Inspection on 22/11/07 for Drake Court

This inspection was carried out on 22nd November 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Drake Court Drake Close Bloxwich Walsall West Midlands WS3 3LW Lead Inspector Keith Salmon Unannounced Inspection 22nd November 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.V355189.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.V355189.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.V355189.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2007 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 a patio area to the rear, and car parking to the front and side aspect of the building. The range of fees payable is not available in information for prospective residents. Readers of this report may wish to contact the service directly for this information. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Regulation Inspectors undertook this Unannounced ‘Key’ Inspection, which, between them, covered a total of eleven hours. Present on behalf of the home were Harvinder Kaur (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 May 2007. As well as the report of that inspection, the Home was required to issue of an ‘Improvement Plan’, the response to which was also monitored at this Inspection. Responsibility for inspection of specific Outcome Areas was divided between the two inspectors, as follows:Keith Salmon reviewed Complaints and Protection, Environment and the Health and Safety element of Management and Administration. Sue Jordan reviewed Choice of Home, Health and Personal Care, Staffing and Management and Administration. The methodology adopted comprised pre-inspection preparation, including the previous inspection report, information received from the service and the history of the Home. During the visit observations were made of non-personal care tasks, including lunch, examination of medicine administration systems, including observation of the lunchtime administration, a tour of the environment, including the kitchen facility and a discussion with the cook. Documents reviewed included care records, including pre-admission information and risk assessments, staff recruitment records, staff training and supervision records and records relating to promotion of a healthy and safe environment. In addition, discussions were held with individual people using the service, some of the staff on duty, and visiting relatives. We held discussions with the acting manager and deputy. However, we were unable to give the manager verbal feedback as she had a prior engagement. Feedback was given to the responsible individual during a subsequent meeting with him on 27/11/07. Ten requirements and fourteen recommendations have been made as a result of this inspection visit. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 6 What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3, 6 - not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home are provided with information to assist them in making an informed decision and their needs are assessed so they can be assured the home can meet their needs. EVIDENCE: The Statement of Purpose has been amended to reflect the changes within the home during 2007, including the appointment of new Manager. However, as it is available in a basic format only it is recommended the Manager consider developing the Home’s documentation in alternative formats, e.g. bold print or pictorial, to enable access to vital information about the service promised to a wider group of persons. We were not able to find current information in any of the documents about the fees charged. This information must be available to the people using the service and any other interested parties. It is further recommended the document be dated as evidence of its currency. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 9 Copies of the Statement of Purpose and Service Users Guide are pinned to the visitors’ board, in the lobby area, together with a copy of a Commission for Social Care Inspection Report. However, the report is not from the most recent inspection. A copy of the most recent Commission for Social Care Inspection (CSCI) report should be available to those persons using the service, relatives, and any other interested parties. We looked at three sets of care records, and evidenced that each person’s needs had been assessed before they took up residency in the home. We also observed that the people using the service had a care plan from the hospital social work team, and a contract for services from Walsall Local Authority. Other documentation relevant to appropriate early assessment of care needs, were satisfactorily completed, and included letters stating the Home was able to meet assessed care needs, a statement of fees to be paid and an ‘Activities of Daily Living’ assessment. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are shortfalls in some of the home’s recording systems but generally, the home monitors the health and personal care needs of the people using the service, and provides staff with the information required to offer appropriate support, however the medication systems require minor improvements to ensure that people are fully safeguarded. EVIDENCE: Three sets of care records were reviewed and found to generally provide the information required by staff to meet the needs of the people using the service. Care plans are specific to meet their needs, including pressure area assessment, nutritional screening and a dependency profile. All were written clearly and concisely, demonstrated evidence of full risk assessment, and had been reviewed monthly. Evidence was also observed of full involvement of the people using the service and/or relative in the development of the care plan. However, some gaps were noted in records relating to the weighing of residents. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 11 Input from clinical professionals from outside the home was recorded, e.g. general practitioners, district nurses and physiotherapists. During the inspection the opportunity was taken to look into a recent complaint, made to the Commission for Social Care Inspection, regarding the alleged ‘rough handling’ of a person using the service, who had been assessed by the referring agency (Walsall Social Services) as being quite heavily dependent in terms of mobility. However, as staff at the home were unable to show us care planning documentation relating to the particular person, it was not possible to ascertain whether that information had been incorporated into the care plan. Entries in the home’s ‘Activities of Daily Living’ documents, daily reports and night reports clearly reflected the mobility difficulties of the person. Therefore, from the standard of the home’s record keeping, and evidence seen in maintained care records, set against the detail of the complaint made by relatives, we were led to conclude that the Home is not complying with Regulations and needs to make sure that their care planning is strengthened. Following an accident resulting in a trip to hospital, staff continued to try and support the person as previously, rather than assessing whether the person’s needs had changed. However, due to their concerns about the person’s condition, the home did initiate a reassessment by the Local Authority, which resulted in the person moving to a home, which would provide nursing care. The medicines management systems were examined, including administration, recording, storage, and stock control. The lunchtime administration of medicines was observed, which was generally conducted in a professional manner. However, it was noticed one of the people using the service had eye drops administered during the lunchtime meal. It is recommended the people using the service be afforded privacy during all clinical procedures, including the administration of eye drops. Medicines are appropriately stored with the possible exception of those requiring refrigeration. Whilst the internal fridge temperatures are monitored and recorded on a daily basis, records suggest that since 11/11/07 the temperature has increased from 8 degrees C to 24.5 degrees C. There is no evidence any action has been taken to correct this fault, or replace the fridge. However, it is possible that one, or more, members of staff are confusing the internal fridge temperature reading with that relating to the ambient temperature of the treatment room. It is recommended relevant temperatures continue to be monitored/ recorded daily and the Manager ensures all staff involved in this activity are competent in undertaking the task. Only the Manager and senior staff administer medicines and all have received training - some having completed the module based distance learning ‘Safe Handling of Medicines’ training. The Manager was advised she should Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 12 undertake a periodic assessment of the staff to ensure their continuing competency in administering medication correctly. It is recommended she undertake this on a six monthly basis. No gaps were found on the administration recording sheets. Whilst medicine stock levels generally appear under control, some anomalies were found, e.g. some staff do not record the balance when medicines are given from stock. The Manager needs to ensure there is an audit trail of all medication in order for accurate information of what stock is held to be available at any given time. Medication was found to be prescribed for one of the people using the service with an ‘as required’ direction. However, there is no information as to when, or under what circumstances, this medication is to be administered. The Manager was advised to contact the general practitioner, and request a change in the prescription and/or to provide staff with the required information. One of the people using the service has a history of refusing to take medication. A staff member explained the procedure used to encourage the person, which is to separate the medication into three doses. However, this approach must match the prescribing clinician’s instructions, and should be recorded on the administration recording sheets to ensure consistency. Creams, liquid medication and eye drops are dated on opening to ensure that they are used within the correct timescales. The Home does not presently administer any controlled drugs although there are appropriate facilities in place if required. Staff were observed in non-personal care tasks and were seen to promote and respect privacy and dignity. Examples: - staff knocking on doors before entering, supporting people in taking medication and in to eating their lunch in a patient manner. The care records were found to be stored collectively. The Manager was reminded that each person’s records must be stored individually in accordance with the Data Protection Act 1998. Daily reports should be completed contemporaneously. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 13 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. The Home provides leisure opportunities, which are consistent with the capabilities of the people using the service who are enabled to choose the pattern of their day, maintain relationships and continue religious practices. EVIDENCE: The Deputy Manager is the nominated Activities Coordinator responsible for planning and issuing the Home’s Activities Plan. We were informed the activities programme is established according to the wishes and preferences expressed by people using the service in the formal monthly meetings held with the Manager and the Owner’s Representative, Mr. Mike Wardle. Evidence was observed confirming discussion covers topics such as the type of activities the home may arrange and provide, i.e. shopping trips, visits to garden centres. With regard to the current programme, the people using the service stated they enjoyed the musical entertainment, trips out for pub lunches, the annual visit to the Walsall Lights, the fitness exercise sessions provided once a week Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 14 and various day trips. To facilitate trips the home has a twelve-seat coach for which the Manager is the named driver. In a particular section of the main lounge one of the people using the service was watching the international cricket on television, and informed us that he and two other people had ‘clubbed together’ and subscribed to ‘Sky Sports’, which has enabled them to enjoy a variety of sporting events. He was very enthusiastic about being able to do this, as it facilitated their continuation of interest in following sporting events. When discussing the people using the service with ‘Key Workers’ they were able to demonstrate a good understanding of their preferences/specific needs e.g. health, emotional and social needs, and how these should best be met. In relation to meals the general consensus of the people using the service is that the range, quality, amount and choice of food provided is good. Comments included… “I like the food here and there is plenty of it.“…”If I don’t like what is on the menu the cook will do something different.” Lunch on the day of inspection comprised two choices, i.e. faggots or fish, frozen vegetables, choice of two sweets (ice cream and fruit or black forest gateau). It was noted meals are plated up in the kitchen thus denying the people using the service opportunity to make a decision concerning, for example, quantity. It is recommended the Manager considers putting tureens of vegetables on the table, gravy and sauces in jugs, a choice of drinks in jugs, and, possibly, (backed by appropriate risk assessment) teapots on tables. Such action would provide the people using the service with a visual choice at meal times, thus promoting opportunities for greater independence. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The interests of the people using the service are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure, although not all staff are adequately trained to carry out their role in safe guarding them from abuse. EVIDENCE: The people using the service and relatives told us that they had nothing to complain about, but if they did were confident the Manager and staff would take the necessary action to resolve any issues raised. Whilst no complaints had been logged in the Home’s Complaints Record since the previous inspection we have received one. Information relating to this can be seen in the Health and Personal Care Outcome Group within this Report. In summary, we found that the Home is not complying with the Regulations regarding care planning. An area of concern relates to the current proportion of staff, who have not undertaken training related to protection of vulnerable adults, i.e. 12 of 27 staff have not undertaken abuse awareness training, 18 of 27 have not undertaken ‘Adult Protection Training’. Accident Records were reviewed and found to be current, presenting no areas for concern. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 16 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. The people using the service live in a reasonably comfortable, generally safe, though rather worn environment, with some carpets, curtains, and dining furniture in need of replacement, although specialist equipment is available, appropriately serviced and maintained. EVIDENCE: At the previous Inspection, held in May of this year, two Requirements were issued under this Outcome Area. The first requirement stated “A refurbishment/redecoration/ replacement programme must be instigated. This programme must include proposed work with planned completion dates for each element of work.” The Home now has such a programme in place and, as a result, it is easier to now determine what improvements have been made and what is planned. Examples of progress include; ongoing painting and decorating, replacement of Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 17 window blinds, due to be fitted in December 2007 following completion of painting. Replacement of carpets and soft furnishings is planned for March 2008. However, it is recommended that carpet replacement in some areas, e.g. entrance hall and main lounge where carpets are particularly worn and grimy, should take place sooner than that date. The second Requirement, which related to a worn carpet presenting a ‘trip’ hazard in the vicinity of room 3, has been resolved. Although the Requirement in respect of the need for a redecoration/ refurbishment plan is considered met, plans to improve décor and furnishings for many areas of the Home have yet to come to fruition. Therefore, the overall judgement remains at only ‘adequate.’ Whilst the Home has two lounges – the second being added as part of a sixbedroom extension - only the original lounge is utilised on a regular basis. Staff explained this was due to the people using the service exercising their preference for where they wish to spend their daytime hours, e.g. “...they like to be with the other Residents so as to know what is going on.” The people using the service confirmed they generally enjoy sitting in the main lounge and dining room areas where they can pursue their own interests of knitting, reading and watching television. One person using the service informed us “…since the home received the people transferred from The Manor about six of us have our meals in the new lounge.” This person also added the meals, whilst generally satisfactory, were sometimes cold by the time they arrived at the ‘overflow’ dining room/lounge. The room itself was cold due to the radiators not being turned on. A person using the service and a visitor confirmed this was often the situation. The Manager explained there had been a problem with the radiators in that lounge, but this had been remedied and the radiators were being re-commissioned that day. The radiators did become effective, and the room warmed during the inspection. It is recommended that the ambient temperature in the second lounge be monitored, so as to ensure a comfortable environment for the people using the service, including meal times. Domestic duties are undertaken by two domestic staff, covering every day of the week, working together on three days, and individually on the remaining four. Throughout the tour of the premises the home was found 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 Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 18 appeared well organised with its effectiveness reflected in the tidy and immaculate appearance of all the people using the service. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty and the skill-mix are sufficient to meet the assessed care needs of the current people using the service and generally the recruitment practices ensure that they are further safeguarded, however the low level of staff training may mean they are not supported by a suitably qualified workforce. EVIDENCE: At the time of this inspection the Home employed sufficient staff to meet the needs of the people using the service. Staff are employed in a variety of roles, including care and auxiliary positions. The management team comprises the Manager, a deputy, and two seniors. The training records were checked and discussions held with three staff. These provided evidence they regularly attend training, and courses are booked in advance to ensure staff are constantly updated. However, there are a number of staff still requiring mandatory training, including adult protection and abuse, food and hygiene and manual handling. Therefore, a requirement is being made that the staff receive mandatory training at the required frequencies to ensure that the people using the service are supported at all times by a trained workforce. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 20 There is little evidence of staff attending supplementary training courses, designed to meet specific, specialist needs. All new staff undertake induction training. Four recruitment files were checked. The Home had obtained results of the Protection of Vulnerable Adults checks for two of the staff before allowing them to work in the Home. Although on the day of the inspection was no evidence, at the Home of the same having been carried out for the other two this was produced by the Responsible Individual at a later date. Furthermore, although references had been sought, they had only received one reference for each of two members of the staff. The Manager is reminded that ‘To whom it may concern’ references are not suitable. All prospective staff had completed an application form. The Manager was advised she must check any gaps in employment with the proposed staff member. Proof of identity must be available in all files. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 21 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, and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management systems in the Home do not fully protect the people using the service, although appropriate priority is given to Health and Safety. EVIDENCE: The Manager, Harvinder Kaur, holds National Vocational Qualification 3 and 4 in Care, the A1 Assessor’s Award and a teaching certificate, and is hoping to commence the Registered Managers Award in the near future. She is an experienced manager of seven years, with just a few months in post at Drake Court, having transferred, together with staff and Residents from the ‘sister’ home, Manor Court. Discussions with a number of staff indicated there is friction within the Home between factions of staff and some individual staff members. The situation is Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 22 causing unrest and distress to all parties, and the staff stated they believed it was also affecting the people using the service. This situation requires management action to find a satisfactory and professional resolution. Harvinder Kaur is not yet registered with the Commission for Social Care Inspection as the manager of Drake Court. This is the third consecutive Inspection at which the importance and purpose of Quality Assurance has been discussed with the Responsible Individual, Mr Mike Wardle. Following the two previous Inspections it was agreed with him that he provide an Annual Quality Assurance Development Plan, based on a systematic cycle of planning, action, review, aims/objectives and outcomes for the people using the service. The previous target date for completion was 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 the people using the service 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 Manager. It will be a Recommendation that the development of methods by which the views of the people using the service are sought, is given some degree of priority. The management team share the responsibility of supervising staff. The records provided evidence that most staff receive regular supervision and staff meetings are held. There is no evidence the Manager receives supervision from her line manager, the Responsible Individual. The Responsible Individual is required by Regulation 26 of The Care Homes Regulations to undertake monthly, unannounced visits at the Home and assess the quality of care provided. The reports held in the Home do not evidence that these are completed every month. The care records are being stored collectively. The Manager was reminded that each person’s records must be stored individually in accordance with the Data Protection Act 1998. In summary, even allowing for evidence of progress in terms of general management performance, and in meeting some of the Requirements, 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 Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 23 Requirements, and evidence of robust and continuing improvement in management performance. In respect of administrative systems for the safeguarding of the personal monies of the people using the service, 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, as noted at the previous inspection, a potential flaw in the integrity of the procedure is that 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 the people using the service 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 – the reported practice of utilising the controlled medicines cupboard, as a temporary repository, is not acceptable. Therefore, it is again recommended that the Manager/Responsible Individual review and revise the current arrangement, in conjunction with Staff, to ensure secure, yet convenient, access to the money of the people using the service, within the confines of the Regulation. It is further recommended that letters should be sent to Relatives/ Representatives, and to the people using the service for their information, advising them of the revised procedure and the names of personnel with whom money may be deposited. The Home’s practices in the context of health, safety and welfare of the people using the service, 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 the people using the service 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.V355189.R01.S.doc Version 5.2 Page 24 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 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X 2 2 X 3 Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 25 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 5 (1) (b) Requirement The Home’s Service Users Guide must contain information regarding the fees charged so that the people using the service know what they can be expected to pay. The care plans must contain the information required by staff to meet the needs of the people using the service. This will ensure that their needs are met at all times, including those people receiving respite care. Timescale for action 31/01/08 2. OP7 15. (1)(2b,c) 31/01/08 3. OP8 12. – 31/01/08 The health needs of the people (1) (a) (b) using the service must be regularly reviewed to ensure that they are provided with the care and support required. 13. – (2) There must be a clear audit trail of medication brought into, administered, and leaving the Home. This will ensure that all times staff know exactly what medication the people using the DS0000020809.V355189.R01.S.doc 4. OP9 10/01/08 Drake Court Version 5.2 Page 26 service are supposed to receive and how much is held on their behalf. 5. OP9 13. – (2) Clear instruction must be 31/01/08 obtained as to the exact circumstances for the administration of ‘As Required’ medication. This will ensure that the people using the service always get this medication in the correct circumstances. Methods of medicines 31/01/08 administration must match the prescribing clinician’s instructions and be recorded in detail, so that the staff can ensure a consistent approach for the people using the service. Staff must receive mandatory training at the required frequencies to ensure that the people using the service are supported at all times by a trained workforce. The organisation must put a manager forward for registration with the Commission for Social Care Inspection. Previous timescale 30/09/07 not met. The manager must ensure that the working relationships in the Home are professional and do not adversely affect the people using the service. 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 DS0000020809.V355189.R01.S.doc 6. OP9 13. – (2) 7. OP30 18. – (1) (c)(i)(ii) 31/01/08 8. OP31 9 (1) (2) 22/11/07 9. OP32 12 (5) (a)(b) 22/12/07 10. OP33 24. - 31/01/08 Drake Court Version 5.2 Page 27 enhance the outcomes for the people using the service. 11. OP33 26. – (1)(3)(4) (5) The Responsible Individual must 31/12/07 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. This is to monitor the service provided in the Home and ensure positive outcomes for the people using the service. 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 Statement of Purpose document be dated as evidence of its currency so that the people using the service can be confident that they have up to date information. 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. It is recommended that internal temperatures for the medicines fridge are monitored/recorded daily and that all staff involved in this activity are competent in undertaking the task, so that the people using the service can receive this medication safely. It is recommended the competency of staff to administer medication should be assessed on a regular basis to DS0000020809.V355189.R01.S.doc Version 5.2 Page 28 2. OP1 3. OP9 4. OP9 Drake Court ensure they continue to do so in a manner which safe guards the people using the service. 5. 6. OP9 OP9 It is recommended that the people using the service are afforded privacy during all clinical procedures. It is recommended that following compliance with the medication issues identified during this inspection, the Home’s medication policy and procedures should be reviewed to ensure that they follow legislation and good practice. It is recommended that the ambient temperature in the second lounge be monitored, so as to ensure a comfortable environment for the people using the service at all times, including meal times. It is recommended that the Manager and staff explore ways of increasing opportunities for the people using the service to make choices – e.g. providing them with a visual choice at meal times, thus promoting opportunities for greater independence. 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. It is recommended that the ambient temperature in the second lounge be monitored, so as to ensure a comfortable environment for the people using the service at all times, including meal times. It is recommended that relatives, visiting clinical and social care professionals and staff are given the opportunity to complete satisfaction questionnaires – anonymously if preferred. It is again recommended that the arrangements for the overnight storage of the personal monies belonging to the people using the service (e.g. received from relatives), be reviewed, to allow them access to their money at all times. Records should be individualised. This includes storage, which should comply with the Data Protection Act 1998. This will ensure confidentiality for the people using the service. DS0000020809.V355189.R01.S.doc Version 5.2 Page 29 7. OP20 8. OP14 9. OP19 10. OP20 11. OP33 12. OP35 13. OP37 Drake Court 14. OP37 It is recommended that all records be completed contemporaneously, so that all times records are known to be accurate and relevant. Drake Court DS0000020809.V355189.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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.V355189.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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