CARE HOMES FOR OLDER PEOPLE
Drayton House 50 West Allington Bridport Dorset DT6 5BH Lead Inspector
Sally Murphy Unannounced Inspection 15th January 2009 11:15 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 Drayton House DS0000036054.V373854.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. Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Drayton House Address 50 West Allington Bridport Dorset DT6 5BH 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) 01308 422835 01308 422835 Miss Andrea Helen Quirk Mrs Isabella Fitzgerald, Mr John Stanley Pitcher, Mrs Mary Josephine Pitcher Manager post vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. That four persons may be accommodated within the category DE(E). Date of last inspection 16th July 2008 Brief Description of the Service: Drayton House is registered to provide personal care for a maximum of 19 older people including up to four with dementia. The accommodation is on the ground and first floors with a small passenger lift serving both floors. Seven of the thirteen single bedrooms have en-suite hygiene facilities and there are 3 larger rooms that may be used to accommodate 2 residents who have made a positive choice to share with each other. None of the shared use rooms have en suite facilities; all bedrooms have a wash hand basin. Communal facilities include two lounges, a small dining room and 3 bathrooms including two for assisted use. Drayton House is within walking distance of Bridport town centre with its shops and services. There is space at the front of the house to park two cars; parking is not permitted in the road in front of Drayton House. Behind the house is a steep raised garden accessible only by steps and therefore rarely used by residents of the home. There is a small patio at the side of the house accessible via patio doors from the rear lounge. Laundering of clothing and household linen is carried out at the home and arrangements can be made for chiropodists, opticians and other health and social care professionals to visit individual residents. At the time of this inspection fees ranged between £473 and £500 each week. Drayton House DS0000036054.V373854.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 1 star. This means the people who use this service experience adequate quality outcomes
This inspection was unannounced and was completed by one inspector over one day. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. During the course of the inspection we (the Commission) spent time with the Registered Manager, staff and people living at the home. Records relating to people, staff members and health and safety were examined, and a tour of the building was completed. Prior to the inspection comment cards (surveys) were sent to people living at the home, staff members, and health care professionals. Fourteen surveys were returned in total and information from these have been included within the report. All of the requirements made at the last key inspection have been met, and a further six made at this key inspection. Seven of the recommendations have been fully met. Two have been partially met and one further recommendation made. The Manager and staff were helpful and welcoming throughout the inspection. We would like to thank the people living at the home, manager and staff members for the assistance during this visit. What the service does well:
People spoken with during the inspection stated that it was ‘very nice here’ and that staff are ‘nice and helpful’. One person said ‘most of the staff are excellent’. The home ensures that pre-admission assessments are completed prior to anyone moving into the home to ensure that they are able to meet people’s assessed needs. Staff are provided with appropriate training, and work with senior staff prior to giving medication. Medication records include information regarding why each
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 6 medication is required and there is appropriate guidance for staff relating to the application of creams. People living at the home are able to participate in a range of activities that are appropriate to their interests and needs. People spoken with during the inspection stated that the enjoyed the meals provided. They confirmed that the Cook has a good knowledge of their dietary needs and preferences. The home has been maintained to a good standard of cleanliness. able to access a range of communal areas. People are There are two staff on duty throughout the day and night. Over 50 of the staff employed have completed the NVQ level 2 qualification in care. People living at the home and staff members confirmed that the manager is helpful and approachable. Accidents are recorded and appropriate action taken to reduce the risk of these re-occurring. What has improved since the last inspection?
Care plans have been reviewed and now provide clear guidance to staff on how to meet people’s needs. Assessments had been completed in relation to the risk of pressure sores, nutrition and falls, and where a high risk was identified, measures had been put in place to address these. The home has obtained information sheets regarding people’s medical conditions and health needs. Care plans had been regularly reviewed and had been updated following changes in people’s needs, such as re-admission into the home from hospital. The Cook and two senior staff are completing a sixteen-week course on the nutritional needs of older people. There is an ongoing program of maintenance at the home. Since the last inspection new carpets have been fitted in hallways, some bedrooms and both lounges have been decorated and the fire escape repaired. At the time of inspection further service user rooms were being re-decorated. The home has ensured that appropriate checks are completed prior to a staff member being employed. A staff training matrix has been maintained. Newly appointed staff have received induction training, and all staff have had regular supervisions with the manager. Staff have received the training required to fully undertake their role. CSCI has been notified of significant events affecting the home, in accordance with Regulation 37 of the Care Home Regulations 2001. Ms Rodway has become the Registered Manager for the home.
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 7 Within the surveys received a number of staff commented that they felt the home had made significant progress in the last twelve months. 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. Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 8 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 Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 9 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): 1,2 & 3. (Standard 6 does not apply) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their families are provided with appropriate guidance to make an informed choice regarding admission to the home. Pre-admission assessments are completed to ensure that the home will be able to meet people’s assessed needs. EVIDENCE: The home has produced a joint document including the Statement of Purpose and Service User Guide. This has been updated since the last key inspection and now includes all required information to ensure that people are able to make an informed choice regarding admission to the home. A copy of the key inspection report from CSCI is available for people to read within the reception area.
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 10 People are provided with written terms and conditions on moving into the home. Contracts were seen for two people and found to contain appropriate information regarding notice periods and fees. Records were examined for one person who had received respite care. This was found to contain appropriate information to enable staff to meet their care needs. Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans have been reviewed and now provide clear guidance to staff on how to meet people’s needs. Medication is generally safe, but some improvements are required to ensure that this follows best practice. EVIDENCE: Since the last inspection care records have been reviewed and updated. Care plans were examined in detail for three people during this inspection. It was found that each plan contained a photograph of the person and appropriate guidance regarding their needs and preferences. Assessments had been completed in relation to the risk of pressure sores, nutrition and falls, and where a high risk was identified, measures had been put in place to address these. Care plans also addressed people’s sensory needs.
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 12 The home has obtained information sheets regarding people’s medical conditions and health needs. Clear guidance had been provided for staff regarding the actions required for a person with diabetes. Care plans had been regularly reviewed and had been updated following changes in people’s needs, such as re-admission following a hospital stay. Within the surveys received from staff members, all respondents stated that they ‘always’ receive up to date information regarding the needs of people they support. Two people living at the home stated that they ‘always’ receive the help and support they need and another that this is ‘usually’ the case. Care records demonstrated that appropriate referrals had been made to health care professionals for specialist advice when needed. Records had been maintained of professional visits, including the reason for the visit, outcome and any changes required to the plan of care. Bedrails had been provided for one person. It was noted that there was some movement in the rails, that may pose a risk of entrapment. The home must seek further advice to ensure that any bed rails are fitted securely and establish a system for monitoring the safety of the bed rail on a regular basis. The manager advised that all staff receive medication training from the prescribing pharmacist and complete a distance-learning course prior to administering medication at the home. She also advised that people shadow a senior carer or herself and are assessed as competent before completing this task alone. The Monitored dose system is used. Medication Administration Records include information on why is medication is required and for creams there is guidance on where this is to be applied. The home does not use homely remedies, but refers any health needs to the person’s GP. Medication Administration Records (MARS) had generally been well maintained. However there were two hand written entries where these had not been checked and signed by a second staff. Most medication is stored securely and there are appropriate facilities for storage of controlled medication. The home should review the storage of medication requiring refrigeration to ensure that this is also stored securely. The midday medication round was observed. People were eating their meals in the dining room. Staff dispensed medication from the trolley and carried this over to people, announcing what the medication was. People had to break from their conversation and eating their meals to take the medication, or receive eye drops. A discussion was held with the manager at the end of the inspection regarding the need to balance people’s health care needs with their dignity and the right to enjoy meals as a social occasion. The Manager agreed to immediately review this practice and ensure that medication and eye drops Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 13 are given before or after the mealtime in a manner that promotes people’s dignity and meets their individual needs. Interaction between staff and people living at the home was observed to be warm and friendly. Staff knocked on doors before entering bedrooms. Within the surveys received from people living at the home all of the people living at the home who responded stated that staff do listen and act on what they say. Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 14 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. The range of activities provided is appropriate to people’s interests and needs. The home provides a well-balanced and nutritious menu. EVIDENCE: People living at the home are able to participate in a range of activities. A weekly program has been developed that includes painting, films, music and movement, board games, flower arranging and sing-a-long. Care staff support people in meeting their social needs as part of their role, and separate activities staff are not employed. There are two lounges meaning that people can spend time engaging in different activities. The mobile library visits the home. People also go out to Blind club and Gateway Club. During the last month, an organist played music at the home and a Christmas party was held for people and their relatives.
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 15 During January it has been arranged that the Donkey Sanctuary will visit the home. Visitors are welcomed and a Christian service takes place at the home each month. The home employs a cook who works during the week. Senior care staff assist with meal preparation during the weekend. The Cook and two senior staff are completing a sixteen-week course on the nutritional needs of older people. The home operates a three week menu, which is based on people’s preferences. Home made cakes are available and cakes are made to celebrate people’s birthdays. Fresh fruit is available for people within the dining room. People are able to eat within the dining room or their room as they prefer. Items such as large cutlery and plate guards are available to promote people’s independence. The meal had been well cooked and presented. People spoken with during the inspection stated that the enjoyed the meals provided and that the Cook has a good knowledge of their dietary needs and preferences. Within the surveys received one person said that the ‘home cooked meals are excellent’. The menu is displayed in the dining room and choice of meals is available each day. Drayton House DS0000036054.V373854.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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate policies and procedures in place to safeguard people living at the home. EVIDENCE: The home has a complaints procedure that is displayed within the home. This provides details of a number of people that may be contacted should someone which to raise a complaint. The details of the management company should be removed as they are no longer employed by the home. The policy states that people may contact CSCI if they are still not happy with how the complaint is dealt with. This should be amended to state that they may contact external agencies, such as CSCI at any time. The policy on the adult abuse has been updated and staff have received training on the protection of vulnerable adults. The home has an appropriate whistle blowing policy. Within the surveys received from staff members all of the staff who responded stated that they what to do if someone had concerns about the home. Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 17 There have been no complaints received by the home or CSCI since the last key inspection. Drayton House DS0000036054.V373854.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): 19,20,21,22,24,25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live within a homely environment. The home has been maintained to a good standard of cleanliness. The registered persons must undertake some further actions to ensure that people’s safety is promoted and infection control practice must be improved. EVIDENCE: Drayton House is a large detached property close to the centre of Bridport. There is an ongoing program of maintenance at the home. Since the last inspection new carpets have been fitted in hallways, some bedrooms and both lounges have been decorated and the fire escape repaired. At the time of inspection further service user rooms were being re-decorated.
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 19 There are two lounges and one dining room on the ground floor. These rooms have been decorated and furnished to a good standard. Call bells were available for people to summon assistance from staff members. The Manager advised that there is plans to reconfigure the use of the rooms to provide a larger dining area, lounge and quiet room. Bedrooms are provided on the ground and first floor. There are three double rooms available for people to share. Bedrooms vary in size and eight have en suite toilet facilities. The manager advised that people are involved in choosing which room they would like. Lockable storage is available. Those bedrooms seen had been personalised to reflect individual tastes and preferences. People’s bedrooms had personalised nameplates. At the time of the inspection the Manager was printing appropriate signage for bathrooms and toilets. Some radiators within the home have guards fitted whilst others do not. One unguarded radiator in the large lounge and within one en suite bathroom felt very hot to touch. Unguarded heaters may pose a risk of scalding should people fall against them, therefore risk assessments must be completed for any unguarded radiators within communal and personal areas and any necessary action taken. The home has a number of vacant rooms at present. These should be kept locked to ensure that people are not at risk from items stored within them. Within some occupied rooms, wardrobes had not been fixed to the wall. Heavy items such as wardrobes may fall on people therefore these should be fixed or an appropriate risk assessment completed. Generally window openings on the first floor had been restricted to prevent risk of people falling. One window within the bathroom opened fully. This was discussed with the manager who agreed to take appropriate action. There are three communal bathrooms. Hot water outlet temperature were measured and found to be within appropriate limits. The home must ensure that there are appropriate hand washing facilities consisting of liquid soap, paper towels and a foot-operated bin in each bathroom, toilet, en suite or bedroom where staff assist people with personal care. The laundry is situated in the cellar. The home has industrial machines that include a sluice facility. Laundry procedures were discussed. The home must review current practice to ensure that people are not put at risk of cross infection from soaking or sluicing soiled laundry by hand. The home is advised to use red alginate bags and seek any further advise from the Health Protection Agency regarding best practice. The flooring in the laundry is split and requires replacement to ensure that it can be thoroughly cleaned. There
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 20 should be appropriate hand washing facilities available for staff members within the laundry and separate areas for dirty and clean washing. Within the kitchen some sealant surrounding the sink requires replacement. Paintwork has become damaged on the window and plasterwork needs repair close to the back door. These areas must be addressed to ensure that the kitchen can be thoroughly cleaned. The registered manager advised that there are plans to replace the kitchen within the refurbishment program for the home. The home had been maintained to a good standard of cleanliness. Care staff complete cleaning duties as part of their role. People spoken with during the inspection confirmed that the home is always clean and fresh. Drayton House DS0000036054.V373854.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): 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. There are sufficient staff on duty to meet people’s needs. Staff have received the appropriate training and supervision to safely undertake their role. EVIDENCE: Duty rotas are maintained. There are two staff on duty throughout the day and night. The rotas demonstrated that there is always at least one staff member on duty who has completed training in First Aid. The Manager is present within the home for 40 hours each week and provides some hands on care to ensure that they remain aware of any changes in people’s needs. A training matrix is maintained. This shows that all staff have completed moving and handling training, and that most staff have received training on adult protection, dementia, medication, infection control and health and safety. Staff involved in the preparation of meals have completed Food Hygiene training. Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 22 A number of new staff have been employed within the last twelve months. Recruitment files were examined for two people who have recently been appointed at the home. These evidenced that two references and a POVA first check had been completed prior to them commencing work. The home had obtained all necessary information regarding the staff member. An interview record had been maintained. This is good practice. Staff members had received a job description and contract of employment. Newly appointed staff have completed induction training. All staff have received regular supervision and appropriate records maintained. Five out of the eight care staff employed have obtained the NVQ level 2 qualification and two more are studying towards this. Three care staff are studying towards NVQ level 3. Drayton House DS0000036054.V373854.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): 31,32,33,34,35,36,37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are appropriate systems in place to seek the views of people living at the home. The registered person must regularly review the service and identify areas for development to ensure that the home continuously improves. EVIDENCE: The Manager is Jeannie Rodway, who has been in post for one year. She has completed the Registered Managers Award and is studying for the NVQ level 4 qualification in care. Shortly after the inspection Ms Rodway’s application to
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 24 become the Registered Manager for the home was approved by CSCI. An updated certificate will be forwarded to the home to reflect this. People living at the home and staff confirmed that the manager was approachable. People said that they would be able to raise any areas of concern with her. The home provides surveys that people may fill in. The Manager has also spent time with people on an individual basis to seek feedback regarding the service provided. One person spoken with during the inspection stated that ‘Jeannie is wonderful’. Regular staff meetings are held. Within the surveys received from staff members, staff said that they also regularly have the opportunity to meet with the manager on an one to one basis. The registered provider completes monthly visits to the home in accordance with Regulation 26 of the Care Home Regulations 2001. Within this report areas for improvement have been identified in relation to medication practice, some health and safety issues and infection control. The registered persons must continue to regularly review the service provided and identify areas for development to ensure that areas such as these may be acted upon and that the service can continuously improve. The home displays appropriate Employers Liability insurance. CSCI has been notified of significant events affecting the home, in accordance with Regulation 37 of the Care Home Regulations 2001. The manager advised that the home does not keep money for people. Those living at the home who require assistance receive support from relatives or solicitors to manage their affairs. Fire safety records were examined. It was found that fire safety equipment has been tested and serviced as required. The home has provided information regarding each person’s mobility needs in the event of an emergency. Dorset Fire Service visited the home on 26/9/08 and required that fire doors must have smoke seals and intumescences seals, that fire doors must not be held open and that the fire escape be repaired. The home has taken appropriate action to address the second and third requirements. The manager advised that work is underway to adjust some doors so that the seals can be fitted. Equipment servicing records had been appropriately maintained. Lifting equipment has been serviced in accordance with LOLER regulations 1998 and the home has a contract for clinical waste. Accident records are completed as required. These are audited on a monthly basis to identify any patterns or areas that require improvement. This is good practice. Following an accident people are observed for a 24-36 hour period to ensure that they do not require further medical assistance.
Drayton House DS0000036054.V373854.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 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 3 3 3 3 X 3 1 1 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 2 3 3 3 3 1 Drayton House DS0000036054.V373854.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 OP8 Regulation 12 (1) [b] Requirement The home must seek further advice to ensure any bed rails are fitted securely and establish a system for monitoring the safety of the bed rail on a regular basis. The times and manner of giving medication must be reviewed to ensure that people are able to enjoy mealtimes as a social occasion and that their dignity is promoted. The registered persons must ensure that risk assessments are completed in relation to: • • • Unguarded radiators in communal and personal areas Heavy items such as wardrobes The unrestricted window opening within the first floor Timescale for action 20/02/09 2. OP9 12 (4) 06/02/09 3. OP25 13 (4) [a] 20/02/09 And undertake any action as necessary.
Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 27 4. OP26 13 (3) The home must review current practice to ensure that people are not put at risk of cross infection. Appropriate hand washing facilities consisting of liquid soap, paper towels and a footoperated bin in each bathroom, toilet, en suite or bedroom where staff assist people with personal care and the laundry. The flooring in the laundry is split and requires replacement. Repair work must be completed within the kitchen to ensure that these areas can be thoroughly cleaned. 06/03/09 5. OP33 24 (1) a & b The registered persons must continue to regularly review the service provided and identify areas for development so that the service can continuously improve. 06/03/09 6. OP38 13 (4) [c] Fire doors must have smoke 06/03/09 seals and intumescences seals as required by Dorset Fire Service during their visit on 26/9/08. 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. Refer to Standard OP9 Good Practice Recommendations All hand written entries on medication records should be checked and signed by a second staff member to reduce the risk of human error.
DS0000036054.V373854.R01.S.doc Version 5.2 Page 28 Drayton House The home should review the storage facilities for medication requiring refrigeration to ensure that this is also stored securely. 2. OP16 The complaints procedure should state that people are able to contact the commission for social care at any stage of a complaint. It is recommended that the signage within the home be improved in order to assist people who live in the home access all areas as independently as possible. (This recommendation had been partially met at this inspection). 3. OP19 Drayton House DS0000036054.V373854.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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