Care Home: Drake House

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What the care home does well The home is well managed by the Administration and Clinical Manager. They collectively produce good records as evidence of the work that is undertaken of the service users and the business management. The staff are well trained and provided with suitable equipment to carry out their duties safely and to the benefit of the service users. The assessment of each service user prior to admission and on a routine basis is of a good standard and any risks to their health are recorded and action taken to reduce them. The home is generally very nicely decorated in a homely way. Service users bedrooms are individualised and look very comfortable. The relationship between the home, the service users and their relatives/advocates is relaxed and nurtures good communication. What has improved since the last inspection? The management of the home has now been decided and is working well. The two roles, business management and clinical management are clearly defined and the two individuals work well together. Risk assessments have been further improved with the addition of a new process for assessing the need for bed guards. The home now has in place experienced trainers to deliver training on the subject of Protection of Vulnerable Adults. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Drake House 4 Nelson Gardens Stoke Plymouth Devon PL1 5RH Lead Inspector Doug Endean Announced Inspection 27th February 2007 9:45 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 Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drake House Address 4 Nelson Gardens Stoke Plymouth Devon PL1 5RH 01752 551859 01752 564525 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) www.drakenursinghome.co.uk Mr George Marshall Vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (32) Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered for max 32 DE(E) service users 65 years and over Registered for max 32 MD(E) service users 65 years and over The home may from time to time admit persons between the ages of 60 to 65 years of age. 18th November 2005 Date of last inspection Brief Description of the Service: Drake House Nursing Home is situated in Stoke, a suburb of the City of Plymouth, which is a short distance away by road. It is a large semi-detached property built on four floors with a large enclosed garden at the rear. Nelson Gardens is a private road that offers some parking at the front of this building accessed directly from the road. The Service Users accommodation is provided on each of the first three floors that are accessed by stairs or the four-person shaft lift, which runs up through the centre of the home. The forth floor has a staffroom that is accessed only by a staircase. The property has been totally refurbished over the past few years by the present owner to provide clean, well-decorated and adapted accommodation for the Service Users who live there. The rear garden is accessed either from the lounge or by level paths from the side entrance of the home. It offers a level, safe space, for the Service Users to sit in during good weather. The home is registered to provide nursing care for up to thirty-two (32) service users over the age of sixty-five (65) years, of either sex, who suffer from a mental illness or dementia. They may also admit from time to time, individuals between the ages of 60 to 65 years who suffer from dementia. The only restriction that the home has regarding admissions are those placed upon it by the category of registration. The bedroom accommodation is provided in a variety of single and double rooms. The home does not have a Registered Manager at present, but the Home Manager and Clinical Manager successfully manage the establishment using their individual professional skills. The fees commence at £433 and increase dependent upon the individually assessed needs of the service users. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 27th February 2007 and began at 09:45 hours. The inspection lasted approximately 6 hours and included a full tour of the home, discussion with three staff members and two relatives visiting the home. The inspector also spoke with the management team including the Registered Person. The inspector sampled various maintenance records, three staff files and the records of three service users who were case tracked. One comment card was received from a General Practitioner. No comment cards have been received from staff or relatives. The manager did provide the inspector with a fully completed pre-inspection form. What the service does well: What has improved since the last inspection? What they could do better: The passage of time is having its effect on some of the communal areas. Although the décor is good in the lounge, dining room and foyer the carpets have suffered. They have received cleaning but this is now obviously not Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 6 effective due to the damage to the carpet by wear and tear. These carpets should be changed. Also in the lounge several chairs are looking aged and one has had a poor quality repair. These chairs should be replaced. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Drake House DS0000003584.V326822.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 Drake House DS0000003584.V326822.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): The homes performance was assessed against Standard 1 and 3. Standard 6 does not apply. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The information that is available about the home and the services offered to prospective service users and their advocates is excellent. The comprehensive information gathered by the home to enable them to make a decision on the suitability of an admission is excellent. EVIDENCE: The home has a Statement of Purpose that is well prepared and available to anyone who wishes to have a copy. It is displayed in the front entrance of the home along with other information that includes a copy of the last inspection report and the complaints procedure and complaints book. The inspector read this book during the inspection. There is a laminated brochure that introduces service users or their advocates to the home, the conditions of residency (including fees), information on staffing and also the complaints procedure in a Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 9 concise format. It also provides the date of the last Commission for Social Care Inspection report, and where the report is located in the home so that it can be read. The home also has a web site that is presently being further developed. The Home Managers office is also just inside the front door, in front of the signing in books, which visitor’s used as they entered the home. The main notice board also provides information to visitors regarding the use of the alcohol gel that is provided, the management structure of the home, the registration certificates, Registered Nursing Homes Association Membership details, and the public liability insurance. The information held in the Statement of Purpose and other material should provide any prospective client, or their advocate, with enough information to make an informed decision about arranging a stay at the home. The only restriction the home has regarding admission is that they must fall within the categories of registration. The home does not otherwise discriminate on grounds of disability, age, race or beliefs. The care files of three service users were read in detail and used in the care tracking process. The files held information that was collected by the Clinical Manager or another nurse as a pre-admission assessment. The information included details of the service users mental health history and behaviour, general health status, and information on nutritional needs, mobility, continence, etc. From this information the home were able to make an informed decision about the suitability of each admission. In addition to this a National Health Services determination assessment is also undertaken on all service users as nursing care is provided. Drake House DS0000003584.V326822.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): The homes performance was assessed against Standard 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans are very good and well supported by the evidence found in the risk assessments. The arrangements for treatments and medication are satisfactory. The staff have a good approach towards the service users that enabled them to provide care whilst maintaining their dignity. EVIDENCE: The notes of three service users were read as part of the case tracking process. The care plans were well structured and presented in a clear format for easy reading. There was evidence of risk assessments that covered many issues and their outcomes were then incorporated into care plans. The risk assessments included such things as the use of bed guards, mobility, wheel chair assessment, use of hoists, incontinence, tissue viability, and behaviour. The clinical Manager explained during the inspection how the home has Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 11 updated the assessment of service users and managed the use of bed guards better. Where bed guards were in use they also had protective cushioning around the guards. Individual sheets were used for each part of the care plan. Each of these sheets had evidence of the date that they had been reviewed by a registered nurse. There is day care planning and also nighttime care plans as the home recognises that service users needs may be different at night especially, such as during period of physical illness. The notes also provided evidence that the nutritional needs of the service users are assessed and that this information is subsequently passed onto the cook so that meals are prepared in a manner that the service users can manage themselves or whilst being supervised. Evidence of the suitability was noted during the main meal that was served in the dining room and seen by the inspector. Monthly weights are taken and the records seen in the service users files. The way this information is used was demonstrated by the Clinical Manager for one of the service users who was being case tracked. The service users were not able to provide the inspector with reliable information about the care they receive due to their illness. However the inspector did observe the staff who were caring for them particularly during the main meal. The service users looked suitably dressed, clean and well cared for at that time. The staff approached the service users in a manner that was respectful and looked to be acceptable to them. Personal care was also provided in the privacy of their own rooms or the bathroom. Each of the service users has a key worker whose responsibility it is to keep up to date about the service user and establish that their care needs have been met even though they may not have provided them themselves. One General Practitioner comment card was received that gave a positive response to each question asked. The home uses the resources of the National Health Services and Social Services to maintain the health of the service users by facilitating consultations with them when necessary. All the service users are registered with a General Practitioner. A General Practitioner from the local surgery has an interest in the speciality. This General Practitioner calls at the home on a regular basis and when needed to provide advice and support. The Community Psychiatric Nurse service also make themselves available for advice should the home request it. The provider recently withdrew the homes dental services. The home manager has made alternative temporary arrangements until a more permanent service can be arranged. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 12 The inspector looked at how the registered nurses manage the treatments and medication for the service users. The treatment room is locked and the registered nurse on duty holds the keys. Medications are stored in either a locked purpose built cabinet or the locked medicine trolley that is also tethered to the wall by a cable. The medication charts held information about the current medication given to service users. The staff were recording the use of medication correctly and there are specimen signatures of the staff who administer medications. To improve service user identification and the administration process, the charts held a photograph of the service user. The medicine fridge temperatures are recorded weekly, the inspector saw this record. There was also a copy of the last pharmacist inspection report that was provided for the inspector to read and was found to be satisfactory. Drake House DS0000003584.V326822.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): The homes performance was assessed against Standard 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and generally attractive environment for the service users to live. The activities are suitable in type and duration for the service users. The information gathered about the service users nutritional needs is good and they provide nutritionally balanced meals. The home treats the service users as individuals whilst meeting the collective needs of everyone. EVIDENCE: During the ongoing assessment of the service users their social, religious, cultural and recreational interests are identified. This information is gathered form the service users and also their relatives and was seen in the re4cords read by the inspector. This information is then transferred into the activities/social care plan and examples were read. The home endeavours to provide activities that will then meet the collective interests of the service users for recreational and therapeutic purposes. There are a small number of Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 14 service users who have individual visits from the church to satisfy their religious beliefs. The home manager drew the inspector’s attention to the large notice board in the foyer of the home that has displayed the activities that are planed for each day of the week. The activities that are offered were also provided in the preinspection questionnaire that had been prepared for this unannounced inspection. These included visits from a theatre group twice yearly, which is reported to be very well received by the residents. Other activities are music, indoor skittles, chair games, painting and colouring, and watching films. The home has also introduced a session of “sandwich making” that was said to be enjoyed by the service users. There was photographic evidence of some activities including the Christmas party. There are no restrictions to visiting at the home. The inspector met and spoke with two visitors who are regular daily attendees to the home. Both had a good rapport with the staff and both gave very good accounts of the care that their relatives receive. They were more than happy with the choice of home and the care given by the staff. Each knew who to speak to if they had any concerns. The home does not manage the affairs of any of the service users. Any purchases for the service users that are not included in the fees will be invoiced to the appropriate person for payment. The home employs a part time Financial Administrator for this purpose. The service users are able to bring their own possessions into the home and this was evident during the tour of the home when the inspector saw how private bedrooms were decorated with personal possessions. The home does what it can to make safe these possessions. Each of the service users has a nutritional assessment that is regularly reviewed. The monthly weight of the service users also provides valuable information about the nutritional status of the service users. Special diets and dietary wishes are met by the home. The kitchen is managed by a cook for 10 hours each day and a kitchen assistant who works 6 hours each day. Meals are prepared fresh each day using the menus as a guide. The home has recently changed the menus to offer a wider choice of food to the service users. These menus were read and appeared to be offering a good variety of meals on a rotational basis over four weeks. The meal offered to service users on the day of the inspection was well presented and of sufficient portions although several service users stated they did not like the sausages that were served. Staff were busy during the main mealtime assisting those service users who needed help to eat and supervising others who were easily distracted from their food. The meal was eaten in a clam and unhurried way with service users either seated in the dining room or in supportive lounge chairs. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 15 The kitchen has its “Safer food, better business” checks in place that were established by the management. One kitchen person is to undergo this standard of training. The kitchen assistant is now to have food handling training. The home has recently had a Environmental Health Inspection (16/11/06) that was satisfactory. The inspector was told that the gas cooker does need servicing, as the oven requires to be lit manually. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and well displayed. The actions taken to help prevent abuse, such as training, are good. EVIDENCE: At the entrance to the home there is a copy of the Statement of Purpose that has a copy of the complaints procedure in it. There is also a laminated brochure for service users or their advocates to take away. This holds information about the home, the staffing, and the terms of residency. It also has a copy of the complaints procedure. Two visitors were asked if they knew how to bring a complaint to the attention of the home. Each were clear about how they would complain should they need to but both remarked that they had always been more than satisfied with the services provided by the home. The complaints and compliments book is inside the front entrance to the home. There is a table and chair for visitors to sit at to read this book and to record any information, including a complaint. The book is read at least weekly as part of the homes quality assurance arrangements. The inspector looked at this book and found it to contain many written cards complimenting the care they give. There were no complaints written and the Commission for Social Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 17 Care Inspection has not dealt with a complaint about this home since the last inspection. The homes recruitment process is satisfactory and provides the service users with a degree of security from unsuitable persons working in the home. They also have a program of staff “Protection of Vulnerable Adults” training. The subject introduced during the induction, and taught during the National Vocational Qualification training in care that staff attends. The home also employs external trainers to deliver vulnerable adults training. All staff are involved in this training not just those who work in direct care. Evidence of this training was provided to the inspector in staff files and in the pre-inspection form. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 19, 20, 21, 23, 24, 25 and 26. 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 cared for and is decorated to a high standard. It provides a warm comfortable environment for the service users to live in. The main communal areas suffer visually from the poor state of the carpets and some lounge chairs. EVIDENCE: The home is located in a quiet residential street that does not have through traffic. There is some parking opposite the front entrance and some street parking. Entrance is via a couple of steps up into the front foyer, where the Managers office can be found, and then a small number of steps up into the main part of the home. There is disabled access also. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 19 An inspection of the premise showed it to be generally very well decorated, clean and odour free. Service users bedrooms were individually furnished with their own possessions where they had brought them to the home. Some have had new carpets laid recently. The majority of beds are now height adjustable and pressure relief mattresses were provided where the assessment had called for them. New bed guards were only in place where the risk assessment had called for them, and security padding was also in place. Evidence of these assessments was in the service users files. The radiators through out the home have been provided with guards to protect the service users and staff from hot surfaces. Sinks in service users rooms and bathrooms had thermostatic restrictor valves in place. A quiet room has been developed on the ground floor and is used for the service users who may be in needs of less stimulation. It is also used for meetings. The nurse call system is in every room that service users have access to. The inspector tested the system, and the staff responded very quickly to the alarm call. The home has a variety of bathing facilities that included disabled bathing facilities and wet rooms (shower room). There are sufficient disabled toilet facilities outside of bedrooms and also located near the dining and lounge room. The dining room had new dining furniture that was of good size and construction offering space and support to the service users. The lounge room was nicely decorated. Unfortunately the passage of time and inevitable result of food being spilt on carpets has had its toll. There was evidence that the carpets in the foyer, dining room and lounge had been cleaned on many occasions. However, this has resulted in the carpet in the front entrance now showing signs of stretching, which may become a hazard to the mobile service users. The dining room and lounge carpet looked in poor condition and need to be replaced. Some of the lounge chairs are also now showing signs of excessive wear and should be replaced with suitable seating. The home has its own laundry that is away from any food storage or preparation area. It is supplied with two modern washing machines that each have a sluicing cycle. There are also two dryers. A full time laundry lady is employed by the home. The collection of soiled waste was noted have changed since the last inspection. It was not practical from an infection control perspective as items were just placed in a swing lid container and not inside a yellow bag. They were also left on the landings for some time after being placed in the bins as the inspection of the premises was carried out during the late morning/early afternoon and they had not been removed. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 20 The home does have suitable sluicing arrangements for bodily waste. There is level access to the rear garden that provides well cared for surrounds for the service users to enjoy in good weather. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment process is good and staff files support this. There are sufficient numbers of staff employed each day that are suitably trained to meet the service users needs. EVIDENCE: The inspector looked at the evidence relating to how the home is staffed (current rota’s) and felt that there are adequate arrangements for the care of the clients and also the management of the ancillary tasks at the home. There is always a registered nurse on duty over the 24-hour day supported by 7 care staff in the morning, and six care staff in the afternoon. A twilight care assistant works until 23:30 hours with the two other care staff and the registered nurse on night shift. The ancillary team includes one person working in the laundry seven days a week, two domestic staff on weekdays and one at weekends. A cook and one assistant staff the kitchen each day. In addition to this there is the Home Manager and the Office Financial Administrator. Either the Registered Person, who is a builder, or a suitably skilled contractor carries out maintenance. Collectively the home employs individuals in sufficient numbers who have the skills to meet the needs of the service users and maintain the premises. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 22 The registered nurses have evidence of their qualification and current registration in their files. The home employs both psychiatric and general trained nurses and the care team is led by the Clinical Manager who is a Registered Mental Health Nurse with many years experience. The Manager demonstrated how the staff has achieved greater than 50 of the staff National Vocational Qualification, level 2 or above. She also provided information in the pre-inspection form of all training undertaken during 2006 and that, which is planned for 2007. The staff has training in Dementia care, as it is primarily caring for service users who suffer from dementia. Other training has included Health & Safety, Protection of Vulnerable Adults, moving and handling and fire. A sample of staff files were reads by the inspector. The recruitment procedure was discussed and the files showed evidence that the procedure is followed. Files had application forms, Criminal Record Bureau checks, two references on the homes own format, training information, proof of identity, etc. There were also copies of the contract of employment and job descriptions in the files. Three staff members were spoken to during the admission who represents different areas of the service. One care assistant has worked in the home for a considerable period of time and made very positive remarks about the present management of the home and the good working atmosphere. She felt that she had received sufficient training that enables her to do her job proficiently. The home does employ a formal training provider for all staff who facilitates the induction training beyond that which the home carries out when a new member of staff begins working at the home. The training that follows does instruct the staff in ways to meet the service users needs safely. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Management arrangements are very good and have resulted in efficient administration of the home and efficient care planning and delivery. EVIDENCE: The home has no Registered Manager at present. However the person in that role has the necessary qualifications and will be submitting a completed application form to the Commission for Social Care Inspection. Although this person is not a nurse she does have care and management experience and has worked at this home for several years. The staff care team is led by a Clinical Manager who is an experienced Mental Health Nurse. The two managers work Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 24 well together as a team so that the home does achieve all of its aims and objectives. They have clear boundaries to their responsibilities and are accountable for their practice. The outcome of this method of management of the home is very good. The homes records are well structured both on the administration/financial/maintenance side and also the care side. The inspector was given examples of the way the home carries out its quality assurance that began with talking to the service users relatives each time they entered the home. They also provided evidence of the results of anonymous questionnaires that have been completed by the service users relatives and advocates. The response rate is recorded in the report that has been completed along with comments that were made by relatives such as, “Staff helpful and kind; confident that the care available is being provided; tactful and professional when dealing with sensitive issues” and, “Incredibly friendly and well run; courteous and good humoured staff”. Service Users do not handle their own money, as they are not able to as a result of their condition. The home does not manage the affairs of any of the service users. The Office Manager showed how client’s money is handled. The inspector saw evidence of bank accounts for client’s money to be held securely in and a trail of records that showed how money that is spent is recorded and backed up with receipts. Drake House DS0000003584.V326822.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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 3 3 X 4 3 3 2 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 4 X 3 X 3 X X 3 Drake House DS0000003584.V326822.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 OP19 Regulation 23(2)(d) Timescale for action All parts of the home should be 30/06/07 kept clean. The carpets in the ground floor communal areas need to be replaced as they are heavily stained despite cleaning. Provide adequate furniture in 30/06/07 rooms occupied by service users. Some lounge chairs need to be replaced. Requirement 2 OP20 16(2)(c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP31 Good Practice Recommendations The Manager should submit her Registered Manager application form as soon as possible. Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Drake House DS0000003584.V326822.R01.S.doc Version 5.2 Page 28 - 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. 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