Inspection on 23/10/08 for Drake Court

This inspection was carried out on 23rd October 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Drake Court 20/04/09

Drake Court 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 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Drake Court Drake Close Bloxwich Walsall West Midlands WS3 3LW Lead Inspector Mandy Beck Unannounced Inspection 23rd October 2008 09:00 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 DS0000020809.V372805.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. DS0000020809.V372805.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.V372805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th April 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 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 of the building. The range of fees payable is not available in the service user guide. Readers of this report may wish to contact the service directly for this information. The most recent inspection report is not on display at the home but a copy is available upon request. DS0000020809.V372805.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 0 Stars. This means that people who use this service experience poor quality outcomes. This was an unannounced visit to the service and took place over one day by two inspectors. 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 well outcomes are being met for people using the service. It also gave us some numerical information about the service. • The improvement plan the service sent to us following the key inspection in April 2008. The improvement plan showed us how the home intended to make improvements and to meet the requirements from the key inspection. • 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 legal requirement. • The previous key inspection and the result of any other visits that we have made to the service in the last 12 months. • 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 three 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: We spoke to the people who live here. They told us “I am very well looked after, I came here because I was lonely at home but all that has changed now”. They also spoke highly of the staff group and praised the care that they are given. We were told, “the staff are wonderful, and they can’t do enough for you”. People told us there were a lot of activities for them to take part in. One person told us they particularly enjoyed the craft mornings especially the needlepoint group. DS0000020809.V372805.R01.S.doc Version 5.2 Page 6 The home provides people with a varied and balanced diet. One person told us “I wasn’t eating before I came here but that is different now, there is always a choice and the food is nicely cooked”. What has improved since the last inspection? What they could do better: The home still needs to make sure that they take action to meet people’s healthcare needs. At our last inspection we made requirements asking the home to record people’s weight and the action they took to address unexplained weight loss, this has not been done. We will be taking further enforcement action with the home to seek improvement. The home has also failed to plan care and complete risk assessments for newly admitted people. This means that staff do not always know people’s needs and people may be at risk as a result. This was an outstanding requirement from the last inspection that has not been met. We will be taking further enforcement action with the home to seek improvement. The home does not have a registered manager in post at the time of this inspection. This is a breach of the Care Standards Act and we may take further enforcement action with the registered providers to seek improvement for the people living in this home. There has been very little improvement in the physical environment. The home continues to need redecoration and refurbishment to make it more comfortable for the people who live there. We have asked the home to take urgent action in addressing the insufficient hot water temperatures and heating. The current situation means that people are not guaranteed hot water and heating due to an insufficient boiler. DS0000020809.V372805.R01.S.doc Version 5.2 Page 7 The home also needs to take action to meet the requirements of the recent fire officer’s visit. It will need to do this so that people living in the home are protected. 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. DS0000020809.V372805.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.V372805.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): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who choose to live in this home may not always have their needs assessed in full prior to their admission. This may mean that staff do not know or understand their needs and they may not be met as a result. EVIDENCE: We looked at the care needs assessment of one new admission since our last inspection. We found that the home had completed an assessment of daily living but there was very limited information contained within it. The person in charge told us that she was still waiting for the care manager’s assessment. She also explained that until this had been returned she was unable to do write any care plans. We have said that people should have care plans and risk assessments in place at the point of admission. This particular person had been in the home for more than three weeks without any care planning or risk management plan. The home must make sure that it is possession of a care manager’s assessment before agreeing to admissions. This will help both the DS0000020809.V372805.R01.S.doc Version 5.2 Page 10 person planning to live there and the staff know if the home is capable of meeting their needs. DS0000020809.V372805.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 poor. This judgement has been made using available evidence including a visit to this service. The home must improve the systems it has in place for monitoring the health and personal care needs of the people living in this home. People cannot be assured their needs will be recognised and met by this service. There have been improvements in medication administration systems that will offer some safeguards to people using the service. EVIDENCE: We looked at the care of three 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. At our last inspection we said the home should record people’s weights regularly and also record the action they have taken to address unexplained weight loss. We found in all three people’s care records this had not been done. We saw that staff had written in one person’s notes “xxxxx is picking up DS0000020809.V372805.R01.S.doc Version 5.2 Page 12 his weight he has been weighed twice this month, the intake of meals is fine”. Records of weight show that he has not been weighed twice this month and has in fact begun to loose weight again. The home had also failed to update the person’s nutritional risk assessment to show that weight loss had occurred. In addition to this there was no care plan to guide staff about what to do to address the weight loss. This was also the case with another person. When we spoke to them they told us “I have lost weight recently, I don’t know why”. We asked the person if they had seen a doctor about the weight loss, they told us “no I haven’t”. This person records show that since June 2008 they have lost over 6kg in weight. The home has not taken action to address this. The third person’s care records we looked at failed to record any weight at all, the nutritional screening tool was also blank. We were concerned about this because in this person’s assessment the home had recorded that the person had a poor appetite. We did speak to the person and asked them about their dietary needs. They told us “I did have a poor appetite before I came to live here but I think it is getting better now, it’s the regular mealtimes and company that helps”. Whilst it is positive the person felt there had been an improvement, the home should still have weighed the person upon admission. This would have given them a baseline to work from when deciding if further action was needed. Furthermore in this person’s case the home had failed to complete any care plans or risk assessments at all. The person in charge had already explained it was because they were waiting for the care manager’s assessment before they did this. People must have care plans at the point of their admission. So that staff are aware of people’s needs and how to meet them. This was concerning because we spoke to three members of staff about this person’s care and they all gave us a different answer. They said “she doesn’t need care just prompting”, another said “she had a fall the other day so we gave some pain killers”, the third person said “she needs help getting in and out of the bath but does her own thing” There was evidence to show us that people are in contact with other health professionals as and when they need them. The doctor visits the home on a regular basis and people told us that they are supported to attend out patient’s appointments at the local hospital. Chiropodists, dentist and optical services all visit the home to make sure people’s needs are addressed. At our last inspection two of the people’s care plans we looked at showed that they were still waiting for Chiropodist visits following their admission. We can report that this has now happened for people. There are generally safe systems in place for administration of medicines in this home but improvements could be made. Only the Manager and senior staff administer medicines and all have received training. At the last DS0000020809.V372805.R01.S.doc Version 5.2 Page 13 inspection it was recommended that the Manager should undertake a periodic assessment of the staff to ensure their continuing competency in administering medication correctly. The manager told us that she does this but does not record this competency assessment anywhere, such as the workers personnel file. It is recommended that this happen so that she can clearly show how she has determined that a member of staff is competent to administer medication. We found that there were no discrepancies with the administration and recording of administration on the Medication Administration Record (MAR). We saw that staff are now recording the amount of medication that is received from the pharmacy onto the MAR sheet. This makes auditing medication possible. There are at present no staff that are trained to administer medication on a night shift. This means that if people needed medication during the night the staff have to contact the “on call” manager who will visit the home and dispense medication. This situation is not ideal and consideration must be given to appropriate training for night staff to avoid any unnecessary delays in treatment for the people who live there. The person in charge told us that training for night staff is now being arranged. There were no medicines that are currently prescribed on an “as required” basis. We did however note that one person was given paracetamol following a fall for pain relief on more than one occasion. This person was not prescribed this medication. The home must make sure that people have medication that is prescribed for them. The person in charge told us the paracetamol had been given using the homely remedy policy. This is acceptable but the person’s own doctor must agree to medicines being administered in this way. Throughout our inspection we observed staff being polite and generally getting on very well with the people who live there. People we spoke to said, “they (staff) are wonderful, they never rush me”, “I am always clean and tidy you can’t ask for more than that can you”. “I don’t think the staff get enough praise for the very hard work they do for us”. We asked people if they felt that they were treated with respect and dignity they said “most definitely couldn’t be any better”. “I never have a problem”. DS0000020809.V372805.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. The home does attempt to support people in leading active lives, maintaining their family contacts and by providing choice in relation to meals. EVIDENCE: The home continues to provide activities for people to take part in. They told us “I like the crafts best of all but there is lots more to do”. “We have a nice man that comes in and sings to us, he’s very good”. “I think there is someone here who does the organising but I’m not too sure”. At our last inspection in April 2008 the person in charge published a report on the quality of the service the home provides. The outcomes were good for most of the report. However, for the second time activities were the area that people wanted to see improvements in. “We are planning to go out when the warmer weather comes on day trips” one member of staff told us. They also said “it would be nice to be able to take them out more, we have a minibus now so it’s a shame not to use it”. When we visited this time we asked people if trips out had been organised in the warmer weather. They told us “yes we DS0000020809.V372805.R01.S.doc Version 5.2 Page 15 went to the Black Country Museum and I think we are going to Merry Hill shopping for Christmas”. There was a steady flow of visitors during our inspection. One person said, “my mum is happy enough, we have no complaints”. Relatives we spoke to said the staff always welcome them and they felt comfortable visiting people. Meal times and meals are a relaxed occasion. We saw breakfast and lunch on both days. People told us “the food is very good, there is always a choice”, “if you don’t like something they make something else for you”. We asked if they were consulted about menus and planning. “Oh yes, they put what you like on”. One person told us they liked their poached egg “runny” and the home makes sure this happens. The home works on a four-week pre planned menu that is displayed in the dining room and also on a notice board next to it. Tables are set and people appeared to enjoy their meals. Fresh fruit and snacks are on offer throughout the day for people to enjoy. The home has made an attempt at recording people’s likes and dislikes in their files. This was seen in one person’s care plan; it stated “enjoys haddock” and “likes small portions”. DS0000020809.V372805.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a system in place for dealing with people’s concerns. People using the service do feel that their concerns are listened to and dealt with. Staff have received training in safeguarding procedures and are better equipped to protect vulnerable people EVIDENCE: The home has not received any complaints since our last inspection in April 2008. There are systems in place to manage complaints should people feel the need to do so. We spoke to people who told us they were aware of whom to speak to if they were unhappy about any aspect of their care. They said, “we would go to the office and get things sorted out”. The complaints policy needs to be updated so that the current contact address of the commission is clearly displayed. This will need to be done so that if people choose to contact the commission with their concerns they can do so. The home has now arranged for all staff to have training in safeguarding vulnerable adults. We spoke to three staff that confirmed that they had attended the training and were able to give examples of different types of abuse and of the action they would take if abuse occurred. The home still needs to obtain a copy of the local authority guidance. DS0000020809.V372805.R01.S.doc Version 5.2 Page 17 There are currently no forms of restraint being used in this home, such as bed rails or wheelchair lapbelts. The home needs to improve the recruitment processes so that vulnerable people are protected from unsuitable people. This will mean that those people who are allowed to begin employment in the home with only a Protection of Vulnerable Adults (PoVAfirst) check in place have a risk assessment completed and a designated supervisor whilst they await the outcome of a satisfactory Criminal Records Bureau disclosure (CRB). DS0000020809.V372805.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. The home is cleaned regularly but needs some improvement work doing to the decoration of the building and replacement of furniture to make it more comfortable for the people who live there. EVIDENCE: There have been no changes in the home since the last inspection. Some of the bedrooms have been decorated but the home is in need of money being spent on it to replenish the furniture that is worn, dirty and looks unsightly. Carpets are soiled and stained in places. The home feels drab and gloomy and needs to be updated. The person in charge told us that there are plans to replace the soiled carpets in the entrance area and corridors leading off within the next few weeks. DS0000020809.V372805.R01.S.doc Version 5.2 Page 19 We noticed that some of the people living here did not have a sufficient hot water supply to their rooms, this was also evident in the bathroom on the ground floor. The hand basin had hot water but the bath failed to reach a satisfactory temperature. We discussed this with the person in charge. We were told that the boiler keeps breaking down because it gets clogged. This means that hot water temperatures are variable at times and also heating. We noticed that people now have portable heaters in their bedrooms. We have written to the home expressing our serious concerns about this situation. They have told us that by the end of November 2008 the new boiler should be installed and the situation rectified. People will have access to hot water and heating. The home must also complete risk assessments for the continued use of the portable heaters and update the home’s fire risk assessment to include this added risk to people. 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 on infection. Staff do need training in current infection control practices, the person in charge told us that this has been arranged for some staff over the next year. We looked at the laundry and saw that there are no hand washing facilties in there for staff to use. We have asked the home to consider providing a sink for this purpose and to reduce the risk of cross infection to people living in the home. DS0000020809.V372805.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff are supplied in sufficient numbers to meet people’s needs. Recruitment procedures need to be improved upon in order to protect vulnerable people from unsuitable workers. EVIDENCE: At our last inspection in April 2008 we raised our concerns about the staffing levels in the home. We said that at times there were not enough staff on duty to meet people’s needs. On this occasion we have found that staffing levels have increased slightly. This means that there is more staff available during the afternoon to assist people with their needs. The staff rota is being kept up to date now and does show an accurate record of the hours and numbers of staff on duty. We looked at the recruitment files for one new worker. We found that the home needs to make improvements in this area if people are to be protected from unsuitable workers. We saw that the application form had not been completed to the required standards. The worker had not provided a full employment history. They had also been permitted to work in the home without a Criminal Records Bureau (CRB) disclosure and only a Protection of Vulnerable Adults (PoVAfirst) check in place without suitable risk assessment DS0000020809.V372805.R01.S.doc Version 5.2 Page 21 and supervision in place. We have recommended that this be done for all new staff that commences employment in this way. This will offer an additional safeguard for the people living in the home. Staff training has been arranged since our last visit. We saw that staff have been attending training in various subjects such as first aid, dementia and fire safety. This means that staff will have the knowledge and skills once this training is completed to meet the needs of the people living here. DS0000020809.V372805.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): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is without a registered manager. It lacks the leadership and direction is should have to meet the needs of the people living here. EVIDENCE: The home does not have a registered manager. We have written to the registered providers expressing our serious concerns about this. We have told them they are currently breaching the Care Standards Act 2000 and we will be seeking further legal advice on this matter. A qualified, experienced and competent manager must manage the home. There are a number of issues raised throughout this report that the person in charge must take action on if the service is to improve. This is the fourth time DS0000020809.V372805.R01.S.doc Version 5.2 Page 23 this service has been judged as being a poor service with poor outcomes for the people who live here. This is not acceptable and improvements must be made. The home did provide us with an Annual Quality Assurance Assessment (AQAA) but the information in it was basic and did not give us a reliable picture of the service. They sent us an improvement plan we requested following our last inspection in April 2008. This improvement plan gave us some of the information we needed but not all of it. There are still two requirements from the inspection in April 2008 that have not been met and we will be considering further enforcement action as a result. The homes own quality assurance systems need to be improved upon. At present the person in charge does completed some audits. They have produced a report based upon her findings from the people’s surveys. This small report has been published and is on display on the notice board in the lounge for people to read. The person in charge should be completing regular audits of for example; medication systems and care planning documentation. If effective audits were being done the shortfalls identified in this report, in relation to risk assessment, weight loss and care planning, would have been identified and the person in charge would be taking action to address them. The arrangements for safe storage and handling of people’s money have now been changed since the last inspection. This means there are better arrangements in place for key holding and this will improve access for people when wishing to get to their money. There were no other concerns with the way people’s money is being handled by the home. The health and safety of people living in the home has given us cause for concern. We have said that we had serious concerns about the intermittent hot water supply and heating. We were also concerned by the recent fire officer’s report. There are a number of requirements in this report that need to be addressed by the home. The home has told us that they are taking action to meet these requirements to the fire officer’s satisfaction. The home will still need to arrange for one member of staff at least to complete fire warden/marshall training. Staff training in relation to health and safety has been addressed and this is an improvement since our last inspection. This will mean that staff should have an understanding of the basic principles of health and safety and will be able to promote people’s safety within the home. DS0000020809.V372805.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 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 2 17 X 18 2 2 2 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 2 X X 2 DS0000020809.V372805.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 OP3 Regulation 14 Requirement Timescale for action 05/12/08 2 OP7 3 OP8 4 OP8 5 OP31 People’s admission to the home must not be agreed until the home is in possession of the care manager’s assessment. This will ensure that staff are aware of people’s needs and can plan their care from the point of admission. 15 People’s assessed needs must be reflected in their plan of care. (Previous timescale of 30/06/08 not met) 13 Risk assessments that identify risk to people must have a clear management plan in place. This needs to be done so that risk is reduced for people. 12 The manager must make sure that people’s weights are recorded and monitored, appropriate action must be taken to address any issues arising. (Previous timescale of 10/05/08 not met) Care The person currently carrying on Standards as manager must cease to do so. Act 2000 They are in breach of section Section 11 11(1) of the Care Standards Act 2000 and are acting illegally. DS0000020809.V372805.R01.S.doc 10/12/08 05/12/08 10/12/08 23/10/08 Version 5.2 Page 26 6 OP31 Care Standards Act Section 11 13 7 OP38 8 OP38 13 9 OP38 13 The registered provider must take action to make sure a registered manager is appointed. (Urgent action letter sent 24/10/08) The home must make sure that it has risk assessed the use of portable heaters in the home. This must be done in order to reduce risks to the people using the service. The home must make sure that they have appropriately updated the fire risk assessment to include information about the use of portable heaters in people’s bedrooms. The home must take action so that people have access to hot water and heating on a consistent basis. This must be done to meet people’s needs in relation to health and safety. (Urgent action letter sent 24/10/08) 31/10/08 05/12/08 05/12/08 05/12/08 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. The current range of fees should be included into the Service User Guide for people’s information. 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 DS0000020809.V372805.R01.S.doc Version 5.2 Page 27 2 OP9 3 OP9 4 5 OP18 OP19 6 OP29 7 OP33 8 OP33 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 ensure they continue to do so in a manner which safe guards the people using the service. The home should have a copy of the local authority guidance on the premises, that all staff have read and aware of. 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. 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. It is recommended that relatives, visiting clinical and social care professionals and staff be given the opportunity to complete satisfaction questionnaires - anonymously if preferred. 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. DS0000020809.V372805.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000020809.V372805.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!