Care Home: Valley Court

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What the care home does well People`s needs are assessed in full before they agree to move into the home. People who answered our surveys told us "we always get the care and support we need", "the staff here are wonderful and nothing is ever too much trouble for them", "I am never rushed by them, they always take their time and give me the support I want". We spoke to some of the people living in the home during this inspection. They told us "staff here are very good". We asked if staff paid particular attention to their dignity and need for privacy. They said, "Oh most definitely they are very caring". We saw staff talking to people in a polite manner and when they were giving assistance to people they did so sensitively and did not rush people.Valley CourtDS0000004829.V376668.R01.S.docVersion 5.2The home has a skill mix of both trained nurses and care workers on duty to meet people`s needs. In addition to the care staff there are housekeeping, kitchen, laundry and maintenance workers all working hard to keep the home running smoothly. One person said "The staff are wonderful there is never anything that is too much trouble". What has improved since the last inspection? The home has improved upon the physical environment. There has been some decoration of the home and more is planned. We saw dining rooms were clean and offered a pleasant place for people to eat their meals. The home has also obtained new crockery and cutlery. Cups, mugs and beakers were much cleaner and were appropriately stored. What the care home could do better: People told us they want to be able to do more activities. They said "we would like to do more". Others said "they try very hard with games and such like". We spoke to staff who told us "we have tried very hard to make it more interesting for people, there have been a couple of outdoor trips and we have more planned. We are going to Worcester and the summer fete". The meals are not as varied as people would like. People said ""the food could be better", "more choice would be better". "The residential side seems to have a better choice than the nursing side". The home needs to continue developing its person centred care planning. It will need to this so people have the individual care they want. Care plans and risk assessments need more detail in them so that staff have complete guidance of how people want their needs met. Key inspection report CARE HOMES FOR OLDER PEOPLE Valley Court Valley Road Cradley Heath West Midlands B64 7LT Lead Inspector Mandy Beck Key Unannounced Inspection 28th July 2009 09:00 DS0000004829.V376668.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valley Court Address Valley Road Cradley Heath West Midlands B64 7LT 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) 01384 411 477 01384 411470 Pepperhall Limited Joan Green Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (69) of places Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) 69 The maximum number of service users who can be accommodated is: 69 8th August 2008 Date of last inspection Brief Description of the Service: Valley Court provides both personal and nursing care to the people who live there. The home is located within easy reach of main routes between Halesowen, Cradley Heath and Dudley with public transport and local amenities easily accessible. It is situated next to a primary school, with a shared driveway. There is ample car parking to the front of the Home and gardens and patio areas to the rear. The Home is separated into two units, one dedicated to Residential Care, the other to Nursing Care. Shared facilities include the kitchen and laundry. People’s accommodation is provided on two floors. All bedrooms are single and the majority of them have en-suite facilities. There are lounges and dining rooms on both units. The home currently has a range of bathing facilities, a nurse call system, passenger lifts and some disabled facilities. Fees vary between £364 to £520 for personal care and £471.66 to £650 for nursing care. The following are not included in the fee: non NHS Chiropody, hairdressing, toiletries, telephone calls and some activities. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the home. • Information we have about how the home has managed any complaints. • What the home has told us about things that have happened in the home, these are called “notification” and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations • We also spent time talking to the people who use the service and to the staff who support them. • We looked at the care of two people who use this service in depth. This is part of our case tracking process and helps us make judgements about the home’s abilities to meet people’s needs. • An expert by experience was also present for part of this inspection. An “expert by experience” is a person who, because of their shared experience of using services visits a home with an inspector to help them get a picture of what it is like to live in or use the service. What the service does well: People’s needs are assessed in full before they agree to move into the home. People who answered our surveys told us “we always get the care and support we need”, “the staff here are wonderful and nothing is ever too much trouble for them”, “I am never rushed by them, they always take their time and give me the support I want”. We spoke to some of the people living in the home during this inspection. They told us “staff here are very good”. We asked if staff paid particular attention to their dignity and need for privacy. They said, “Oh most definitely they are very caring”. We saw staff talking to people in a polite manner and when they were giving assistance to people they did so sensitively and did not rush people. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 6 The home has a skill mix of both trained nurses and care workers on duty to meet people’s needs. In addition to the care staff there are housekeeping, kitchen, laundry and maintenance workers all working hard to keep the home running smoothly. One person said “The staff are wonderful there is never anything that is too much trouble”. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Valley Court DS0000004829.V376668.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 Valley Court DS0000004829.V376668.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given all of the information they will need in order to make a choice about living in this home. They can feel confident their needs will be assessed in full prior to admission. EVIDENCE: The home has both a Statement of Purpose and Service User Guide that give people all of the information they will need to know about the service the home provides. It includes the range of fees people are expected to pay and the additional extras that will not be included in the weekly fee. Before people agree to move into the home the manager will spend time with them completing an assessment of their needs. This is done to make sure the home is able to meet people’s needs and that it will be the right place for Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 9 them. We looked at the needs assessments of four people during this inspection and found that each one had been completed and provided a sound basis for staff to be able to plan care for people. People choosing to live here are given ample opportunity to sample the service before they agree to move in. We were told that people are encouraged to spend time in the home on trial visits. One person told us “I had been to several places but chose this one”. The home does not provide intermediate care facilities at this time. Valley Court DS0000004829.V376668.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home have the assistance they need in order to meet their personal and healthcare needs. Medication practices are good and mean that people have their medication as prescribed. EVIDENCE: We looked at the care records of four people during this inspection. This is part of our case tracking process. We found that each person had their own individual plan of care. The home has taken time to sit with people to discuss their needs and preferences and as a result care plans have been tailored to individual need. The home makes sure that each person is assessed for their risk of developing pressure sores, being malnourished and falls. Where risks are highlighted the home completes a risk management plan and records what action they will Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 11 take to reduce the risks to people. All care plans are kept under regular review and are updated to reflect any change in a person’s condition. We have made recommendations that moving and handling risk assessments are updated to include the type of hoist and sling so that staff can be sure of the equipment they need to use when moving people. We have also recommended that some care plans have additional information. For example we looked at the care plan for one person who has a tube feed. The care plan included the feeding regime but no information about cleaning the tube insertion site or how to make sure the person is in the right position whilst being fed. We discussed this with the staff and manager during the inspection and these recommendations will be actioned. People who answered our surveys told us “we always get the care and support we need”, “the staff here are wonderful and nothing is ever too much trouble for them”, “I am never rushed by them, they always take their time and give me the support I want”. We spent time talking to staff during this inspection and they were able to give us a detailed account of people’s needs and the support they wanted. They told us “We are told by the nurses who needs what care but most of the time it’s nice to sit with the resident and ask them”. The home is also supported by community services such as doctors, psychiatrists and community mental health nurses. People also have access to dentists, chiropodists and opticians, as they need it. People told us “if I feel under the weather there is no hesitation in calling for the doctor”. We looked at the systems in place for the ordering, safe storage and administration of medication. We found the home has good systems in place and medication is administered as the doctor has prescribed it. There are safe systems in place for the storage and administration of controlled drugs. We spoke to some of the people living in the home during this inspection. They told us “staff here are very good”. We asked if staff paid particular attention to their dignity and need for privacy. They said, “Oh most definitely they are very caring”. We saw staff talking to people in a polite manner and when they were giving assistance to people they did so sensitively and did not rush people. We saw that the home is making progress with the end of life care planning for people. One person’s care plan we saw was comprehensively completed and guided staff so that the person could be sure their needs would be met in the final days of their life. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by the home to take part in some activities. People are not satisfied with the meals on offer but arrangements are being made to improve this. EVIDENCE: People we spoke to during this inspection said “we would like to do more”. Others said “they try very hard with games and such like”. We spoke to staff who told us “we have tried very hard to make it more interesting for people, there have been a couple of outdoor trips and we have more planned. We are going to Worcester and the summer fete”. Our expert spoke with people and concluded “there was a variety of activities offered by Valley Court including Crafts; Bingo; Games among many others. One person said that she did not participate in the in-house games but preferred to interact with her local community especially with her church and Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 13 their weekly activities. ‘I don’t join them but my friends pick me up and drop me off for Church activities.” The same person also thought it would be a great idea if there could be a ride to the park so they can get an opportunity to explore the beautiful neighbouring park. We were also able to speak to one of the activities co-ordinator who was keen to show us some of the crafts that people had made. The crafts were sold and generated income for the home’s “resident fund”. People are encouraged to have visitors when they like. We saw plenty of people visiting throughout this inspection. One visitor said “I am very satisfied with the care but sometimes I think the home could be a bit brighter”. We saw some people’s bedrooms as part of our case tracking process. We saw that each person had taken the opportunity to decorate their rooms with their own person belongings in some cases. The manager also told us the home is slowly replacing bed linen and bedspreads so that there is a more coordinated feel to the home. People who responded to our surveys told us they would most like to improve the standards of the meals in the home. They said “the food could be better”, “more choice would be better”. “The residential side seems to have a better choice than the nursing side”. We had the opportunity to have a meal with some people during this inspection. We found that each person was offered at least two choices for lunch and dessert. Everyone finished their meals. People told us “the food is ok”, “it’s not like being at home is it”. We discussed these comments with the manager. The manager told us that she had already planned a meeting with all the people living in the home to discuss what could be done about the meals and the current menu system. This was due to happen in the near future. The dining rooms were all pleasantly decorated and were clean. This was an improvement upon our last inspection. The manager also told us that new crockery and cutlery had been supplied. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service should feel confident their views would be listened to and acted upon. Staff have the knowledge and skills to keep people free from harm and abuse. EVIDENCE: The home has a complaints policy that is available to all people. A copy of the complaints policy is in the service user guide and in each person’s bedroom. Since the last inspection in August 2008 there have been no complaints recorded. The manager told us that she is always there to talk through any concerns that people have and will always act upon them. The commission has not been made aware of any concerns about the home. Those people who answered our surveys told us “I would always speak to the nurse in charge” and “I know who to speak to I needed to make a complaint. I wouldn’t hesitate the manager and the staff always try and smooth things out for us”. One person has told us “I am not happy that at times some of my concerns appear not to be taken seriously”. These comments were bought to the manager’s attention. People who responded to our survey said “At times it feels as though no one is listening”, “I know that the home will always try to sort out the smallest of problems”. The manager told us that she is aware of Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 15 them and will be addressing them as part of the action plan following a recent satisfaction survey conducted in the home. The home has policies in place for dealing with allegations of abuse and keeping people safe from harm. We call this safeguarding vulnerable adults. We spoke to staff about this. All of the staff we spoke to were able to tell us what different types of abuse there were and how they would recognise the signs of abuse. Generally most of the staff knew who to refer to if an allegation was made to them or they had witnessed an act of abuse. The manager of the home understands what is expected of her in relation to reporting of incidents and allegations to the safeguarding team. The home does use bed rails for some people in order to keep them safe whilst in bed. We looked at the risk assessment for their use and have recommended a more comprehensive risk assessment should be obtained by the home in order to fully address the risk to the person using bed rails. This will offer added protection to them. We looked at recruitment practices and found the home is taking steps to prevent unsuitable people from working with vulnerable adults. This includes required checks against the Protection of Vulnerable Adults list (PoVA) and a Criminal Records Bureau disclosure (CRB). Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well maintained and clean home. People can be assured that will have access to appropriate equipment in order to meet their needs. EVIDENCE: The premises are clean and free from any offensive odours. We did take time to look around the premises during our inspection. We saw that people are encouraged to make their rooms their own by bringing in their own possessions from home. One person said “My bedroom is lovely I tidy it sometimes myself”. During our last inspection we raised concerns about the general cleanliness of the home and the equipment in use. It was pleasing to see this time that this Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 17 has been addressed. We saw dining rooms were clean and offered a pleasant place for people to eat their meals. The home has also obtained new crockery and cutlery. Cups, mugs and beakers were much cleaner and were appropriately stored. People spoken with were mostly happy with the cleanliness of the home, especially with reference to their own bedrooms. One person told us “I am unhappy with the cleanliness of the windows inside I don’t feel they have been cleaned for some time”. The manager was aware of this persons view and is taking steps to address their concerns. Several bedrooms, including bedroom of the people involved in case tracking, were viewed. Rooms were comfortable, cosy and well decorated. Most bedrooms have en suite facilities. People had taken the opportunity to bring in personal items, for example small pieces of furniture, pictures and ornaments. One person also commented “the nursing unit always seems as though it is not given the attention to detail the residential unit gets, it always looks much cleaner and tidier”. During our last visit we saw that thermometers were not available in all bathrooms for staff to use. The use of thermometers allow staff to check the temperature of the bath before use and make sure that the risk of scalds has been reduced. We noted during this inspection that this has now been addressed. The home has also purchased more profiling beds for people’s added comfort and safety. People we case tracked had all of the equipment they needed to keep them safe and to meet their needs. The home has a good sized garden. It has been designed to offer some sensory stimulation for people and a relaxing place to sit and enjoy the surroundings. Staff have had training in infection control and throughout the premises each toilet and bathroom had hand washing facilities with liquid soap and paper towels. Staff also said they had access to plastic aprons and gloves when they needed to assist people with personal care. All of these measures will help reduce the risk of cross infection to the people living here. Since our last inspection the cleanliness in the sluice area has improved. The home has also put key pad locks on the door for people’s added protection. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are appropriate numbers of staff on duty to meet people’s needs. Staff are trained and have the knowledge and understanding to meet people’s needs. EVIDENCE: The home has a skill mix of both trained nurses and care workers on duty to meet people’s needs. In addition to the care staff there are housekeeping, kitchen, laundry and maintenance workers all working hard to keep the home running smoothly. One person said “The staff are wonderful there is never anything that is too much trouble”. The home supports all care staff through training in National Vocational Qualifications. Staff we spoke to confirmed that they had completed both their level 2 and 3 NVQ training in Health and Social Care. This means that staff have the knowledge and understanding to be able to meet the people’s needs who live in the home. We looked at the recruitment processes in the home. We saw the staff files of four people. All of them contained the required information and security Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 19 checks such as previously mentioned Protection of Vulnerable Adults (PoVA)first, and CRB’s. This means the home has systems in place to prevent unsuitable people from working with vulnerable adults. We looked at the training records for some staff; the home has supplied us with information of training that has been arranged. It is clear that staff will be trained as required. We spoke to several staff on duty during the inspection who confirmed they regularly take part in training and keep their knowledge and skills up to date. New workers are supported through an induction that meets the Skills for Care common induction standards. This induction will provide staff with the basic skills needed for completed their NVQ training. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed well. The manager is aware of the home’s shortfalls and is addressing them. People will be consulted about the service they receive and the home will respond to their views. EVIDENCE: There has been no change in the management of the home since our last inspection. People who responded to our surveys told us “the matron is very good, she can sort things out”, “sometimes I wish the management were more visible so that I could talk to them”. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 21 The home’s Quality Assurance file contained evidence that audits are carried out on the services provided in the home and identifies areas for improvement. We looked at some of the comments people had provided as a result of the home’s most recent surveys. Generally they were very positive. Most people were happy with the way in which they received their care and the way staff carry on their work. Most of people’s concerns were around the home’s activity schedule and the decoration of the home itself. The home is currently in the process of providing an action plan to address the issues raised as a result of these surveys. The home’s Annual Quality Assurance Assessment (AQAA) was received on time and gave us a realistic picture of the service the home provides. It also shows us the home is continuing to plan for improvement of the home over the next twelve months. In addition to surveying the people living in the home the manager also completes monthly audits of accidents and incidents, care plans and the environment. This allows the home to identify problems earlier and to take action to prevent further problems occurring. We also spent time talking to the manager about her role and responsibility in understanding the principles and practice of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Both the manager and deputy manager have received training in this area and understand their role in making applications to the appropriate authority should they feel that people’s liberty is being deprived. The manager also told us there are further plans to arrange training for all staff. The service takes charge of some personal monies on behalf of people who use the service. The monies are kept securely and written records are kept of all transactions. An audit takes place each day. A random sample of the monies and accompanying records were seen during our inspection and there were no discrepancies. Staff training in ongoing, recent training has included moving and handling and fire safety. Training is completed at least yearly and this gives staff a chance to keep their knowledge up to date and make sure that people’s safety is promoted. There is a Fire Risk Assessment in place and a fire drill takes place at least every six months. The Fire Alarms must be tested each week (a test took place during our inspection). The Emergency Lights are tested on a monthly basis and records were seen to verify this. Records were seen to verify the regular servicing and maintenance of various systems, including: the emergency lighting system, the gas system and boiler, the hoists, the lift, the electricity system and all electrical equipment. The water system is regularly tested for legionella and the tanks disinfected. The water temperatures at outlets accessible to service users is tested regularly and recorded. There are Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 22 policies and risk assessments in place with regard to safe working practices. Staff receive training in safe working practice topics during their induction. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 23 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 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 X 3 X 3 X X 3 Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The home should include the type of hoist and size of sling in all moving and handling risk assessments. This is so staff will be clear about the equipment they will need to use for each person. The home should include further information in the care plans for those people who required PEG feeding. This should include care of the PEG insertion site and correct positions for feeding. This is so people are not place at risk by incorrect action by staff. The home should seek confirmation from the supplying pharmacist about the suitability of medications being passed through the PEG tube. This should be clearly documented in the person’s care plan. The home needs to take into consideration people’s DS0000004829.V376668.R01.S.doc Version 5.2 Page 25 2 OP8 3 OP9 4 OP19 Valley Court 5 6 OP38 OP38 comments about the home environment and take action to address them. The home should consider the use of a more detailed bed rail risk assessment for people needing this type of restraint. The home should consider further training in bed rail safety for all its staff by accessing the Health and Safety Executive website and bed rail training. Valley Court DS0000004829.V376668.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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