Inspection on 15/01/07 for Drakes Place

This inspection was carried out on 15th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drakes Place 24/06/08

Drakes Place 04/01/06

Drakes Place 07/06/05

Drakes Place 02/02/05

Drakes Place 03/08/04

Drakes Place 24/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Drakes Place Taunton Road Wellington Somerset TA21 8TD Lead Inspector David Kidner Unannounced Inspection 15 – 16 January 2007 11:00 th th Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 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 Drakes Place DS0000059632.V315863.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 Adults 18-65. 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. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drakes Place Address Taunton Road Wellington Somerset TA21 8TD 01823 662347 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) Voyage Ltd Caroline Gudgeon Care Home 28 Category(ies) of Learning disability (28), Physical disability (28) registration, with number of places Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. registered for 28 persons in categories LD and PD Date of last inspection 04/01/06 Brief Description of the Service: Drakes Place is registered to provide care for up to 27 people with a Learning Disability. Voyage Ltd owns the home. Drakes Place is a large detached period property set in extensive and well maintained gardens. All bedrooms are of single occupancy and some have full en-suite facilities. There are a number of communal facilities. The home is within walking distance of Wellington town centre close to all local facilities and resources. The home has a discreet on-site day resource. This provides opportunities for leisure, recreational and educational activities for all service users at Drakes Place. Resources include an art room, heated swimming pool and a computing resource. The Registered Manager is Caroline Gudgeon. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted this Key Unannounced inspection over two days. (13.5hrs). Drakes Place has undergone major refurbishment and redecoration. The environment has been vastly improved providing a comfortable environment with a high standard of furnishings and fittings. Service users care staff and relatives were involved in the refurbishment and chose furnishings and colours for communal and individual space. The accommodation area known as Squirrel Park needs further development in relation improving natural light and communal space. The inspector was advised that these matters will be addressed and that the funding has been agreed. The Inspector was made to feel very welcome at the home by the service users, Manager and the staff team. Care staff were very approachable and are committed in providing quality service to the service users that live at Drakes Place. Staff were observed to speak to service users in a caring and supportive manner. As part of the Inspection process the Inspector sent comment cards to all service users. Due to the needs of the service users the Inspector only received four comment cards. However, the Inspector spoke to a large number of service users at the time of the inspection. Most service users stated that they liked living at Drakes Place and that they are offered choices in many aspects of daily living. Everyone spoken to stated that their privacy is respected and that the staff are nice and listen to them. The Inspector sent comment cards to the local GP and other Health Care Professionals. Comments were very positive. One healthcare professional stated that the staff are approachable and open and that communication is good. All stated that they were satisfied with the overall care provided. Comment cards were sent to Relatives/Carers. One relative commented that the staff are excellent. Another stated that staff are kind and considerate. However, some comments stated that more activities could be provided especially at weekends and on occasions, staffing levels needed to be improved. All relatives/carers stated that the staff make them feel welcome and that they are satisfied with the overall care provided. As a result of this inspection the home has three requirements and four recommendations. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home could do the following better: The recruitment files must contain the required documentation. Some matters relating to health and safety and Infection control must be addressed. The Registered Manager should review the staffing levels on a regular basis to ensure that the home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff should receive formal supervision on a regular basis. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 7 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. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides appropriate information for service users; their relative or other interested stakeholders before making a decision to move to the home. Pre-admission Assessments are conducted before a service user moves to the home. These are detailed and well documented. EVIDENCE: The home has a detailed Statement of Purpose and Service User’s Guide. The home conducts a detailed Pre-admission Assessment before a service user moves to the home. There have not been any new admissions to the home since December 2003. The Inspector was advised that a prospective service user is due to move to the home in the near future. Transitions are taking place and adaptations to the service users bedroom are being undertaken. The fees vary depending on individual assessed need. The current fees vary from £508 - £1400 per week. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans are detailed and well presented and service users are offered choices in day-to-day living. Risk assessments are conducted as and when needed. EVIDENCE: The Inspector viewed four care plans. The care plans contained detailed information in relation the care and support needs of the individual. This includes information and guidance relating to equality and diversity matters. The service provides support to service users from a variety of cultural backgrounds. All service users have a key worker. Individual records are kept on a day-to-day basis of how the service user has spent their day. The key worker completes a monthly summary that includes all activities that have taken place, visits to health care professionals, accidents and incidents and Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 11 contact with family and friends. All service users have an annual review. Risk assessments have been reviewed where needed. A number of service users use alternative methods of communication. The staff team are trained in different communication methods and some information is produced in Somerset Total Communication (STC). Signs, symbols and photographs are used where needed. The staff team offer service users as much choice as possible. The Inspector observed the staff offering serviced users choices in activities, food, drink, occupation, which staff member offers support to them and what they wished to do with their day. It was noted that the residents meeting minutes stated that service users were asked to consider what activities, holidays and other daily events they wish to pursue. The staff team support the service users in managing their personal finances. The home keeps records of all financial transactions. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home encourages service users to become part of the local community and encourages and supports service users to take part in a variety of leisure activities. Good relationships have been developed with relatives and carers. EVIDENCE: Service users have access to specialist interventions and opportunities if needed. Records of such interventions are recorded. Some service users continue to access the local college and it was very pleasing to be told that some other service users are due to go to college in the near future. For some of the service users this is a great achievement. Some service users also have work placements. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 13 The Inspector spoke to a number of staff at the time of the inspection in relation to activities and how these are offered and recorded. The Inspector was advised that all service users have the opportunity to access a variety of social and leisure activities. Each service user has a weekly activity timetable. The vast majority of staff stated that in their opinion service users access a wide variety of activities. Some service users access more than other but this is mainly due to some service users being able to access the wider community unsupported. At the time of the inspection the Inspector noted that some service users took part in a music session, arts and crafts, day trips out and personal hobbies. Some service user chose to sit and listen to music and indicated to staff that they wished the music to be changed. Some service users sat and actively watched television. It was apparent that this was the activity they had chosen and it was obvious that they were enjoying the television programme. Staff confirmed and records viewed indicated that activities that take place are recorded in the day-to-day reports for each individual. The residents meeting minutes that the Inspector viewed confirmed that service users are consulted about the types of activities that they wish to be provided with and sought. Some service users have recently been on holiday. The home actively encourages and supports service users family and friends to keep in regular contact with their relative. The feedback received from the Relatives/Carers comment cards was unanimous in that the staff welcomes them into the home. The vast majority of comments also stated that they are kept informed of important matter that affects their relative. Again without exception all comments receive stated that they are overall satisfied with the care provided at Drakes Place. The Inspector spoke to a number of service users who stated that they feel that the staff respect their privacy and that they always knock on bedroom doors before entering. All service users have a key to their own room if so wished. The Inspector observed the staff communicating with service users in a respectful and professional manner. The Inspector noted that staff were using alternative methods of communication to converse with service users. It was very evident that the service users felt very comfortable in the home. Some service users have lived at Drakes Place for many years and view Drakes Place as their home. Friendships have been developed. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 21 Quality in this outcome area good This judgement has been made using available evidence including a visit to this service. Drakes Place promotes privacy, dignity and independence. The home ensures that service users have access to health care professionals. The home ensures that all medicines are recorded and managed in the correct manner. EVIDENCE: The service users that the Inspector spoke to stated that the care staff are nice and help them with their personal care. Some service users confirmed that the care staff help them with the things they need help with and ensure that they are left to do some things for themselves. Service users confirmed that staff always knock bedroom doors before coming in and promote their privacy if they are supporting them with personal care. Service users choose the clothing they wish to wear. It was noted that service users were very well attired. Some female service users were wearing making Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 15 and jewellery. Hairstyles reflected the wishes and preferences of the service users. Care plans and daily running records confirmed that service users visit a variety of health care professionals as and when needed. Healthcare professionals also visit the home. The home has a number of aids and adaptations to meet the individual needs of service users. The Inspector viewed the MAR sheets. They were all maintained satisfactorily. Records are kept of all medicines that are returned to the Pharmacy. The Inspector viewed the records relating to Controlled medicines. Recording systems were accurate and stocks checks correct. Appropriate records are kept and a spot check was conducted. The home is very pro-active in ensuring that ageing service users and service user who are ill are treated with sensitivity and respect. The Inspector has been kept informed of service users whose health needs are causing concern, and was able to view documentation that the care team makes when supporting service users who require high care and support needs. The home has received compliments from relatives and other healthcare professionals in relation to supporting service users who have been very ill. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a robust Complaints Procedure and a policies for safeguarding vulnerable adults. EVIDENCE: The home has a complaints procedure. The home has received one formal complaint. Documentation was seen as to how the Registered Manager addressed the complaint; this resulted in a satisfactory outcome. The Commission for Social Care Inspection has received an anonymous complaint about the service. At this inspection the Inspector investigated the areas of concerned raised in the anonymous complaint. The Inspector was not able to substantiate the concerns raised. Some service users that the Inspector spoke to were able to identify whom they would speak to if they had any concerns or complaints. Care staff spoken to were aware of the home’s whistle blowing policy and demonstrated their awareness and action that would be taken. The home has a policies and procedures in relation to the management of service user’s finances. Records are kept of all service users financial transactions. Each service user has an individual bank account. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 17 The home completes Enhanced CRB disclosures and POVA First checks before being allowed to work at the home. Staff are supervised at all times following a POVA First check. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Following refurbishment most areas of the home offer very comfortable and homely facilities. Some areas of the service need further improvement. Service users bedrooms reflected individual likes and preferences. On the day of the inspection the home was clean and hygienic. EVIDENCE: Drakes Place has recently undergone major refurbishment and redecoration resulting in the environment being arranged in three main accommodation areas. These areas are known as The Main House, Squirrel Park and The Oaks. The Inspector viewed all areas of the home and spent time talking to service users, care staff and managers about the changes in the environment and the effect this had had on the service users. The Inspector also received comments from some relatives/carers in relation to this. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 19 Most areas of the service offer homely accommodation. The decoration, furnishings and fittings are of a high standard. The lounge, kitchen and dining areas are very well presented and have many homely touches. However, some areas of Squirrel Park would benefit from being made more homely. This was discussed with the Registered Manager at the time of the inspection and stated that the service is aware of this and will be addressing this in the near future. Some care staff and relatives have raised concerns over natural light in the accommodation area known as Squirrel Park. The Inspector spent some time in Squirrel Park and agrees that this is an issue that needs resolving. The Registered Manager stated that this has been raised and discussed at length with senior managers within Voyage. Funding has been agreed to alter the environment to allow more natural light into the accommodation area. It is also understood that the garden area will also be landscaped to provide a safe area for service users to use. Again, it is understood that funding has already been agreed for this. Addressing these matters should have a positive effect on the environment. Following further discussion with the Registered Manager, the Inspector recommends that consideration should be given to review the style of the doors to Squirrel Park accommodation area to further promote natural light and to create a more ‘open’ feeling to the area. Care staff advised the Inspector that some service users have ‘blossomed’ since the alterations have been made. The Inspector was able to acknowledge these comments as it was noted that one service user in particular their demeanour has changed. It was the first time the Inspector was able to have a very brief conversation with the service user and also noted that the service user appeared much calmer, content and happy in their ‘new’ environment. The majority of the service users that were able to express an opinion were happy with the changes in the home. One service user said that they were happy with their new bedroom and pleased with the decoration. Most bedrooms and en-suite facilities were viewed. The bedrooms viewed reflected individual needs and preferences. Many had personal possessions and pictures of family members. Service users were involved as much as possible in choosing the furnishing and colours for bedrooms that were redecorated as part of the refurbishment programme. En-suite and communal bathing facilities have been improved but some are still in need of being more homely in appearance. One service user has expressed their concern over the difficulties they have encountered in relation to their en-suite facilities. The Registered Manager is aware of the service users views and is taking appropriate action to address this. The home has a variety of aids and adaptations to promote service users independence and to support them in their personal care needs. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 20 On the day of the inspection the home was clean and hygienic. The home has an Infection Control Policy. The laundry facilities at the home appeared to meet the needs of the service and on the day of the inspection were well organised. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is proactive in ensuring that staff are competent and qualified. At the time of inspection the home appeared adequately staffed but this needs to be regularly reviewed to ensure service users access social and leisure facilities. The recruitment files did not contain the appropriate documentation to demonstrate a robust procedure. Staff do not receive regular formal 1:1 supervision. EVIDENCE: There is currently ten of the forty care staff that has an NVQ qualification. This equates to 25 of the workforce. The home has an action plan to ensure that 50 of the workforce obtains an NVQ qualification. The Inspector is aware that the home is committed to promoting the qualification of its workforce. Staff also undertake the Learning Disability Award Framework (LDAF). Staff have Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 22 specialist training in behaviour management, promotion of mobility and alternative methods of communication. On the day of the inspection the Inspector observed care staff conducting themselves in a professional manner and appeared interested, motivated and committed. It was apparent that staff are aware of the needs of the service users. The Inspector viewed the minutes to staff meetings. It was noted that there have been six staff meetings in the last 12 months. Matters such as confidentiality, care practices, activities, health and safety, respect to service users, behaviour management guidelines and staff conduct had been discussed. Recruitment files of four recently appointed staff were viewed. Not all files contained the required documentation as listed in Schedule 2 of the Care Homes Regulations 2001. This must be addressed. The Inspector viewed the records of the training that staff have recently received. Training included epilepsy training, manual handling, fire training, Non-Violent Crisis Intervention (NVCI), medication, autism, introduction to learning disabilities, intensive interaction and aspects of ageing. Each staff member has a record of the training that they have undertaken. The Registered Manager has confirmed that 25 of the care team have a first aid certificate. The Inspector was advised that the home has a Training and Development Plan but this was not available at the time of the inspection. There is currently ten of the forty care staff that has an NVQ qualification. This equates to 25 of the workforce. The home has an action plan to ensure that 50 of the workforce obtains an NVQ qualification. The Inspector is aware that the home is committed to promoting the qualification of its workforce. Staff also undertake the Learning Disability Award Framework (LDAF). At the time of the inspection the Inspector was advised that there are currently 300 hours of care staff vacancies. The Inspector was informed that some staff work extra hours to ensure that adequate staffing levels are maintained. The home is actively recruiting staff to fill the staffing vacancies. The home has not used agency staff. As previously mentioned the home has three accommodation areas. Staff will work in all areas of the service. However, this is currently being reviewed as it is expected that there will be three distinct teams and therefore each accommodation area will have a ‘dedicated’ staff team. On the day of the inspection it appeared that there was adequate staff on duty to meet the needs of the service users. Staff were observed to be supporting service users in daily living skills and various activities. In one accommodation area service users need close support and care staff remain close at hand to offer support when needed. Some staff commented that in their opinion more staff were required in this accommodation area. This will then allow staff to offer more social and leisure opportunities. This was Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 23 discussed with the Registered Manager at the time of the inspection. It is anticipated that following recruitment staffing levels will improve. Following these discussions the Registered Manager should regularly review staffing levels at the home to ensure that the home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times, including to continue and improve to provide social and leisure activities. The Registered Manager and some care staff stated that regular formal supervision has not taken place. Records viewed indicated that this was the case, as a number of staff are not receiving regular formal supervision. This should be addressed. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Drakes Place is very well managed and has good quality assurance systems. The home is pro-active in Health and Safety matters but needs to address a few matters relating to this. EVIDENCE: Caroline Gudgeon is the Registered Manager of Drakes Place. Caroline has worked at Drakes Place for many years and is very aware of the needs of the service users. Caroline has completed the Registered Managers Award, undertakes regular refresher training and updates herself where needed. The home also employs two Deputy Managers to support Caroline. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 25 The Inspector spoke to a number of staff and service users at the Inspection. Staff commented that Caroline listens to staff views, is approachable, has good people skills, is informative, calm and knows the service users very well. Service users also spoke very well of Caroline. The home and Voyage as an Organisation, continuously self-monitor the service. Copies of the Regulation 26 visits are sent to the CSCI (Commission for Social Care Inspection) for information. The home’s policies and procedures are regularly reviewed. Service users, parents/relatives and other interested stakeholders have access to the homes policies and procedures. All records are well maintained, up to date and are stored securely in accordance with the Data Protection Act 1998. The Inspector viewed a number of records in relation to health and safety. Gas Safety: It was noted that the Gas Safety certificate is dated 06/06/06. Electrical Hardwiring: This certificate is dated 04/11/02 and valid for 5yrs. Portable Appliance Testing: This was conducted on 30/10/06. Hoists: All hoists were serviced on 08/01/07. Passenger Lift: The annual service was conducted on 16/11/06 Bed Rails: Maintenance records are kept for the bed rails and weekly checks are conducted. They were last checked on 14/01/07. Hot water temperatures: It was noted that some hot water outlets exceeded the Health and Safety Executive guidelines of 44 degrees for baths. This was bought to the attention of the Registered Manager and must be addressed. Fridge, freezer and food temperatures: Daily records are kept of fridge and freezer temperatures. Infection Control: The home must ensure that hand washing and hand drying facilities are provided in all communal toilet and bathroom facilities. Staff must be provided with such facilities in service users bedrooms where intimate personal care is given. Fire Safety: The home maintains good records in relation to fire safety. All records were satisfactory. An annual service on the fire system and emergency lighting was conducted on 29.09.06. Regular fire drills are undertaken. Weekly fire checks are conducted and monthly checks are maintained on the emergency lighting and the torches. The fire extinguishers were last serviced on 14/01/07. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 26 COSSH: Records are well maintained. The home keeps records of all accidents and these are audited on a monthly basis. Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 3 X 2 X Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 28 NO 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 YA34 Regulation 19 Requirement The Registered Manager must ensure that the recruitment files contain the correct documentation as listed in Schedule 2 of the Care Homes Regulations 2001. The Registered Manager must ensure that the temperature of the hot water outlets do not exceed the temperatures as recommended by the HSE. The Registered Manager must ensure that hand washing and hand drying facilities are provided in all communal toilet and bathroom facilities. Staff must be provided with such facilities in service users bedrooms where intimate personal care is given. Timescale for action 11/02/07 2 YA42 13 (2) 18/02/07 3 YA42 13 (2) 18/02/07 Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 29 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 2 Refer to Standard YA24 YA24 Good Practice Recommendations The Registered Manager should continue to implement the proposed changes to Squirrel Park and advise the CSCI of the completion of the works. The Registered Manager should review the style of the doors to Squirrel Park accommodation area to further promote natural light and to create a more ‘open’ feeling to the area. The Registered Manager should regularly review staffing levels at the home to ensure that the home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. The Registered Manager should ensure that all staff receive regular supervision. 3 YA33 4. YA33 Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Drakes Place DS0000059632.V315863.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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