to Residents for their information. 2. OP33 3. OP35 4. OP35 Drake Court DS0000020809.V340617.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000020809.V340617.R01.S.doc Version 5.2 Page 31 - 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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