Inspection on 27/11/06 for Drake Court

This inspection was carried out on 27th November 2006.

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

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

Other inspections for this house

Drake Court 20/04/09

Drake Court 23/10/08

Drake Court 29/04/08

Drake Court 22/11/07

Drake Court 18/05/07

Drake Court 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 Chris Fuller Key Unannounced Inspection 27th November 2006 08:30 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.V321385.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.V321385.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 Mrs Gillian Bates Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20.7.06 Brief Description of the Service: Drake Court is a two-storey purpose built home which provides accommodation for twenty-nine elderly service users. The home is situated close to Bloxwich town centre and local amenities. The home is maintained to a high standard with adequate parking to the front and side of the property. There are twentyseven single rooms and one double room, all with a toilet and washbasin. The current scale of charges is £327.15 to £341.36 per week. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This year the Commission for Social Care Inspection is making a key inspection of a selected number of the National Minimum Standards. The focus remains on assessing the quality of care provided through the experience and outcomes for service users, to review progress on meeting statutory requirements from last years inspections and focusing on aspects of service provision that require further development, or pose the most significant risk to service users. An unannounced inspection was made on Monday 27th November 2006. There was evidence that progress was being made towards meeting requirements though a number remain outstanding. The inspector spoke with staff on shift and with residents. A sample of residents files and staff records were seen. Mealtimes and administration of medication were observed and a tour of the premises was made. This has been a very difficult year for the residents and staff at the home. There have been major changes in senior management with Mr Seesurrun delegating the duties of responsible individual to his accountant Mr Mike Wardle. At the beginning of the year two serious complaints were made to the Commission of Social Care Inspection. Several forms of investigation followed with a disciplinary investigation by the home with an outcome that the registered manager no longer works at the home. The original concerns raised in the complaints continued to be monitored through the inspection process. The newly designated Responsible Individual gave assurances these matters would be addressed. Both complaints related to the level of care provided to residents once there was a change in their health and wellbeing. The former registered manager had significant periods of time off work during the past year. The deputy manager and care staff have demonstrated a commitment to providing care in a homely and comfortable environment. It was evident that staff had been working hard to maintain the standards and to make improvements in recording systems. The Responsible Individual has consistently failed to establish regular monitoring visits and reporting and effective quality assurance systems and management of the home. To compound this the registered manager has been unable to establish regular supervision of staff and implement effective monitoring systems of the care practice in the home. There have been long periods of the year where there has been very limited management support to staff due to the prolonged absence of the manager and business commitments of the Responsible Individual. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 6 The staff group have shown commitment in maintaining a service with insufficient numbers of staff to cover the care and ancillary duties and meet the needs of service users. The residents express appreciation of the friendly and helpful attitude of most members of staff. There is evidence in the admissions and discharge records of the home of a history of inappropriate admissions outside the category of people the home is registered to care for. This has been brought to the attention of the registered manager on previous inspection visits. What the service does well: What has improved since the last inspection? Since the last inspection an effort has been made by the new responsible individual to meet some of the statutory requirements made in the last report. There has been some improvement with information given to residents and their relatives and with involving residents in their own care planning: • • • • • • • • The Service Users’ Guide and statement of purpose are issued to the residents and their representatives. Each resident has a contract which is signed and dated by the relevant parties. The home confirms in writing to the prospective resident and demonstrate the home’s capacity to meet their needs prior to their admission. A care plan is produced for the resident upon admission to the home. The health care needs of residents and how these will be met are detailed within the care plan. Residents have access to specialist services e.g. chiropody. Care plans record residents choice of activities and how these will be met. Residents are given the opportunity and consulted about services provided through anonymous questionnaires, residents meetings etc. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 7 One of the residents said “The food is very good and the staff take good care of me. I am very settled at Drake Court”. Policy and procedures in respect of storage of medication and involvement of family and friends at the time of a resident’s illness and or death: • • A written record is kept of the medication fridge temperature and of temperatures in the medication room to ensure drugs are stored at appropriate temperature levels. Practice and procedures have been reviewed to ensure the service user’s family and friends are involved (if that is what the resident wants) with planning for and dealing with increasing infirmity, terminal illness and death. The moving and handling policy, procedures and practice in the home have been revised and a copy provided to the CSCI and issued to staff for guidance. • A range of staffing issues have been improved providing increased security for residents and support to staff: • • Staffing numbers, abilities and skill mix of qualified /unqualified staff are appropriate to the assessed needs of the residents at all times. There are a sufficient number of ancillary staff employed to cover the duties over a seven-day period. There has been considerable change within the staff group and in addition to new care staff another domestic staff and a kitchen assistant have been employed. All staff receive a contract with terms and conditions and a job description. The revised documents are to include lifting and handling tasks. A copy of both are kept on the staff file. The home reorganised staff files and there is an improvement with the recruitment process. • • The new Responsible Individual has followed the company procedures and made an internal investigation of a complaint made earlier in the year and also instigated staff disciplinary procedures. Other management issues addressed to improve operational management are as follows: • Formats for providing evidence of judgements made have been produced and implemented. These ensure the health and wellbeing of residents. such as appropriate admissions, instructions to staff and deployment of staff on shift rotas. An example of this is ensuring that residents can have access to their personal records. Management and key workers encourage and help them to contribute to and maintain them. • Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 8 • As with staff files the resident’s files have been restructured and staff instructed to make sure all recording formats are implemented and completed. What they could do better: A meeting was held with the new Responsible Individual due to concerns that the home is establishing a history of non-compliance and failure to meet National Minimum Standards of Care and failure to meet statutory requirements within agreed timescales. Past inspection reports evidence recurring issues and concerns regarding the lack of action taken by the previous Responsible Individual and the manager of the home to address issues highlighted in reports and discussed and agreed at inspections. Prior to the current inspection the new Responsible Individual submitted an action plan for the previous inspection stating how the outstanding requirements will be met and the timescales for completion. It was found that this action plan had not been fully met. At the inspection the new Responsible Individual gave assurances every effort was being made to address the above and some progress has been made. However there are some statutory requirements that remain outstanding. There are also some issues still to be resolved; not least the internal investigation of a complaint and the employee disciplinary proceedings regarding the registered manager of the home. The matters still to be addressed include the following: • • • The home must revise the statement of purpose and provide copies to prospective residents and their families so they can make an informed choice about living at the home. Most importantly the registered manager must not admit anyone to the home unless a full assessment of need has been made and she is satisfied and can demonstrate that the home can meet those needs. The new Responsible Individual stated that suitable arrangements would be made to receive and store resident’s fees and monies in a safe and secure manner. A letter will be sent out to relatives to advise them of the procedure and personnel to who money can be given. Staff would be informed of new procedures. The aforementioned matters are all basic to good care practice and ensuring an appropriate placement for prospective residents. These matters have been raised with the manager before. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 9 During a tour of the building the Inspector noted that: • The carpets in communal areas and hallways were looking worn and stained which make the home look unclean. This shortfall could pose a danger to residents and also needs to be addressed immediately. Support to staff is particularly important during a period of instability and / or changes in management: • • • • Regular supervision sessions and staff appraisals must be provided and completed. Staff need to undertake training in Adult Protection and Complaints. The home needs a quality assurance system and a business and financial plan. The provider needs to ensure that the monthly unannounced visits are made to the home and that the required reports are produced. The Responsible Individual is attempting to address the operational management issues in the home and intends to seek the support of the deputy manager and management from other homes in the group to standardise good practice and develop an open, positive and inclusive atmosphere. The newly designated Responsible Individual has given a commitment to support the management and staff team at the home to address the above issues in a timely manner. 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.V321385.R01.S.doc Version 5.2 Page 10 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.V321385.R01.S.doc Version 5.2 Page 11 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): 1,2,3 and 4 Quality in this outcome area is adequate. The admission procedure must be implemented by the registered manager and staff at the home before people move in. A full assessment of needs must be made by the home and assurance given that a resident’s care needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new Responsible Individual provides the Statement of Purpose for the home and this can be found in residents individual rooms frequently on the back of their doors. This is due to be reviewed and updated. The Service Users’ Guide as been revised and is issued to the residents and their families at the time of enquiry or admission. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 12 Each resident is issued a contract which is signed and dated by the relevant parties at the time of admission to the home. Copies are given to the resident and or their relative and a copy held on their individual file. During the past twelvemonths resident’s files have been audited and restructured to make sure the correct documents and records are held on file. Residents can ask to see their personal files and records at any time. The home has a history of making admissions without completing a comprehensive assessment of the residents needs and of admitting residents who are diagnosed with Dementia care needs, Physical, Medical or Mental Health care needs which they are not able or registered to provide care for. The home does have a format for making assessments and the sample of records seen on this occasion were varied some held information from health and social care agencies and some with nursing assessments. This does not indicate appropriate assessments by the home are being made. The home does have a format for a letter to be issued following assessment confirming that the home is able to meet those needs. There was a letter on file of one of the residents files seen. The new Responsible Individual confirmed the letter is now being issued to prospective residents. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 13 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 and 10 Quality in this outcome area is adequate. Individual resident’s records hold details of arrangements for the health care needs of residents. Key workers complete regular care plan reviews and make changes to meet the resident’s needs. The administration of medication must be monitored to ensure practice is safe and standardised for the wellbeing of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of residents files were seen and each held a care plan produced for the resident upon admission to the home. There is evidence that staff are reviewing care plans with residents and their families and being asked to contribute their comments and sign and date care plans. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 14 The health care needs of residents are recorded in the care plan with details of how these will be met. Evidence was seen on residents files of procedures and formats for assessments for appropriate admissions, recording of action taken for seeking medical advice to ensure the health and wellbeing of residents and sufficient deployment of staff on shift rotas. Residents are given access to specialist services e.g. chiropody. Initially a request for health services are made through the residents own GP. For those who choose due to pressing health care needs or who prefer private services may be sought. The inspector observed staff administering medication during the lunchtime period. It was noted that staff do not observe resident’s taking their medication. This would seem to be a common practice as it was an issue at the previous inspection. This needs to be monitored by the registered manager to raise staff awareness of poor practice in this area. Potentially this places residents at risk if medication is not issued appropriately. All staff who administer medication must complete the accredited training in the safe handling and administration of medication. The Deputy manager and senior staff currently administer medication. It was requested at the previous inspection that a record of the names of staff and completion dates of those that have completed accredited medication training is kept. However as yet this has not been made available. Some progress has been made as a written record is now kept of the medication fridge temperature and that in the medication room to ensure drugs are stored at appropriate temperature levels. Practice and procedures to ensure the service user’s family and friends are involved (if that is what the resident wants) with planning for and dealing with increasing infirmity, terminal illness and death have been revised and brought to the attention of staff. The new procedure is wall mounted in the staff office for their guidance. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 15 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 and 15 Quality in this outcome area is good. The resident’s are encouraged to maintain social contacts in the community and with their relatives. Staff provide some social activities in the home and celebrate calendar events and individual birthdays. There has been a change of cook and residents enjoy the choice of meals offered and are satisfied with the quality of meals provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The sample of files seen held information of individual residents choice of activities and how these will be met. Case records note the daily routines and activities of resident’s. Resident’s care plans have been reviewed and a record of their choice of activities and how these will be met has been made. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 16 Residents spoken with said they enjoyed playing bingo, sing along, playing dominoes and chair exercise sessions once a week. They also spoke of visits to relatives and one or two are independent and will walk out to the shops or continue to attend local clubs they were members of when they lived in the community. Some said they would like more variety and the option of some trips out or entertainment in the home. The inspector observed conversation and good humour between staff and residents. There are two lounge areas both with a TV. Generally the TV is on in one area of the lounge for those that watch it in the morning and music from old records in the afternoon. Some of the residents shared the cost and had sky put in for the sports programmes. They also had a meeting with the staff and asked about the possibility of a dartboard and snooker table, as there was sufficient interest from a number of male residents. Residents and staff had been out for a pub lunch and an entertainer for song and dance had visited the home. Most recently there had been a Halloween Party when staff decorated the lounge and a Halloween menus was served. Residents said they thought the change of cook had not been problematic. The meals were tasty and there was always enough to eat and more if you asked for it. Residents had met the cook and felt they could say their preferences. The cook is supported by the care staff in fulfilling the kitchen duties particularly at mealtimes with serving up etc. A new oven and extractor fan had been provided in the kitchen. The inspector asked about the cleaning schedule for the kitchen as some items such as the cleaning of wall tiles and defrosting of the freezer needed to be prioritised. The dining room was in need of improvement to the carpets, fabric and furnishing all looking worn and soiled. This is addressed in the environment section. Drake Court DS0000020809.V321385.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. There is no evidence of improvement in the recording of complaints. However the new Responsible Individual is implementing Complaints procedures and investigations. It is important that relatives and residents have confidence that their concerns will be listened to, taken seriously and acted upon in order to safeguard the safety and well being of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The following comments were taken from the previous inspection report as there was no evidence of any change in the home relating to the process and practice by management and staff of taking and recording complaints. “The home has a book for the recording of complaints however there were no records of complaints received during the past inspection year. The Commission for Social Care Inspection had received two written complaints and these had been notified in writing to the Responsible Individual and the registered manager of the home. The registered manager had also received concerns from a relative of another resident however this was not recorded as a complaint. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 18 The Commission for Social Care Inspection investigated the two complaints, which respectively held a range of issues relating to the care provided. In both instances a number of the issues were found to be upheld and some upheld in part whilst others it was not possible to substantiate. The complaints raised gave serious cause for concern regarding the policy and procedures and practice in the home relating to admissions, moving and handling of residents and sharing of information and involvement of relatives. Other matters of serious concern were the judgements made by the registered manager and lack of action taken to address a residents needs. As a result of the CSCI complaint investigation a number of statutory requirements were made and the Responsible Individual and registered manager submitted an action plan to meet the requirements. Progress of these matters has been monitored and will continue to be monitored through the inspection process.” There has been some progress with the above and the new Responsible Individual is following the company’s internal employee disciplinary procedures in respect of the registered manager of the home. The lack of recorded complaints and limited number of residents and staff meetings indicates there are few opportunities for concerns and complaints to be heard, taken seriously, recorded and resolved. It is important that management and staff complete training in this area. One of the complainants had reported their concerns to the Adult Protection Team and procedures were followed and an investigation of the events made. The home has Adult Protection Policy and Procedures and these were last reviewed in 2005. Staff do attend the local authority adult protection courses however given the number of new staff these should be nominated to attend. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 19 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): 19,22,24 and 26 Quality in this outcome area is adequate. The home and gardens are reasonably well maintained. However there has been limited improvement in the fabric, furnishings and decoration of individual and communal areas of the home. Carpets and furniture are showing signs of wear and tear. The home still needs to be assessed for suitable aids, adaptations and equipment to provide a pleasant, comfortable and safe environment for residents to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A limited tour of the premises was made with an inspection of the communal areas and a sample of individual rooms. The outdoor areas, car parks and exterior of the house were tidy and reasonably well maintained. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 20 The dining room chairs and tables are worn and in need of replacement. The new Responsible Individual confirmed that there were plans to make improvements to the fabric and furnishings in the home and already new curtains were on order. Similarly the carpets in the dining room, lounge and downstairs hallways are in need of replacement. The new Responsible Individual said that all the carpets had been deep cleansed and this had made some improvement however accepted that these would eventually be replaced. The potential trip hazard of the worn carpet by room 3 was discussed and agreed that this would be given priority. The new Responsible Individual stated that none of the residents require the use of hoists or additional aids and adaptations at the present time. The new Responsible Individual stated residents needs had been assessed by the manager / deputy manager and are regularly reviewed and as a result a slide belt had been provided. Additional equipment would be provided if this were considered necessary. The inspector recommends that and occupational therapists assessment of the premises is sought to determine the appropriate provision of e aids, hoists and assisted toilets and baths which are capable of meeting the assessed needs of the residents. The faulty washing machine has been replaced. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 21 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. There has been some improvement in the recruitment procedures and structure and content of staff records. There is evidence of some training for staff. The staff group vary in their skills, qualifications and experience and need support and development to ensure they are competent in all aspects of the care they provide. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was not in work at the time of the inspection but was suspended for the purpose of a disciplinary investigation. The statutory requirement regarding the registered manager remaining supernumerary at all times could not be inspected; the deputy manager was acting manager covering some management duties but still on the shift rotas. There was a sufficient number of staffing on duty at the time of the inspection. The morning and afternoon/evening shift had four staff on each shift with seventeen residents in the home. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 22 The home had recruited to the vacant posts and had a sufficient number of ancillary staff employed to cover the duties over a seven-day period. Additional domestic staff and a kitchen assistant had been employed. There has been a considerable change in the staff group during the past twelvemonths. The new Responsible Individual and senior management need to ensure that new staff receive appropriate support to achieve the NVQ level 2 to make sure the staff group are adequately qualified with a minimum ratio of 50 of care staff (NVQ level 2) employed in the home. The Responsible person confirmed that all staff have a revised contract with terms and conditions and a job description. The revised documents include lifting and handling tasks. In the sample of staff files seen one held the above information. The Responsible person explained that one person was very recently employed and the copies had not yet been placed on file and the other was employed some years ago and staff files were still being updated however all had been issued with new contracts. Some staff had received training in the following topics: Lifting and Handling and Infection Control. Training that remains outstanding are: Adult Protection, and Complaints. The Responsible person provided a copy of the revised Moving and handling policy to CSCI. This has been implemented at Drake Court. He states that some equipment has been provided (a belt slide) and all staff have been informed of the new policy and procedure and attended Moving and Handling training. There was no evidence seen on staff files of current annual staff appraisals. It is important these are completed to provide support to staff, develop skills and monitor care practice. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is poor. There has been some improvement in the management of the home. However progress is slow and there are a number of management issues to be addressed to ensure the health and well being of residents is safeguarded and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new Responsible Individual is taking action to ensure the registered manager is competent to run the home and meet its stated purpose, aims and objectives. The registered manager is currently suspended from employment in the home whilst the Responsible person makes an investigation under the Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 24 staff disciplinary procedures of a complaint made earlier in the year. There were several statutory requirements made relating to management duties and responsibilities and some of these have been addressed by the management team. Feedback from care staff at the home during inspection visits and the number of staff leaving employment at the home and the poor level of support given to staff through lack of supervision and staff meetings are all indicators of a poor working relationships between the management and staff at the home. The management approach at the home must improve to create an open, positive and inclusive atmosphere. The Regulation 33 monthly visits are not being made to the home and a comprehensive written report provided to the registered manager of the home and the Commission for Social Care Inspection. The new Responsible Individual made a commitment to ensure that these would be done on a regular basis to monitor the service delivery in the home and to provide feedback and support to the management and staff at the home. Residents are given the opportunity and consulted about services provided through anonymous questionnaires and residents meetings. Following a discussion regarding the importance and purpose of Quality Assurance. The new Responsible Individual also agreed to provide an Annual Quality Assurance development plan for the home, based on a systematic cycle of planning, action, review, aims and objectives and outcomes for service users by the end of March 2007. The new Responsible Individual submitted and Action Plan in response to the Inspection report made on the 21st June 2006, confirming that action had been taken or would be taken in line with the timescales given on the report. However at this inspection a few weeks later it was found that at least half of the matters remain to be addressed. It is required that action is progressed within agreed timescales to implement requirements identified in the Commission for Social Care inspection reports to safeguard the well being of residents. The new Responsible Individual has not yet provided a business and financial plan for the home available and open to inspection and reviewed annually. The new Responsible Individual stated that suitable arrangements would be made to receive and store resident’s fees and monies in a safe and secure manner (in the safe) providing receipts with copies held in the home. It is planned to write to the relatives of residents and make alternative arrangements for the payment of monies if they are unable to pay directly to the manager of the home or the new Responsible Individual. The new procedure would also be explained to staff and a record book set up to record all monies received and outgoings. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 25 The sample of staff files seen and feedback from staff spoken with demonstrates that staff do not receive regular supervision (at least every two months). This needs to be established to monitor care practice in the home and provide support and guidance to staff. A sample of residents files have been seen and these were found to be in good order with a front index and file dividers for the contents. There was a comprehensive range of information formats including assessment, care plans, risk assessments, medication log, relatives contact form, health records and daily / monthly reports. The safe working practice topics were not fully inspected on this occasion. The new Responsible Individual had provided the pre-inspection questionnaire in July 2006 and this gave a comprehensive list of the current checks and certificates for all topics. The majority had been completed for 2006 and some were due. It is noted that the Fire Officer’s last visit was recorded as 3.05.02 and the Environmental Health officer last visited in 2005. The training plan for staff includes all of the safe working topics. Drake Court DS0000020809.V321385.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 3 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X 2 X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 1 2 1 3 3 Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement The Responsible Individual must ensure that the Statement of Purpose for the home is reviewed and updated. The registered manager must ensure new residents are admitted only on the basis of a full assessment and where the home can demonstrate it is able to meet those needs. 3.1 The timescale of 23/07/06 has not been met. The registered manager must monitor the administration of medication to ensure staff observe resident’s taking their medication. 9.3 The timescale 30/07/06 has not been met. Ensure all staff who administer medication have completed the accredited training in the safe handling and administration of medication. Timescale for action 31/03/07 2. OP3 14 30/11/06 3. OP9 17 30/11/06 4. OP9 17 31/05/07 Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 28 5. OP9 13 The registered manager must maintain a central record (with the medication administration sheets), of the names of staff and completion dates of those that have completed accredited medication training. 9.7 The timescale of 31/08/06 has not been met. The Responsible Individual and the registered manager must ensure a record is kept of all complaints. 16.3 The timescale of 31/08/06 has not been met. The Responsible Individual and the registered manager must ensure the worn carpet by room 3 producing a trip hazard is made safe. 19.1 The timescale of 23/07/06 has not been met. The Responsible Individual and the registered manager must replace the dining room chairs and tables. 19.2 The timescale of 30/09/06 has not been met. The Responsible Individual and the registered manager must replace carpets in the dining room, lounge and downstairs hallways. The timescale of 30/09/06 has not been met.19.2 The Responsible Individual must ensure the registered manager must provide aids, hoists and assisted toilets and baths, which are capable of meeting the assessed needs of the residents. 22.4 DS0000020809.V321385.R01.S.doc 28/02/07 6. OP16 17 28/02/07 7. OP19 13 28/02/07 8. OP19 23 31/03/07 9. OP19 23 31/03/07 10. OP22 14 31/03/07 Drake Court Version 5.2 Page 29 The timescale of 30/09/06 has not been met. 11. OP27 18 The Responsible Individual must ensure the registered manager or acting manager remains supernumerary at all times. 27.7 Not inspected on this occasion. The Responsible Individual and the registered manager must ensure there is a minimum ratio of 50 of care staff (NVQ level 2) employed in the home. The registered manager must ensure all staff receive training in the following topics: Adult Protection, and Complaints. 30.3 The timescale of 30/09/06 has not been met. The Responsible Individual and registered manager must ensure that all staff have an annual staff appraisal. The Responsible Individual must ensure that the registered manager is competent to run the home and meet its stated purpose, aims and objectives. The registered manager must ensure that the management approach of the home creates an open, positive and inclusive atmosphere. 32.1 The timescale of 30/09/06 has not been met. The Responsible Individual must ensure that at least once a month an unannounced visit is made to the home and a comprehensive written report is provided to the registered DS0000020809.V321385.R01.S.doc 30/11/06 12. OP28 18 31/03/07 13. OP30 12 31/03/07 14. OP30 12 30/04/07 15. OP31 9 28/02/07 16. OP32 10,12 31/03/07 17. OP33 24,26 31/03/07 Drake Court Version 5.2 Page 30 manager of the home and the Commission for Social Care Inspection. The timescale of 30/07/05 has not been met. 18. OP33 24 The Registered Manager must produce an annual Quality Assurance development plan for the home, based on a systematic cycle of planning, action, review, aims and objectives and outcomes for service users. The timescale of 30/07/05 has not been met. The Responsible Individual and the registered manager must ensure that action is progressed within agreed timescales to implement requirements identified in the Commission for Social Care inspection reports. 33.10The timescale of 30/09/06 has not been met. The Responsible Individual must ensure that there is a business and financial plan for the home, open to inspection and reviewed annually. The timescale of 30/07/05 has not been met. The Responsible Individual and the registered manager must make suitable arrangements to receive and store resident’s fees and monies in a safe and secure manner (in the safe) providing receipts with copies held in the home. 35.5 The timescale of 23/07/06 has not been met. The registered manager must ensure all staff receive regular supervision (at least every two months). 36.2 The timescale of 31/08/06 has not been met. DS0000020809.V321385.R01.S.doc 31/03/07 19. OP33 24 31/03/07 20. OP34 25 31/03/07 21. OP35 12 30/11/06 22. OP36 18 31/03/07 Drake Court Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP22 Good Practice Recommendations The Responsible Individual and registered manager should obtain advice and assessment of the premises by an occupational therapist in respect of providing aids and adaptations that reflect and meet the needs of the residents. Drake Court DS0000020809.V321385.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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.V321385.R01.S.doc Version 5.2 Page 33 - 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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