Inspection on 28/01/06 for Drake Court

This inspection was carried out on 28th January 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 27/11/06

Drake Court 19/07/06

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 Lancashire Unannounced Inspection 28th January 2006 10:00 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 Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 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.V281247.R01.S.doc Version 5.1 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 Miss Gillian Rosemary Edwards Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Drake Court is a two-storey, purpose built home which provides accommodation for twenty-nine elderly service users. This home is situated close to Bloxwich town centre where there are local amenities. The home is well maintained with adequate parking at the front and side of the property. There are twenty-seven single rooms and one double room, all with WC and hand basin. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a short unannounced inspection, carried out on a Saturday afternoon. The main purpose of the visit was to assess those key standards not assessed the previous inspection and to check that the requirements made in the last report had been met. The inspector spoke with five members of staff, two of whom assisted in providing relevant records. She held brief conversations with three residents who confirmed that they were content. It was disappointing to note that, although some progress had been made towards meeting requirements, many have not been addressed. These are beyond the control of the care staff and need to be addressed by the manager and provider. Staff informed the inspector that the manager had been away from the home for five weeks at the time of this visit. It was evident that staff had been working hard to maintain the standards and to make improvements in recording systems. What the service does well: What has improved since the last inspection? Since the last inspection, some of the requirements made in the report have been met. Improvements have been made to the organisation of the residents’ files, so that information is easier to access. Care plans are now reviewed on a regular basis. The preferences of residents in relation to the action to be taken by the home following their death are recorded. There have been improvements in the recording of non-prescription medication and staff medication is no longer inappropriately stored. The complaints procedure has been updated to include details of the Commission for Social Care Inspection. Redecoration has been undertaken in various areas, as required in the last report. Items which were stored inappropriately have been relocated. Storage containers in the kitchen have been replaced and the washing machine has been repaired. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 6 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. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 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.V281247.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 (Standard 6 does not apply at this home) Service users and their representatives need to be supplied with the necessary information about the home. Service users have contracts/statements of terms and conditions with the home, but care needs to be taken to ensure that these are all signed and dated. The needs of prospective service users are assessed and they are assured that these will be met. EVIDENCE: In the previous report, the inspector required that the home should issue service users and their representatives with the Statement of Purpose and service user guide for the home. Staff on duty at the time of this inspection had no knowledge of this process and could not find a supply of these documents. The requirement remains. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 9 Staff described the process by which all residents have been provided with a contract with the home. However, examination of seven sampled files revealed that two contracts could not be found and three others had been signed but not dated. The manager must ensure that all residents have contracts which are signed and dated. Staff described the process by which the needs of prospective service users are assessed. Sampled files contained copies of letters and assessments by the home (or by social services and health) confirming a placement at the home and indicating that the needs of service users can be met. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9(partly),10,11 Service users’ needs are outlined in a personal care plan. Service users’ health needs are met. Improvements are needed in the storage of medication, so that all medication is stored at the correct temperature. Service users are treated with respect and their privacy is upheld. Service users are assured that staff will treat them and their family with respect at the time of their death. EVIDENCE: There are care plans for each resident and these outline their needs in a variety of areas. Care plans are drawn up using the information which is received from other professionals at the time of referral. Details are then checked with the residents and their representatives/relatives. By the time of admission, the home has a plan which includes health, social and physical needs. These are reviewed on a monthly basis and appropriately signed and dated. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 11 Residents are involved in the preparation and review of their plans and are encouraged to sign these. The sampled information seen was current, with basic details recorded, signed and dated. Health care needs such as optician, chiropody, dental care etc. are monitored by the key worker and relevant health care agencies accessed and appointments and treatments obtained. Discussion with staff revealed knowledge of the particular needs of individual residents. There have been improvements in the recording of purchase and administration of non-prescription medication. A book is now maintained with all relevant details. At the previous inspection, homely remedies belonging to staff were being stored inappropriately. These have now been removed. It was also found that ‘the heat from the fridge warms medication stored in the cupboard directly above it, potentially making it unsuitable for use.’ The inspector required that the medication refrigerator must be moved to a more suitable location, in order to ensure that correct temperatures are maintained. At this inspection, the situation was found to be of even greater concern, as the refrigerator has not been moved, but it has been turned off and is no longer in use. All medication, including that which needs to be at a specific temperature, is now stored in the trolley. This practice must cease and all medication must be stored at the correct temperature. The importance of the refrigerator being in a suitable location and being turned on was stressed to staff at the visit and a telephone call was made to the manager, who assured that inspector that the matter would be dealt with immediately. At the time of the arrival of the inspector, staff were dealing with an event which required the services of an ambulance. Staff were careful to protect the privacy of the resident concerned and to ensure that the other residents were reassured and remained calm. Staff also demonstrated their awareness of the need to respect the confidentiality of some sensitive information. They demonstrated respect for privacy as a partial tour of the building was undertaken by the inspector. Staff demonstrated a commitment to ensuring that the wishes and preferences of residents and their families are respected at the time of their death. Details of the relevant contacts and any specific preferences were seen for each resident. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. All the key standards in this section were met at the last inspection. EVIDENCE: Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a suitable complaints procedure. As there have been no recent complaints, there is no way of assessing practice in this area. EVIDENCE: The complaints procedure had been issued to all service users and displayed on the doors of their individual rooms. This information has been updated and now includes the current details of the Commission For Social Care Inspection. The complaints book was seen by the inspector and contained no recent complaints. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26, Service users live in a safe and well-maintained environment. The home is clean, but hygiene is compromised by the lack of lids on bins in WCs and the kitchen. EVIDENCE: Decoration in specific areas, as required in the last report has been undertaken. All areas seen by the inspector were in a reasonable state of repair and decoration, but lids were missing on some bins in WCs. These must be replaced. The kitchen was in good order and had recently been cleaned by the cook. The requirement made at the previous inspection for deep cleansing of the ventilation shaft by a competent contractor has not been met. Food storage containers had been replaced. However, there was no lid on the bin. The washing machine had been repaired. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 Service users’ needs are met by the numbers and skill mix of staff, but further recruitment needs to be undertaken to ensure that no members of staff work excessive hours. Service users are in safe hands at all times. Staff receive training, but further training is required in supervision skills and dementia care. EVIDENCE: The shortfall in domestic hours has been met and there is now cover each day of the week. There was one cook on duty on the day of the inspection. A member of care staff currently undertakes the duties of the vacant post. An additional cook’s post has been advertised and filled. Staff informed the inspector that the appointee is awaiting the results of a Criminal Records Bureau check before commencing duties. The rotas show that there are usually four members of staff on each shift, in addition to the manager. This is achieved at times by some members of staff working long hours and by senior staff covering shortages. Staff informed the inspector that some new staff had been appointed, but had failed to arrive for duty and that further recruitment is planned. Staff provided details of those who had completed NVQ training to level 2 or 3. This includes all night staff. One member of staff is currently undertaking level 4. The home meets the requirement to have a minimum of 50 trained staff. The requirements to provide training in supervision skills to supervisors and dementia care training to staff have not been met. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36,38 The home lacks formal systems to ensure that it is run in the best interests of service users. Staff are supervised, but staff providing supervision need to undertake suitable training in this area. The health safety and welfare of the service users are protected but there is an outstanding requirement in relation to cleaning in the kitchen. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 17 EVIDENCE: The registered person has delegated the duty of the monthly unannounced visits to the home and the production of the written report, for the Registered Manager of the home and the Commission for Social Care Inspection, to the Accounts manager Mr Wardle. Staff could not recall any recent visits or find any reports and the inspector could find no evidence that reports have been sent to the Commission for Social Care Inspection as required. There was no evidence in the home of a quality assurance system or an annual quality assurance and development plan for the home. No business or financial plan could be found. Staff were unable to find evidence that these had been completed. There has been some progress with supervision arrangements. Senior care staff have been delegated some supervisory duties. The supervising staff on duty showed the inspector examples of the formats used for supervision and some examples of sessions held. They have clearly made great efforts to undertake this role, despite a lack of training. The requirement for training in this area was made at the last inspection and has not been met. The certificate of the five-yearly electrical service by a competent electrician, asked for at the last visit, was produced. Action taken in relation to the requirement made regarding the ventilation shaft for the cooker and the tiles and flooring in the kitchen has been mentioned elsewhere in this report. Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 18 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X 2 X 2 Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4&5 Requirement The Registered Person must ensure that the Statement of Purpose for the home and the Service Users’ Guide are issued to the service users and their representatives. (original date for compliance 31/07/05) The manager must ensure that each resident has a contract which is signed and dated by the relevant parties. The manager must ensure suitable location of the medication refrigerator and this must be turned on. (original date for compliance 30/06/05) The manager must ensure that bin lids are provided to all bins throughout the property. (original date for compliance 30/06/05) The registered provider must ensure that the registered manager and other staff providing supervision sessions receive training in supervision skills. DS0000020809.V281247.R01.S.doc Timescale for action 01/03/06 2 OP2 5 01/04/06 3 OP9 13 01/02/06 4 OP26 12 01/02/06 5 OP30 12 01/05/06 Drake Court Version 5.1 Page 20 6 OP30 12 and 18 7 OP33 26 8 OP33 24 9 OP34 25 10 OP38 13 (original date for compliance 30/09/05) The registered person must ensure that staff receive training in dementia care. (original date for compliance 30/09/05) The registered person must ensure that at least once a month an unannounced visit is made to the home and a comprehensive written report is provided to the registered manager of the home and the Commission for Social Care Inspection. (original date for compliance 30/07/05) 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. (original date for compliance 30/07/05) The Registered Provider must ensure that there is a business and financial plan for the home, open to inspection and reviewed annually. (original date for compliance 30/07/05) The registered person must ensure the ventilation shaft for the cooker is deep cleansed by a competent contractor at least once a year and as necessary. (original date for compliance 30/09/05) 01/05/06 01/04/06 01/04/06 01/04/06 01/04/06 Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Drake Court DS0000020809.V281247.R01.S.doc Version 5.1 Page 22 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: 0845 015 0120 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.V281247.R01.S.doc Version 5.1 Page 23 - 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!