Inspection on 17/10/07 for Drayton House

This inspection was carried out on 17th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Drayton House 02/02/10

Drayton House 17/09/09

Drayton House 15/01/09

Drayton House 16/07/08

Drayton House 22/01/08

Drayton House 19/06/06

Drayton House 23/11/05

Drayton House 09/08/05

Drayton House 13/09/04

Drayton House 13/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Drayton House 50 West Allington Bridport Dorset DT6 5BH Lead Inspector John Hurley Key Unannounced Inspection 17/10/07 10:00 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.V345776.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.V345776.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 Vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Drayton House DS0000036054.V345776.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 19th June 2006 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. Miss Andrea Quirk is the Responsible Individual; she also owns a number of other registered services, including Glencairn in Dorchester. The accommodation is on the ground and first floors with a small passenger lift serving both floors. 7 of the 13 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. Fees are charged weekly and at present range between £417 and £450 per person. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of Drayton house care home for the inspection year 2007/8. The inspection process followed the Commission for Social Care Inspection Inspecting for Better Lives methodology. The views of the people who use the service and people important to them were sought. The inspector received feedback from these people by way of questionnaires; where appropriate their comments are included in this report. The inspection took place over two days and lasted a total of 10 hours. The first part of this inspection, carried out on the 09/10/07, was conducted by one inspector, the second part carried out on the 17/10/07 was by two. On both occasions the inspector toured the building, spoke with the management and staff on duty and spoke privately with people who use the service on an individual basis. They inspected a sample of the documentation relating to the individuals who reside at the home along with records relating to staff and other documents required by regulation. What the service does well: The feedback received from people who use the service and people important to them indicated satisfaction with the service on offer. Several people made comments such as “ at the moment I am very happy” and “the staff are very supportive”. Those individuals who can, confirm that they are able to go out with and invite friends to the home. They further confirmed that the quantity and quality of the food was good. The home keeps a record of what people have eaten. A number of the recruitment practices are positive such as giving prospective staff a structured interview in line with equal opportunities practice. These interviews are also recorded and the notes used to assess the persons suitability. There is sufficient evidence to suggest that staff receive a structured induction and are formally supervised at regular intervals. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The responsible individual (proprietor) must ensure that; • • • There is sufficient evidence recorded on file to establish that new residents have agreed to and wish to live at Drayton House. Initial assessments of need reflect any completed by the placing organization. All manual handling assessments are reviewed and any action that is required to ensure the safety of the people who use the service and staff are recorded and acted upon. There is a recorded rationale and practice guidelines for the administration of medication via the per required needs route in order to protect the people who use the service. All medication records are maintained in good order in order to protect the people who use the service. No staff to administer medication if they have not been adequately trained in order to protect the people who use the service. The home has a fire evacuation plan that demonstrates how the staff will safely look after the needs of the people who use the service in the case of fire All people who use the service have a detailed care plan, which accurately reflects the individuals needs and is reviewed on a monthly basis. Activities are based on individuals needs and aspirations All environmental risks are assessed and action taken to minimize the risk in order to protect those who reside at the home, staff and visitors. Robust employment practices must be established in order to protect the people who use the service. DS0000036054.V345776.R01.S.doc Version 5.2 Page 7 • • • • • • • • Drayton House • The services whistle blowing policy is updated to reflect the local authorities policies to demonstrate that people can complain to the Commission for Social Care Inspection at any time. The services complaints policy is updated to demonstrate that people can complain to the Commission for Social Care Inspection at any time. Staff training records are reliable and kept in good order so as to ensure the staff are suitably trained for the roles they undertake. They ensure that all substances hazardous to health are appropriately stored. They must establish good practice in relation to the use of the kitchen by staff in relation to food hygiene practices. All accidents that happen within the home are formally evaluated and the evaluation used to influence future risk assessments and the individuals care plan • • • • • 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.V345776.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.V345776.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): 1,2,3,6. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The information supplied by the home to prospective residents does not include all of that required by regulation. The pre-admission assessments do not identify key issues that may affect the well being of the people who use the service. EVIDENCE: The inspectors sampled the homes statement of purpose and service user guide. These documents need to be updated to reflect the services on offer, for example there registration allows for four places to be taken up by people who have a dementia type illness but this is not mentioned in either of the documents. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 10 The registered manager makes arrangements for an assessment of need to be completed prior to any prospective resident moving into the home. During both inspection days a wide sample of these assessments were inspected, four of those being permanent residents and three being recent respite admissions. The records relating to people taking up temporary residence on a respite basis did not contain full assessments of needs for example; the medical history of the person was not documented and risk assessments regarding selfmedication had not been made. There were no apparent signatures of those who were about to receive a service to indicate that they were in agreement with the care package on offer. For those who had taken up permanent residency the initial assessment was more complete. Although there were gaps in the information at initial assessment some of this had been obtained during the first weeks of residency. The inspectors examined a selection of the local authorities assessments and matched them with the assessments the home had made. This evidenced that significant details such as the person’s history of falls had not been reflected in the homes own assessment or initial care plan documentation. It was noted in the individual’s files that the contract between the home and the resident was in place. The feedback gained via questionnaires indicated that some people felt they did not have one. It would be helpful if this matter was investigated by the home and copies give to those who require one. The registered manager stated that the home does not offer intermediate care. Drayton House DS0000036054.V345776.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 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Care records do not provide sufficient detail to ensure that individual’s personal needs are being fully and safely met. Significant incidents do not influence care plans, which may put individuals at risk. The home has systems in place for managing residents’ medicines but these fail to protect people who use the service. EVIDENCE: The registered manager informed the inspectors that they had purchased new care planning documentation. The inspectors looked at the care plans that had been generated from the initial assessments and subsequent reviews. It was unclear to the inspectors as to how the peoples care plans were being developed in a way that reflected the assessments carried out by the local authorities care managers. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 12 For example one service user has mental health care needs, these needs were not clearly identified in the documentation supplied but an assessment had been made using a tool that gave a numerical rating. The recording of these ratings used to identify levels of need were outside of the parameters set by the assessment tool, for example one section required a score of 1 to 20, the score was recorded as 49. The manager explained that these were new care planning tools and the staff were getting to grips with using the new formats. The sections being used for risk assessments sometimes identified those at risk but then failed to document what to do to reduce the assessed risk. Some of the risk assessments seen failed to acknowledge the persons history prior to coming into the home for example, one person identified as being at high risk of falls by the local authority prior to them going into Drayton house is recorded as no risk as they had no falls within the home. The accident book was sampled and it was found that even though people were falling there was no robust evaluation of why they fell. There are examples of people falling out of bed only to fall again later with no measures to stop further occurrences. There are examples of people hitting their heads or face with no recorded action relating to staff monitoring the individual. There is an example of bed rails being used without any documented risk assessment or evidence that other professionals such as district nurses had been consulted about there use. Due to the nature of confusion with the care plans one inspector asked a member of staff on duty if a resident has continence problems. Although the staff member confirmed that the person in question was wearing continence aids they did not know if these aids were required, the response from the staff “just in case.” The inspectors viewed the medication administration recording (MAR) sheets and noted a number of issues that needed to be addressed. Some directions required medication on a Per Required Needs (PRN) basis but the rationale for administration on this basis was not available (either on the medication sheets or the individual’s files). The MAR sheets contained many hand written entries, which did not state the amount of medication received into the home. At the first inspection the inspector asked for the controlled drugs register used to record all dispensing of controlled drugs. This was not available until an hour later when a staff member returned it to the home. The register was examined and an audit carried out against the medication in the medication cabinet. The findings of this audit revealed that there was more tablets on the premises than were recorded. The register was poorly kept and a number of basic numeric errors were apparent. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 13 The registered manager agreed with the inspector’s observations. The inspector returned 3 days later to briefly look at the controlled drugs register again and found that it had been falsified to take into account the medication on the premises. Again the registered manager agreed with the inspector’s observations. Drayton House DS0000036054.V345776.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 poor. This judgement has been made using available evidence including a visit to this service. The home would benefit from identifying individuals social care preferences and provide activities to ensure that they are providing some form of stimulation to those who reside at the home. Relatives can visit at any reasonable time. The food on offer appears to meet the individual’s needs. EVIDENCE: The registered manager informed the inspectors that there is an activities programme mainly in the afternoons. At the first inspection it was noted that the staff had a sing along with residents in the afternoon. At the second inspection one inspector sat with four residents in the front lounge and observed staff interaction with this group. Over the hour and a half this observation was carried out there was little to no staff interaction with the residents. It was however clear that when a staff member entered the room the residents became alert and responsive to that staff member. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 15 In the rear lounge the inspector noted one of the two staff on duty helped a person with a large child’s jigsaw, which the staff member put together on the floor. The staff member was called away to assist elsewhere saying they would be back but did not complete this activity. At lunch time some of the residents were helped to the dinning room, some eating the front lounge. After lunch residents were helped back to the front lounge. No activities were observed when the inspectors left at 3.30pm. People who use the service receive visitors whenever they wish. A record is maintained of all visitors to the home. The home encourages friends and relatives to keep in contact. Visitors spoken with confirmed that they were always made welcome by the staff. One inspector spoke with a visiting relative during the first inspection who informed them that they were happy with the service on offer and considered the staff to be helpful and attentive to their relatives needs. Through discussion with the people who use the service it was established that the food is good, home cooked and plentiful. A menu is displayed and food is cooked fresh each day. The dinner menu evidences a degree of choice over what to eat. The residents files demonstrate that the home keeps a record of what people have had for their lunch. Drayton House DS0000036054.V345776.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 poor. This judgement has been made using available evidence including a visit to this service. The complaints policy requires to be updated to ensure the National Minimum Standards are adhered to. The vulnerable adults procedure requires to be updated in order to protect the people who use the service. EVIDENCE: The home has a complaints procedure, that includes details of external agencies that service users and their families may contact, including CSCI. However, it does not state that the agencies identified can be contacted at any time, only after the individual has gone through the homes management. The feedback from the people who use the service and people important to them indicated that they have made no complaints and are satisfied with the service on offer. At the time of the inspection the local authority was investigating an issue of concern. The inspectors looked at the policy documents relating to whistle blowing. These documents do not encourage people and staff to raise issues of concern and require to be updated in line with the reporting procedures set out by the local authority safe guarding adults policies. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is generally furnished to an acceptable standard. More needs to be done to ensure that all of the people who use the service can assess all areas of the home independently. More needs to be done to ensure the environment is safe. EVIDENCE: Drayton House is a traditionally built house, with a purpose built extension. It offers homely bedrooms, bathrooms equipped for the use of persons requiring assistance and communal rooms. There is a passenger lift from the ground to the first floor aiding the less mobile to access all areas of the home. There are a number of handrails which also aid people to access areas independently. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 18 There are 13 single bedrooms seven have en-suite facilities. There are 3 larger rooms that may be used to accommodate 2 residents who have made a positive choice to share with each other. One of these is now used as a single room. 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. All of the bathrooms and toilets have sliding doors. In the bathrooms it was noted that latex gloves and some plastic aprons were available and on display. The feedback from people who use the service confirmed that they are satisfied with their allocated bedrooms. These rooms have been personalised to reflect the individual’s tastes and preferences. The bedding was noted as both clean and appropriate for the time of year. The quality of the bedroom furniture was seen to be generally good. It was noted that in one bedroom a portable electric heater was in use as the heating system was causing problems, it would be helpful if the registered manager carried out a risk assessment relating to the use of this heater. It was also noted that large wardrobes are not fixed to the wall to stop them toppling on top of the resident. At the first inspection the inspector did not look at individual rooms in any depth but concentrated on the communal areas. It was noted that the rear lounges carpet was heavily stained and was showing signs of wear which may present a tripping hazard in the near future, it was noted that this carpet had been cleaned since the second inspection. It was noted that infection control practices were poor with a number of hand towels and communal soap available in the bathrooms; this had improved at the second inspection, the chemicals that were also in these areas had also been removed at the second inspection. At least one toileting aid that required replacing had been so by the second inspection. Whilst the home has retained a certain degree of a domestic nature it does not contain any visual clues as to where a person may be in the building. As the home has a registration which includes those who suffer from dementia this may mean that they are less confident to move around the building independently. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. At times there are insufficient staff to meet all of the residents needs. Whilst staff receive some training it is not always evident that they put this training into practice, putting those who use the service at risk. In general terms the recruitment practices at the home met the National Minimum Standards. EVIDENCE: At the time of the first inspection there were two staff on duty. These two staff were responsible for care duties, as well as laundry, one also cooking the mid day meal. At the second inspection there was four staff, the registered manager, two care staff and a cook. The observations at the second inspection strongly indicated that the care staff were generally involved with tasks and there was little observed social contact for the less able and confused. The inspectors looked at the training matrix which indicated training activities but was not robust enough to fully evidence that staff are adequately trained to cater for the complex needs of the present resident group. For example the matrix did not cover any specialist training such as dementia care, a category Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 20 the home is registered to cater for. Through discussion with the registered manager it was unclear as to who had received training in this area but the most reliable records indicated that a low percentage of staff had received a two hour course back in 2005. The registered manager confirmed that all new staff have undergone a thorough recruitment and selection process by way of a formal structured interview which is fully documented, as well as a number of statutory checks to establish their suitability to work in the home. On inspection of the staff’s files it was confirmed that staff receive a comprehensive induction when they start at the home. All elements of the induction process are signed to confirm each element has been completed and understood. One of the staff files that were sampled evidenced that a new staff member had commenced working at the home having received a POVA first check whilst awaiting a full Criminal Records Bureau check. There was no documented evidence with regards to the supervision arrangements of this person as required whilst working on a POVA first check only. Staff have undertaken mandatory training such as Fire Awareness, Moving and Handling, Food Hygiene and Infection Control. Some care staff has undertaken the NVQ Award in Care at varying levels. Although some staff have received training in the safe administration of medication they do not appear to be putting training into practice. (As discussed in section two Health and Personal Care, medication) Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 21 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): 31,32,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. More needs to be done to ensure that the people who use the service have had their needs met. The management need to ensure that issues that significantly affect the well being of those who use the service are risk assessed and evaluated in order to protect individuals from harm. The management must ensure that changes to care planning documentation enhance the lives of those who live at the home. Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 22 EVIDENCE: The inspectors consider that there is sufficient evidence to suggest that the home had not been managed appropriately. The medication administration procedures give a good example of how poor practice have been in place for an extended period with no regular audit that should have identified problems. Similarly the lack of evaluation of falls and accidents at the home illustrate how people can be put at risk through the lack of management and leadership with regards to these issues. Risk assessments in many areas had not been undertaken or revaluated when significant changes occur in areas such as portable heaters, use of bed rails, environmental risks, risk of falls, manual handling etc. The care planning and review documentation had been renewed since the inspection in 2006. The use of these tools had not been evaluated and there did not appear to be any leadership in ensuring these documents were being used in a way that met the National Minimum Standards. During the first inspection the inspector noted a range of cleaning products that were in the communal bathrooms, these could poise a risk to the health of the people who use the service. They also noted that some cleaning products had been decanted from their original containers into unmarked spray bottles for cleaning the toilets. These were placed on top of the toilet cistern. At the second inspection there was no issues apparent relating to cleaning materials. At both inspections staff were observed entering the kitchen without putting on an apron thus undermining infection control practices. A programme of staff training and fire drills were sampled which appeared to evidence that staff had received in house training in relation to fire safety. The last fire drill to take place is recorded as having taken 13 minutes to achieve. The home does not have a fire evacuation plan that demonstrates how the staff will safely look after the needs of the people who use the service in the case of fire. Drayton House DS0000036054.V345776.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 2 2 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 2 2 x 3 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 x x x x 1 Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes 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 OP9 Regulation 12 Requirement Each occasion of Controlled Drug administration must be accurately recorded by staff trained in the handling of prescribed medicines. The previous timescale for meeting this requirement was 03/05/07 Timescale for action 01/11/07 2 OP1 17(2) 3 OP3 14 schedule 3 (a) 4 OP7 15(1)(2) The registered person must 20/11/07 update the statement of purpose to accurately reflect the services on offer at the home so that people can make an informed choice. The registered person must 01/11/07 ensure that someone qualified to do so makes the initial assessment of need for all prospective service users. The records made must comment are all areas identified in standard 3 of the Care home regulations , Care Standards Act 2000. The registered person must 20/11/07 ensure that the residents care records include an action plan with sufficient detail to provide clear guidance to staff on the DS0000036054.V345776.R01.S.doc Version 5.2 Page 25 Drayton House actions to be taken to meet all their identified needs. The resident or their representative must be consulted when preparing the care plan and sign the plan to evidence they agree with actions taken on their behalf. 5 OP9 13 (2) The registered person shall make 01/11/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in the care home including: 1. must ensure that staff that administers medication have been suitable trained and hold the appropriate certificates relating to there competence 2. Recording the rationale for administering Per required needs’ administration of medication. 3. To ensure that all returned, disposed of or medication given to others such as paramedics is robustly accounted for. The registered person must ensure that all individuals have an appropriate risk assessment that identifies that action to be taken to minimise the risk. After consultation with the people who use the service the registered person must provide social activities to meet their individual needs. 6 OP7 13 (4) 10/11/07 8 OP12 16(n) 20/11/07 Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 26 9 OP18 13(6) The registered person must ensure that the homes policy with regards to vulnerable adult reporting reflects the local authorities policy in order to protect those who use the service The registered person must ensure that the homes policy with regards to complaints is updated to inform that people can contact the CSCI at any time. The registered person must ensure that if a new employee starts work at the home without having a full cleared Criminal Records Bureau check in place and only a POVA first check the supervision arrangements for that staff member are fully documented. The registered person must ensure that the persons working at the home receive training appropriate to the needs of the people living at the home. The registered person must ensure that all staff comply with health and safety legislation with regards to the kitchen area in order to protect the people who use the service from infection and possible contamination of foodstuffs. The registered person must ensure that all accidents that occur within the home are fully evaluated and action taken to minimise risk of further occurrence. The registered person must ensure that the home has been fully risk assessed and action taken to minimise any risk found. DS0000036054.V345776.R01.S.doc 01/12/07 10 OP16 22 01/12/07 11 OP29 19 01/11/07 12 OP30 18(c)(1) 01/01/08 13 OP38 16(J) 01/11/07 14 OP38 13(4) 01/11/07 15 OP38 13(4) 15/11/07 Drayton House Version 5.2 Page 27 16 17 OP38 OP38 13(4) 13(4)(C) The registered person must ensure that there is a fire evacuation plan in place. The registered person must establish and maintain a COSHH register and ensure that all substances identified on the register are kept in line with the COSHH legislation in order to protect those who use the service. The registered person must ensure that infection control policies are robustly maintained 01/11/07 10/11/07 18 OP38 13(4) 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP19 Good Practice Recommendations It is recommended that all residents be reissued with their up to date contrast. It is recommended that the signage within the home is improved in order to assist people who live in the home access all areas as independently as possible. It is recommended that the registered person review the staffing levels within the home. 3 OP27 Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Drayton House DS0000036054.V345776.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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