Inspection on 20/04/09 for Drake Court

This inspection was carried out on 20th April 2009.

CQC 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 CQC judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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 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 09/07/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Drake Court Drake Close Bloxwich Walsall West Midlands WS3 3LW Lead Inspector Mandy Beck Unannounced Inspection 20th April 2009 07:00 DS0000020809.V375039.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. DS0000020809.V375039.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address DS0000020809.V375039.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 Healthcare Limited Manager post vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places DS0000020809.V375039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 2008 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 people in 27 single and 1 double room, all have en-suite toilet facilities. There is small garden with a patio area to the rear, and car parking to the front and side of the building. The most recent inspection report is not on display at the home but a copy is available upon request. The range of fees applying to this financial year, were not included in the Service User Guide so persons should contact the service for current fee rates. DS0000020809.V375039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means that people who use this service experience Adequate quality outcomes. This unannounced key inspection was carried out on one day between 07.00 and 13.00 hours by one Inspector and one Local Area Manager. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self assessment that focuses on how ell outcomes are being met for people using the service. It also gave us some numerical information about the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called “notifications” and are a legal requirement. • The previous key inspection and the result of any other visits that we have made to the service in the last six months. • The results of any enforcement work we have undertaken since the last inspection. • Relevant information from other organisations • We also spent time talking to the people who use the service and to the staff who support them • We looked at the care of two people who use this service in depth. This is part of our case tracking process and helps us make judgements about the service’s ability to meet people’s needs. What the service does well: The service encourages people to have contact with family and friends. Visitors are made very welcome and are made to feel comfortable. Generally the home offers a good selection of activities for people to enjoy. The people we spoke with were positive about the service. They told us; “ I’m happy enough, nice people”. “I’ve got nothing to worry or grumble about”. “ They treat us well and feed us well”. DS0000020809.V375039.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Management must make sure that information provided to people before they are admitted is current and correct to help them decide if the service will be suitable for them. The home has been served with two Statutory Requirement Notices because we found they were in breach of the Care Homes Regulations 2001. We expected the home to make improvements in care planning and assessment of the people living in the home and to take appropriate action to meet people’s health care needs. We visited in January 2009 and found the home had continued to be in breach of these regulations. This inspection has shown that the home has now taken action to meet the Statutory Requirement Notices by improving their care planning sufficiently in order to protect the people living in the home. We found that staff have sought appropriate medical attention for people living in the home. The home needs to further develop the care planning and risk assessment systems in place so that a more individualised approach to care can be demonstrated. The home needs to identify the individual religious needs of people to be able to secure input to meet these needs. Menus and meals should be regularly reviewed to make sure that meals are suitable and meet people’s individual needs and preferences. DS0000020809.V375039.R01.S.doc Version 5.2 Page 7 Activity provision should be reviewed to ensure that people’s individual social and recreational needs are being met. The home needs to address the decoration and refurbishment of the environment for people’s comfort. Staff should all be trained in how to deal with complaints effectively this will make sure that people’s complaints are listened to and acted on properly. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. DS0000020809.V375039.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 DS0000020809.V375039.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements could be made by ensuring that information offered to people who may choose to use the service is correct and current in order for them to be able to make a decision about the suitability of the service for them. EVIDENCE: We were given a copy of both the service’s Statement Of Purpose and Service user Guide documents. We saw that there was no date on these documents to confirm when they were produced but as the new acting managers name N was included it was clear they had been produced recently. N confirmed when we asked, “Yes these are the most up to date”. We noted that there was incorrect information in the documents for example; the fees included in Service User Guide were £361.30. The acting manager informed us these fees were last year’s fees and were no longer correct. DS0000020809.V375039.R01.S.doc Version 5.2 Page 10 Page four of the Statement of purpose said; ‘ Drake Court is a luxury purpose built Residential EMI home,’ but when we looked at the service’s registration certificate number E080000170 dated 8.3.07 it read; ‘Old age not falling into any other category’ therefore, the service is not allowed to admit people with ‘EMI’ or dementia care needs. Incorrect information in these documents may mean that people may choose this service but then the service would not be able to meet their needs. The home has admitted people in the past without being in possession of all the information about their needs. This has been an outstanding requirement for the home to address. As a result the home had agreed to stop admissions into the home until improvements had been made. This agreement has been in place since February 2009, although the home has admitted one person during this time. We looked at the assessment information of one person during this inspection. We found that the home had obtained a copy of the care manager’s needs assessment and they had also visited the person prior to their admission. They had done this to make sure that both the person and the home were confident they could meet their needs. The assessment was more detailed than we have seen in previous visits and did reflect the person’s needs. The service does not provide intermediate care. DS0000020809.V375039.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is able to meet the healthcare needs of people living there but they need to improve upon the record keeping systems they have in place to make sure that all these needs are met. EVIDENCE: In November 2008 we served the home with two Statutory Requirement Notices (SRN) because they were in breach of the Care Home Regulations 2001. We visited the home again in January 2009 to check the compliance with the notices we found that they were still in breach of the Regulations. This lead the Care Quality Commission being very worried about the home’s ability to meet people’s needs in these cases. The provider Mr Seesurrun has given us assurances that improvements in the service have been made and will be maintained. DS0000020809.V375039.R01.S.doc Version 5.2 Page 12 We looked at the care of two people. We looked at their care plans and risk assessments. We also spent time talking to the people whose care records we had looked at. We did this so that we could find out how the home is meeting people’s needs and the requirements of the SRN’s. We saw that the home has improved the care planning system however it does need to be developed further. We saw that care plans contained little information to guide staff in meeting people’s needs. For instance, one person’s care plan for “assistance with washing and dressing”, did say that the person needed the assistance of one carer but there was no description of what form this assistance should take, or any mention of the person’s physical limitations in this case. The home needs to develop a more individualised approach to care planning so that people are given the assistance they need. We did see that some good examples of this type of planning are beginning to emerge and the home should continue to build upon this. For example, the home had written specific night time care plans that showed how people liked to be settled at night before going to sleep. It was also noted that each person living in the home did have a care plan that reflected their needs. The home keeps care plans and risk assessments under review. However it must improve the way in which this happens. We saw that staff are routinely writing “no changes” when it is evident that people’s needs have changed either through short term illness such as a chest or urine infection. One person had also experienced a fall and sustained a serious injury but the care plan review of her mobility stated that there had been no changes. We saw improvements in the home’s recording of people’s weights. The home is also completing a nutritional screening tool for people and keeping this under regular review. In doing this, the home should be able to take action when people experience unplanned weight loss or gain. At this time none of the people who we case tracked had lost weight. This was a required action of the SRN and is now considered to be met. The home must however continue to maintain and build upon this improvement. When we visited in January 2009 we found the home had failed to take appropriate action in meeting people’s healthcare needs. For instance the home had recorded that one person was in a great deal of pain but they could not reasonably demonstrate they had taken any action to address this. We looked again at the way the home is managing pain relief for people and found an improvement. The medication administration records (MAR) sheets showed that pain relief is being administered and monitored by the home staff. The home has introduced a new risk assessment so that any risks involved with the care of people are recorded. We found the risk assessment difficult to understand and asked staff to assist us. Staff told us they had not received guidance or training in how to use this. We have recommended the home DS0000020809.V375039.R01.S.doc Version 5.2 Page 13 does this so that people’s risk can be assessed competently and effectively managed by the home. There was evidence to show us that people are being seen by their own doctors, community mental health nurses and other specialist community practitioners. People also told us “the home are very good at telling me when my mother is ill”. “if she needs to go to the hospital they always escort her there”. The medication systems in the home are satisfactory. We have made some good practice recommendations for the home to take action on. We noted that staff are recording the minimum and maximum temperatures of the fridge that is used for the cold storage of medication. The minimum and maximum range was too high and we have asked the home to address this. They should do this to ensure that those medications that require cold storage are being kept as per manufacturer’s instructions. The home has developed care plans to guide staff in the use of creams and lotions and of the use of “as required” medication. Whilst it is positive this has happened, the staff should consider further development of this plan. At the present time the care plan only contains the details of the Medication Administration Record (MAR) sheet and no other actions care staff may take. For instance one person has a care plan in place for taking Lactulose for constipation. The care plan says “administer medication as prescribed” but does not include any other detail about the management of the constipation, such as considering a high fibre diet, monitoring of bowel movements or what action to take if the medication is not considered to be working. DS0000020809.V375039.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Regular review of individual needs and preferences concerning meals, activities and religion against what the service provides would mean that these needs can be better met. The service encourages people to have contact with family and friends. EVIDENCE: People told us that they had choice in their routines and how they spend their time. One person told us; “ I come into the lounge for a bit in the morning then go back to my room”. One night staff member told us; “We don’t get everyone up in the morning. We ask people if they want to get up, if they don’t want to get up we leave them in bed’. During the morning we saw that people got up at different times. We looked at in-house surveys completed by relatives for people who use the service although positive, these did show that some improvement may be needed in terms of activities for individuals. One person commented; ‘ I don’t DS0000020809.V375039.R01.S.doc Version 5.2 Page 15 think the residents have enough to stimulate the minds. I realise staff have a lot to do but half an hour in the afternoon could be fitted in to do activities with them’. This person assessed activity provision to be poor. The acting manager told us; “The activity programme is not structured enough but we are looking into that”. An activity programme was on display in the lounge, we did see that this had expired on 31.3.09. The acting manager told us that this was going to be updated the following day. A range of activities are provided by the service an activity person visits twice a week on Tuesdays and Fridays. Another person comes in to do exercise on a Wednesday. The acting manager said; “other than these days staff do try to do something with people in the afternoons”. The acting manager also told us that they had secured input from another activity person who would also be visiting. We saw that two people were knitting in the lounge. One of these people told us; “I like knitting it keeps my mind and hands active”. We found no evidence to show that the service is assessing to address people’s religious needs. Presently there is no religious input although some people may wish to have this. A staff member told us; “ One person likes to sit in their room reading their bible. We do not have any religious input in the home. Other places I have worked at all have”. The acting manager said; “ I don’t know of any religious people visiting since I have been here”. The registered owner told us that he would look into the lack of religious input. The service does very much encourage people to maintain contact with family and friends. During our previous visits for example; in Autumn 2008 we saw visitors coming to the service throughout the day as we did during this visit. The Service User Guide document we looked at read; ‘The home operates an open visiting policy. However, due to security reasons the front door is locked and it would be helpful if you could inform staff if your visitors plan to stay or visit late.’ A relative commented; ‘ All staff are very welcoming and friendly when you arrive at the home’. A person who uses the service told us; “My daughters come and see me a lot. There are no restrictions”. An on-going review of meals and menus in terms of people’s individual preferences may mean that their dietary needs will be better met. The service has a rolling four week menu programme which was not dated, the cook and acting manager could not tell us the last time meals were reviewed. In-house questionnaires about food showed that out of 18 completed all but one of these were satisfied with the food. A staff member told us; “Tea time and supper food could do with looking at as not much choice”. People we spoke to told us; “The food is alright and we have enough to eat. I’m fussy about food so if I can eat it, it must be ok”. The cook told us how the service meets the dietary needs of people who have diabetes. She told us; “ We buy cakes and puddings which do not have sugar DS0000020809.V375039.R01.S.doc Version 5.2 Page 16 in them”. We asked why cakes and puddings are purchased rather than made on the premises and was told; “ The cook although very good at main meals and savouries is not able to make cakes. We have bought some cook books and she is going to learn”. DS0000020809.V375039.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and protection processes should be better managed so that people can be fully confident that their complaints will be listened to and acted upon and that they are safeguarded. EVIDENCE: Although people using this service have a range of needs the acting manager told us that the complaints procedure is not produced in other formats. This may mean that people could have difficulty in reading or understanding the procedure. We looked at the complaints section in the Service User Guide document which read, “We are always pleased to have feedback on our services and should any residents/relatives have cause for complaint we will investigate the matter fully. Please see our complaints procedure enclosed for further details”. Although we looked we could not find an enclosed complaints procedure. We asked the acting manager to give us a copy of what should be enclosed he could not. He said, “I would give a copy of the complaints procedure that is in the hallway”. He could not however, give assurance that staff in his absence would do the same. We saw that a Complaints Procedure was on display in hallway but this had no date to show when it had been last reviewed. The acting manager said ‘if that’s the one in the hallway that’s the most up to date’. DS0000020809.V375039.R01.S.doc Version 5.2 Page 18 We saw in the March 2009 monthly report produced by a senior manager that a complaint had been received and was being investigated. To track this we asked to look at the complaints book. The complaints book did not have any commencement date and did not have any entries in it. The acting manager was not able to tell us how long the complaints book had been in use or show us where the complaint identified in the senior manager’s March 2009 report had been recorded. We asked staff to tell us how they would deal with a complaint if they received one. They told us “report it to the manager”, “try and deal with it myself first then tell the person in charge”. Other staff needed prompting to say they would record it in the complaints book. We asked two people who use the service if they knew how to make a complaint. Both confirmed that they did not. One said that she would tell her daughter the other said they had no need yet to make a complaint. The acting manager was not able to provide us with any information to confirm that staff have received complaints training he said; “ Staff had not had any training on complaints”. Later on the senior manager was able to show us that the complaint had been dealt with. He did say; “I asked staff to record this complaint in the complaints book, I don’t know why this was not done”. We made a recommendation following our last inspection for the service to obtain Walsall Councils ‘ Multi-agency safeguarding procedures’ and to ensure that staff read and understood these procedures. We saw that there was a copy of these procedures on the office shelf. The acting manager told us; “The staff have not yet all read or looked at these”. We spoke to staff about their knowledge and understanding of safeguarding and their role and responsibility in reporting allegations or incidents. All of the staff said that they had completed training and that they were aware of most of the types abuse people could experience. They were unsure about the safeguarding process once they had initially reported their concerns to the person in charge. The week before our visit we received information from Walsall Safeguarding team about an allegation that had been made about a person using the service. We looked into this during our inspection but could not uphold the allegation. The home is currently in the process of conducting their own investigation once completed they will report their findings to Walsall Safeguarding Team. The home does not use bedrails or any other type of restraint in the care of people living in this home. We were unable to look at files of new staff members during this inspection because the home has not recruited new staff. However during our last inspection in 2008 we were satisfied the home is taking steps to prevent unsuitable people from working with vulnerable adults. DS0000020809.V375039.R01.S.doc Version 5.2 Page 19 DS0000020809.V375039.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and tidy but improvements in the environment would make it more of a pleasant place for people to live. EVIDENCE: There has been no change in the home environment since our last key inspection October 2008. We saw during our October 2008 inspection the home was not able to supply hot water to each person because of problems with the boiler. We were informed by the home in January 2009 this had been replaced in November 2008 and hot water was now in consistent supply throughout the home. We spot checked the hot water during this inspection and noted the water pressure was so low that water was trickling out of the tap. We noted that one member DS0000020809.V375039.R01.S.doc Version 5.2 Page 21 of staff was running a bath for someone, they told us “this is the fast running bath, the other one is so slow by the time its filled the bath is cold”. This was also discussed with the provider during the feedback at the end of this inspection. The home is expected to take action to address this. We sat and spoke to people in the lounge. We saw a large fish tank with a number of fish swimming around in it. People who use the service like the fish, one person said;“ I like watching the fish it’s very relaxing”. Another person told us that he enjoyed watching the fish. We saw that people are encouraged to decorate their own bedrooms with items from home in an effort to personalise them. Rooms were clean and tidy. We were told by one person “my room is clean but I don’t really spend a lot of time in it”. Another person told us; “I’ve got a good size bedroom. I like spending time in there on my own. I’ve got a TV in there that I like”. People who responded to the home’s own surveys said “they should consider having a television in a separate room my mom struggles to hear both the television and the radio at the same time”, “cleanliness is good but they need to pay attention to tops of lightshades”, “we feel the home should start and invest in new hand towels and linen, they could also consider some comfy chairs”. The home has told us in the AQAA “the home is cleaned seven days a week”. We saw from the staff rota that this is not the case; the domestic cover for the home has recently been reduced. The home will need to monitor this situation and if standards of cleanliness begin to fall they should take action to address this. The home has not told us of any other improvements planned for the home other than the replacement of the carpet in the reception area in the very near future. The home is taking some steps to reduce the risk of cross infection to the people who live there. There is anti bacterial hand scrub in the reception area for visitors to use. Each toilet and bathroom has its own supply of liquid soap and paper towels. Gloves and aprons are also available for staff use to prevent the spread of infection. There is still no hand washing facility in the home laundry, we have recommended the home considers this as another measure in reducing cross infection in the home. DS0000020809.V375039.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are supplied in sufficient numbers to meet people’s basic care needs. The home needs to keep staffing levels under review to make sure people’s needs are being met. EVIDENCE: Staffing levels have remained unchanged since our last visit. The home has less people living there at this time and people’s needs are being met at this time by the current staffing levels. Staff did comment “the afternoon’s are the worst because we have to do teas, caring and it’s a bit mad at times”. Other told us “cleaning hours have been cut so I hope that this doesn’t mean we are going to have to do more work and less caring”. The home will need to keep staffing levels under review and make sure that there are enough staff on duty to meet people’s needs. Staff confirmed that they are being supported to complete training for their National Vocational Qualifications level 2. The home needs to improve on the number of staff with an NVQ information supplied in the AQAA tells us “a lot of staff have completed their NVQ”, but they did not supply exact numbers. DS0000020809.V375039.R01.S.doc Version 5.2 Page 23 We did not look at the recruitment processes in place. The home has not recruited new staff since our last inspection. We made good practice recommendations which we will check during the home’s next inspection. We did check the staff files of current employees and found the home had obtained the missing documents we had identified at the last inspection. DS0000020809.V375039.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Permanent management arrangements would give more assurance that the service is being run in the best interests of those who use it. EVIDENCE: This home has been without a registered manager for some considerable time. The previous manager was unregistered and since our last visits has left the service. The home has an acting manager at present. The owner told us that a new manager has been provisionally appointed subject to the required checks. The home will benefit from a new manager to give clear leadership, control and review practice and care provided. DS0000020809.V375039.R01.S.doc Version 5.2 Page 25 The home has provided us with their AQAA, it contains little information about how the service intends to move forward over the next twelve months. Since our last key inspection carried out in the autumn of 2008 due to concerns raised the registered owner has been involved more with the service. He told us; “ I am here three to four times a week”. We looked at the monthly reports produced by senior management about the service. The last one available to us was dated March 2009. The senior manager told us that he had done a report for April 2009 but it was in his office. We saw that some audits are being carried out concerning medications and the kitchen but were told that this process is to be more frequent and will look at other areas this will mean that the service will be able to better identify their own shortfalls and deal with them accordingly to improve life for people who use the service. We saw that questionnaires had been sent to and had been completed by 18 people or their relatives which is good as it shows that the service is trying to gain the views of people involved with it to see what areas of development and improvement are needed. We looked at records for three people’s money held in safekeeping by the service. One of the three did not have any money, the other two people’s money was correct against recorded balances. We did note that for the last couple of transactions there was only one signature to verify. Two signatures would better safeguard both the staff member dealing with the money and the people’s money. We randomly looked at records to confirm in-house checks for equipment and service certificates. We saw that the emergency lighting had been checked by an engineer in April 2009 who had identified that some lights needed to be replaced. The registered owner told us that he was not aware of this but would chase it up. We saw a certificate to prove that the lift had been serviced in February 2009. It was unclear if all staff have been involved in a recent fire drill. This needs to be reviewed as it is vital in terms of people’s safety that all staff know what to do if a fire were to happen. When we spoke to staff they were able to confirm that they had received training in health and safety, infection control and food hygiene. We also noted when looking at accident records there have been two serious injuries in the home both people had sustained fractured bones. The acting manager confirmed that they had not reported this under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1985. They were advised to do this. DS0000020809.V375039.R01.S.doc Version 5.2 Page 26 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 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 DS0000020809.V375039.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Requirement The home must make sure that people’s care plans are kept under review and that any changes in a person’s condition relevant to the plan are considered in this process. Staff must be trained in the use of the new risk assessment so that people’s needs are recorded accurately and an effective risk management plan can be drawn up. Timescale for action 30/07/09 2 OP8 12 30/07/09 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 OP1 Good Practice Recommendations It is recommended that the manager consider developing the Home’s documentation in alternative formats, for example bold print or pictorial, to enable more people access to vital information about the service promised. DS0000020809.V375039.R01.S.doc Version 5.2 Page 28 2 3 OP7 OP9 4 5 6 7 8. OP9 OP12 OP12 OP15 OP19 9 OP16 The current range of fees should be included into the Service User Guide for people’s information. The home needs to develop the person centred and individualised approach to care planning for people It is recommended the competency of staff to administer medication should be assessed on a regular basis to ensure they continue to do so in a manner which safe guards the people using the service. The home needs to make sure that the temperature of the medication fridge is with recommended temperatures at all times. At this time those temperatures are 2oc –8oc. The home needs to consult with people living there about activity provision and try to include as many of their choices as possible into the monthly plan The home should consult with the people living there in order to establish if they would like more help in meeting their religious and spiritual needs. The home should consider reviewing the menus on a regular basis with the people who are using the service. It is recommended that carpet replacement in some areas (e.g. entrance hall and main lounge where the carpets are particularly worn and grimy) should receive priority to ensure that the people using the service live in a pleasant environment. The home should consider providing the complaints procedure in different formats for people to access. The home should also consider training staff in complaints management. This will mean that people’s views are being listened to and acted upon by the home. The home should make sure that all staff have read and aware of Walsall safeguarding guidance. People who begin work with only a PoVAfirst check in place must have a suitable risk assessment and be supervised by a nominated worker. This will provide an added safeguard for people using this service. (not assessed during this inspection because no new staff have been recruited since our last visit) A system for evaluating the quality of services provided at the care home must be established and maintained, based on a systematic cycle of planning, action and review, to enhance the outcomes for the people using the service. The home must make sure that it is complying with relevant legislation including Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1985. 10. 11 OP18 OP29 12 OP33 13 OP38 DS0000020809.V375039.R01.S.doc Version 5.2 Page 29 DS0000020809.V375039.R01.S.doc Version 5.2 Page 30 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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