Care Home: Delves Court Care Home

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What the care home does well Care services are provided in a comfortable, homely environment, and demonstrate a good response to the needs, and preferences, of individual Residents and their supporters. This is enabled through comprehensive, and careful, assessment prior to admission ensuring Residents` assessed care needs can be fully met. The Home is actively, and effectively, led by a Manager who is constantly seeking to improve the quality of the environment, for the Residents, and of the services they receive. There is a well-organised, and varied activity programme. A particularly impressive aspect of the Home, given its relatively large number of residents, is the manner in which each floor unit retains its own identity whilst remaining an fully integral part of home. What has improved since the last inspection? What the care home could do better: CARE HOMES FOR OLDER PEOPLE Delves Court Care Home 2 Walstead Road Walsall West Midlands WS5 4NZ Lead Inspector Keith Salmon Unannounced Inspection 11th December 2007 09:45 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 Delves Court Care Home DS0000029398.V352195.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. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delves Court Care Home Address 2 Walstead Road Walsall West Midlands WS5 4NZ 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) 01922 722722 01922 722922 susan.nicholls@hallmarkhealthcare.co.uk Hallmark Healthcare (Walsall) Limited Susan Nicholls Care Home 64 Category(ies) of Old age, not falling within any other category registration, with number (64) of places Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide 2 step-down/intermediate care beds, providing all elements of N.M.S. 6 (Care Homes for Older People) are met at all times. 10th August 2006 Date of last inspection Brief Description of the Service: Delves Court is a care home providing accommodation, nursing and personal care for up to sixty four older people. Situated in the Bescot area of Walsall, close to shops and local amenities, the home is owned by Hallmark Healthcare (Walsall) Ltd. Opened in March 2002, the property is purpose built with an attractive, well maintained, patio garden area to the rear of the building and off road parking to one side. Nursing care is provided on the first and second floors. Accommodation comprises 60 single bedrooms, 26 having en-suite facilities, and 2 double bedrooms. Each floor is self sufficient for communal rooms, bathing and toilet facilities. Ancillary services for catering, laundry, housekeeping and maintenance are all provided in-house. The range of fees payable is not available in information for prospective residents. Readers of this report may wish to contact the service directly for this information. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced ‘Key’ Inspection commenced at 9.45am, concluded at 3.30pm, and was conducted by Mr Keith Salmon. Present on behalf of the Home was the Registered Manager, Mrs Susan Nicholls. In addition to an inspection of ‘Key’ Standards, this Inspection also sought to review progress in meeting ‘Requirements’ arising from the most recent Unannounced ‘Key’ Inspection, held in August 2006. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff files and duty rotas, plus a range of other documents/records reflecting the general operation of the home. The Inspector also held individual discussions with 7 Residents, 3 Visitors, the Manager, and several other members of staff. What the service does well: What has improved since the last inspection? All eight requirements cited at the previous inspection have been met, successfully addressing issues relating to • • • Medicines storage and disposal The level of detail in care planning documentation Ambient temperatures in communal rooms DS0000029398.V352195.R01.S.doc Version 5.2 Page 6 Delves Court Care Home • • • • Provision of lifting equipment Staffing levels Response to nurse call bells The need for regular documented visits to the Home by representatives from the parent company What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective Residents (or their Representative) are provided with relevant information to help them make an informed choice about ‘where best to live’ but this does not include details of the range of fees. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: A requirement arising from the previous ‘key’ inspection, held on 10 August 2006 was – “The registered manager must ensure that service user assessments are fully completed at all times and kept under review.” Records/Care Plans ‘case tracking’ relating to six Resident’s (the two most recent admissions and four others chosen at random) demonstrated that prior Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 9 to any offer of a place in the home, and subsequent acceptance of such offer, all had undergone assessment of their care needs by the Registered Manager. The above requirement, is therefore, considered to be met. Although the home is registered to provide 2 ‘step-down/intermediate’ care beds, new residents are no longer admitted for this level of care. We understand the provision of Intermediate Care has been grouped in a care home elsewhere within the Hallmark Group, and the parent company has no intention of resurrecting this type of care within Delves Court. The range of fees payable is not available in information for prospective residents. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan, utilised by the Home, sets out a Resident’s health, personal and social care needs and enables them to meet these assessed care needs. The care provided is delivered considerately and effectively. The storage, reception, disposal, and record keeping, relating to medicine administration are generally in accordance with accepted ‘good practice.’ However, a shortfall in respect of ‘good’ practice remains in the lack of a purpose designed medicines trolley. Residents’ privacy and dignity is respected. EVIDENCE: Three requirements relating to this ‘outcome’ area were cited at the previous inspection. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 11 The first addressed shortfalls in the comprehensiveness of care planning, specifically – “The registered manager must ensure that all identified needs have a care plan to address them.” Since the previous inspection the care planning documentation has been changed so as to be inline with the corporate model used elsewhere within the Hallmark Group. The transfer of care planning information for existing Residents from the ‘old’ to the ‘new’ model has been completed. One area particularly addressed has been in the assessment of each Resident’s risk in developing pressure sores, in that the risk assessment tool has been changed from the ‘Waterlow’ score to the ‘Braden’ scoring system. Care staff have received appropriate training in this new system. Review of the care planning documents, relating to six Residents selected at random for ‘case tracking’, demonstrated the design is now sufficiently robust and comprehensive to meet Residents’ individual care needs, and reliably maintained by Care Staff. Areas of care addressed by the care plan now include; full range of risk assessments based on ‘activities of daily living’; pressure sore risk assessment; nutritional state, including daily food and fluid intake; regular weighing (frequency determined by assessed need); records of visits by clinical/social care professionals, e.g. GP, Community Nurse, Social Worker, Optometrist. Residents’ interests, hobbies, and preferences are now also recorded. Evidence was also observed of involvement by Residents/’supporters’ in the needs assessment, and care planning process, together with regular review (at least monthly) and with change where necessary. The Manager is developing a greater involvement by care staff in the care planning/reporting process. Care Staff are encouraged to make written entries in addition to maintaining ‘care diaries’ for Residents to whom they have been allocated as the ‘key-worker’. No gaps were found in the care plans sampled. This requirement is considered met. The further two requirements related to the storage of medicines, i.e. “The registered person must ensure that medicines are stored safely and appropriately at the correct temperature” This requirement had a previous timescale, which had not been met (31.10.05) and an Immediate Requirement was served. “The registered person must take steps to reduce the amount of waste medication accumulating in the treatment room” Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 12 A review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicine refrigerator temperatures), the maintenance of medicine administration records (MAR Sheets), and the maintenance of the Controlled Drugs Register. The Inspector also reviewed the contents of the medicine cupboard, and systems/records relating to the receipt and disposal of medicines. In relation to the above requirements we observed a mobile air-conditioning unit has been placed in the ‘medicines room’ with the ambient temperature being sampled on a daily basis. Records confirmed temperatures have not exceeded 72o F since installation of the unit. With regard to the accumulation of ‘waste’ medicines, i.e. medicines no longer needed and awaiting return to the supplying pharmacy for disposal, the previous arrangement, comprising a range of cardboard boxes, has been replaced with suitably designed heavy duty, lidded, plastic tubs. It is planned to move from the current position of one ‘medicine’ room, based on the ground floor, which serves the whole home, to having a ‘medicine/ treatment room’ on each of the three floors. In the meantime, the storage of medicines awaiting disposal is more secure and much tidier. The above Requirements are met. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure opportunities provided are generally consistent with Residents’ capabilities. However, activities provided for Residents with dementia related needs should be developed further. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: The Home employs a full time activities coordinator who works Monday to Friday, but is also available for special events held at evenings, weekends, and Bank Holidays. The main role of this staff member is in planning the activities programme, taking a major role in its implementation, and also recruiting assistance from available staff, on a day to day basis, dependent on staff numbers and overall workload. Particular attention is given to ensuring Residents on each of the three floors enjoy leisure/social activities consistent with their individual preferences and capabilities. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 14 Specific examples of activities, reflected in the Home’s published programme, individual care plans, and comments made by Residents/Relatives to us include; exercise and ‘musical movement’ sessions, bingo, traditional games (cards, dominoes, darts), outings, and visiting entertainers. Residents commented to the Inspector they were able to take part in whichever activities interested them, and were encouraged, though not pressurised, to do so. Seasonal activities observed during the inspection were Christmas card making, hanging decorations and tree decoration. Other planned Christmas activities include visiting carol singers from two local schools, a Carol Service, cake decorating, mince pie making, a Residents and Relatives Christmas party, and a Christmas Eve ‘nibble’ at which Staff don fancy dress. A recommendation following the previous inspection was – “The manager should seek to find ways to include reluctant service users in social interaction.” At this inspection it was observed the Manager and Staff have managed to affect some progress in this area. However, the Manager agrees there is room for further development. In our discussions with Residents and Relatives a number confirmed the home provides a variety of activities and pastimes consistent with meeting their needs. The home encourages and welcomes visitors, and one relative, who is a frequent visitor, commented, … ”They look after my Relative very well, and treat me like an old friend.” The home operates a four weekly menu, giving Service Users a choice of two meals each day for lunch, plus a wider choice if necessary, with the opportunity for drinks and snacks throughout the day. Residents commented to the Inspector how much they enjoyed the food, both the quality and quantity. A particular strength of meals provision is in seeking to provide food to the particular liking of Residents of Asian and Afro-Caribbean origins. Apart from adhoc choices this entails the provision of a hot meal at tea time, four days per week. Feedback on the success of this has been made through Residents’ meetings and Residents also commented to us that not only were the nature/range of this cuisine accurate, it was also cooked properly. The efforts of the chef and catering assistants have been recognised by the recent award of ‘Four Stars’ by the local environmental health department, and is to be commended. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse and of taking appropriate action should it be necessary. EVIDENCE: The Home’s Complaints Procedure is displayed within the entrance to the Home, and up-to-date information advising on how to proceed in making a complaint can be found in the Service Users’ Guide. Procedures are in place regarding Protection of Vulnerable People, Restraint, Aggressive Behaviour and Whistle Blowing. It was noted at a ’Random’ inspection, held in August 2007, that 22 members of staff had not received ‘abuse awareness training’. A review of staff records demonstrated this has now been remedied, and, in addition, arrangements for 5 new members of staff are in hand, via induction, NVQ Level 2 training and in-house video training sessions. Advocacy details are displayed in the corridor by the front door. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 16 Residents and Visitors, consulted during the inspection, confirmed they would have no hesitation in raising any matters of concern with the Manager, and were confident issues raised would be dealt with properly. Since April 2007 the Home has assisted relevant agencies in two adult protection investigations. Whilst the investigations evidenced the allegations not to be as serious as may have been initially implied, the Home has reacted positively by making changes in care practices and to related record keeping. A review of the Complaints Log evidenced a small number of complaints during the past fifteen months – all were recorded and satisfactorily resolved. There were no complaints received by the Commission during this period, and a review of the accidents/incidents log demonstrated nothing to cause concern. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 17 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, 25, & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a safe, if, in many parts, rather worn environment. Whilst some previously noted areas of concern have been addressed there remain various aspects relating to the fabric and décor of the Home, which require attention. Specialist equipment, consistent with meeting the assessed care needs of service users and the demands of tasks carried out by Care Staff, and is appropriately serviced and maintained. The home is clean and there are satisfactory standards of hygiene. EVIDENCE: The tour of the Home demonstrated it offers comfortable, clean, and homely accommodation. There is separate lounge and dining provision, and bedrooms Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 18 were pleasant, comfortable and evidenced Residents bring their own personal possessions into the Home. However, as indicated in the ‘judgement’ above, many areas of the home are looking rather worn. This is recognised by the parent company in that a significant amount of funding has been made available to be spent on redecoration and refurbishment, commencing January 2008. This work will mainly concentrate on redecorating and re-carpeting corridors and communal rooms on all three floors, in addition to improvements in the main entrance area. With regard to bedrooms, as is the current practice, these are repainted as and when they become vacant with, where possible, direct input from the Resident, e.g. colour schemes. Two requirements relating to ‘environment’ were issued at the previous ‘key’ inspection. The first was served as an ‘immediate’ requirement, stating:“The registered person must ensure that the temperatures on the first and second floor are not excessive and that service users are comfortable at all times.” At this inspection ambient temperatures were found to be satisfactory, with the concern mainly relating to the effect of sunshine raising the temperature in communal rooms on one side of the building. It is planned that, as part of the 2008 improvement schedule, air conditioning will be introduced in the communal rooms. In view of these proposals the requirement is considered met. However, it is recommended that, if possible, the air-conditioning provided be of the ‘built-in’ variety rather than stand alone/mobile units. A second requirement was “The registered person must ensure that there is adequate provision of lifting equipment on each floor.” A survey of lifting equipment available on each floor suggested provision is now sufficient to meet care needs of the current resident population. Staff told us that, in their view, they had both “…the right equipment and sufficient of it.” This requirement is considered met. A recommendation was: “The responsible person is recommended to consider fitting a means of protecting doors from damage by the moving of equipment.” Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 19 The Manager stated this had not yet been resolved, but would be addressed as part of redecoration/refurbishment carried out during 2008. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and skill mix are, overall, sufficient to ensure the provision of safe care to Residents. Recruitment procedures are sufficiently robust to ensure that Residents are not placed at risk. Staff receive training, which enables them to be competent to carry out their role in providing safe care to Residents. EVIDENCE: Two requirements relating to staffing were cited at the previous ‘key’ inspection. These were:“The registered manager must review staffing levels to ensure that service users are not waiting for long periods of time for care staff to attend to their needs.” “The manager should seek ways to maintain staff visibility to visitors during peak activity periods for service users.” Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 21 The current staffing rota, plus those from the immediately preceding weeks, were examined and compared to staff numbers on duty at the time of the Inspection. These demonstrated staffing numbers, and skill-mix, enable a service provision, which generally meets the care needs of the Service Users, but with one possible exception. This exception being the level of cover at night, on the two ‘nursing’ floors, where three care assistants are shared over the two floors. Given the levels of dependency in the ‘nursing’ section of the home, we feel there is need to provide facility for the Manager to increase this number to two per floor when necessary. It is recommended that dependency levels of Residents based on the ‘nursing’ floors be surveyed with a view to ensuring appropriate levels of care staff. The second requirement was based on comments by a number of Residents, which suggested that when Residents used their ‘call-bells’ response by staff was sometimes very slow. During this inspection such delays were not apparent and Resident’s and relatives stated that staff were always available in the communal areas and, for those who were in their bedrooms response was good. Staff advised the matter had been discussed at staff meetings, so everyone is regularly reminded of the need to respond without undue delay. Both requirements are considered met. A review of staff personal files, and discussions with staff, provided evidence they receive thorough induction, with mentor support from the Manager, plus foundation training, e.g. moving and handling, first aid, fire safety, food hygiene, infection control, ‘on-going’ training development training, e.g. National Vocational Qualifications, and the Manager undertakes regular ‘supervision’ for each staff member. Some staff training, e.g. core induction, health and safety, food hygiene, is conducted in-house by means of a laptop computer that utilises training software (El Box). Records further demonstrated a very high proportion (87 ) of care staff have attained NVQ Level 2, or higher. With regard to specialist training to meet care needs of Residents with dementia, the parent company has introduced a designated post in which the holder, Mr. Mike Broughton, has responsibility for ensuring staff have appropriate skills in respect of this area of care. Mr. Broughton was visiting the Home at the time of this inspection. During the Inspection numerous incidents of positive inter-action between Staff and Residents were observed. All appeared friendly, professional, and respectful. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is well managed by the Registered Manager and is operationally well organised, with lines of accountability being clearly defined and observed. The ambience is warm, friendly, and inclusive, with the central purpose being ‘the best interests of Residents’. Views of Residents, and other interested parties, are actively sought by the Home, and acted upon. Service Users are safeguarded by the financial procedures operated within the Home. All Staff are subject to effective support with regular supervision, and appeared involved and happy in their work. Health and Safety Policies/Procedures/Practices are satisfactory. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Manager, Mrs Susan Nicholls, is an experienced Registered General Nurse who has attained NVQ Level 4 in Management and Care. Comments from Residents, Staff and Visitors, and our own observations, suggest the Home is currently being very well managed. The management organisational structure of the Home is headed by Mrs. Nicholls who is supported by two unit managers, each of whom have responsibility for one of the two ‘nursing’ floors, plus acting as deputy for the Manager as the need arises. The ground floor (‘residential’) is under day-today management of a senior carer. The Manager is generally supernumerary. Hallmark Healthcare provides an annual service user questionnaire to seek the views of the people who use their services. We reviewed returned questionnaires from the most recent survey and, although final analysis of information is awaited, it was clear the responses are very complimentary about services provided at the Home. The Manager completes regular monthly audits to ensure the home is running in the best interests of the service users. In addition, the Manager holds monthly meetings with Residents, and formal meetings with Staff at least once every three months. Minutes seen demonstrated a range of issues raised, and that a generally satisfactory resolution is achieved through consensus. A requirement cited at the previous ‘key’ inspection in relation to ‘management’ was:“The registered person must ensure that unannounced visits take place at least monthly and forward a copy to the CSCI.” The parent company’s Regional Manager, or the Project Manager, now undertake an unannounced inspection visit at least monthly. Reports of those visits are held at the home, and included detail of tours of the home, review of records (including audit of financial and medicines practices) and interviews with residents, relatives, and staff. This requirement is met. Policies and procedures within the home are regularly reviewed and generally in line with current good practice. Where Residents or relatives request it the home will hold a small sum of money to be used for such items as the weekly hairdresser or other Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 24 incidentals. Examination of related records, and retained amounts of cash, evidenced arrangements to be robust and in order. The home has an ongoing training programme for all staff, which includes mandatory training such as infection control, food hygiene, moving and handling and fire safety. The home is well maintained and all systems such as fire alarms, emergency lighting, gas, and electricity are checked as required with certificates to evidence this. Accidents are reported appropriately and there are risk assessments in place for ensuring safe working practices. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 X 18 3 2 X X 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(1)(b) Requirement The service user’s guide must include information about the range of fees payable so that people can make a fully informed choice about whether or not to use the service. Timescale for action 30/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP12 OP19 OP19 OP27 Good Practice Recommendations It is recommended there be further development in introducing practices to include reluctant service users in social interaction. It is recommended to consider fitting a means of protecting doors from damage by the moving of equipment. It is recommended that air-conditioning provided for communal areas be of the ‘built-in’ variety rather than stand alone/mobile units. It is recommended that dependency levels for residents based on the ‘nursing’ floors be surveyed with a view to ensuring appropriate levels of care staff at all times of the DS0000029398.V352195.R01.S.doc Version 5.2 Page 27 Delves Court Care Home day and night. Delves Court Care Home DS0000029398.V352195.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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