Inspection on 09/08/05 for Drayton House

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 17/10/07

Drayton House 19/06/06

Drayton House 23/11/05

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 Gloria Ashwell Unannounced 9, 12 & 15 August 2005 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 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 D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Drayton House Address 50 West Allington Bridport Dorset DT6 5BH 01308 422835 01308 422835 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss A Quirk, Mrs Isabella Fitzgerald, Mr John Stanley Pitcher & Mrs Mary Josephine Pitcher Mrs S Dean CRH PC- Care home only 19 Category(ies) of OP Old age (19) registration, with number of places Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1: That four persons may be accommodated within the category DE(E). The condition is met. Date of last inspection 13th September 2005 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 care home, including Glencairn in Dorchester. The registered manager of Drayton House is Mrs Sharon Dean. 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. There are also 3 larger rooms which may be used to accommodate 2 residents who have made a positive choice to share with each other. None of the ‘shared use’ rooms has en suite facilities; all bedrooms have a wash hand basin. The communal facilities include two lounges, a small dining room and three 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. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was one of the two statutory inspections required in accordance with the Care Standards Act 2000. Since the last inspection no formal complaints against the home have been received or investigated. The inspection took place over three days; the inspector arrived (unannounced) at 14.00 on 9 August 2005. During the inspection she spoke to 8 residents and 3 care workers. The inspector observed staff interaction with residents, the carrying out of routine tasks and toured the premises, departing at 16.00. The inspector left a selection of ‘Comment Cards’ and prepaid envelopes (for return to the Commission) with staff for later distribution to residents and their relatives. Before departing the home the inspector issued Immediate Requirements in respect of medicine use, food and hazardous cleaning product storage, unrestricted upper floor windows and a defective fire door. The inspector returned to the home (unannounced) at 11.45 on 12 August 2005 to examine care records and monitor compliance with the Immediate Requirements issued at the previous visit. Another Immediate Requirement relating to the defective fire door was issued. The inspector telephoned the home during the morning of 15 August 2005 and arranged with the manager to visit the home at 14.00 on that day and together with the manager and deputy manager considered other evidence relating to the National Minimum Standards, as described in this report. An Immediate Requirement relating to fire safety training of staff was issued. The duration of the inspection (the 3 days combined) was 7 hours and 25 minutes. Additional information used to inform the inspection process included reports occasionally provided to the Commission by the home and 8 ‘visitor questionnaires’, completed between 23 June 2005 and 9 September 2005 which indicate general satisfaction with the home. What the service does well: Drayton House must improve all aspects of service provision. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 6 Standard 6 is not applicable because the home does not provide intermediate care. A written contract is provided to each resident at the time they enter the home to ensure clarity regarding fees and what they do and do not cover. Prior to admission, the needs of each proposed resident are assessed but essential information is frequently overlooked, so the home does not always obtain a comprehensive portrayal of the person’s needs/circumstances and may not adequately understand or be able to meet their needs. Following assessment the home writes to prospective residents confirming the ability to properly care for them. EVIDENCE: The records of a recently admitted resident included those of a pre-admission assessment carried out by a senior staff member when she visited the person in hospital. Records provided by the hospital indicated that the resident had a number of serious health conditions but these were not referred to in the Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 9 home’s assessment; a related requirement has been made to address this shortfall in practice. The records contained a letter from the home to the resident, describing terms and conditions of residency including fees and the number of the available room. Following pre-admission assessment, if the home decides to offer a place to a new resident, they then write to the person stating that Drayton House will be able to meet their assessed needs. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 11 Staff do not have information necessary to provide correct care to each resident. Care needs are briefly and sometimes inadequately described in a written plan of care. Many care plans are significantly out of date and inaccurate. High risk behavioural and health aspects e.g. epilepsy, aggression, wound care are frequently overlooked in care plans so these aspects of need may not receive appropriate attention. Since the previous inspection the home has implemented a system for identifying and minimising risks to residents prone to falling or other accident. Better arrangements for protecting residents from risks of incorrect medication use and processes for administration of prescribed medicines by staff are necessary to ensure that residents continue to receive the correct medicines and that all medicines held in the home are properly stored. The written procedure for the management of death does not provide staff with clear and accurate guidance so may result in dying residents receiving inappropriate care. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 11 EVIDENCE: Care plans are frequently out of date and no longer accurate; many omit significant aspects of high behavioural and health risk. Essential information including appropriate management of aggression and possible deterioration in condition, emergency action to be taken by staff, and details of on-going care needs was not stated for a number of residents with special health needs and in discussion with the inspector a member of senior care staff demonstrated no knowledge or understanding of the condition of a particular resident. All accidents are recorded and since the previous inspection the home has periodically audited accidents to identify any trends or patterns (e.g. in time, place, person or activity) and subsequently introduced some measures to reduce the risks. Residents do not feel involved in their care, comments made to the inspector about medicine administration included “it comes every mealtime but I don’t know what it’s for…perhaps it’s a pain killer, but there’s no “have you a pain?” or anything…”. Records indicated that in general medicines had been accurately administered but it was noted that for one resident who was at the time in hospital, on one morning a care worker had signed the record confirming that all prescribed medicines had been administered and had later crossed out and overwritten the signature. This indicates that the proper procedure for medicine administration had not been observed and must be improved to ensure that residents receive correct medicines and doses, and that the home can properly account for all medicines held. During the tour of the premises the inspector noted that in two bedrooms were creams prescribed and dispensed for service users not accommodated in these rooms, and creams were also in a communal use bathroom with prescription labels removed. An Immediate Requirement was issued to ensure that medicines (including creams, lotions and other medicaments) are only administered to service users for whom they have been dispensed. The same Immediate Requirement had been issued at the previous inspection but remained unmet. In accordance with recommendations included in the last inspection report a number of staff are at present receiving accredited training in medicine handling and Controlled Drug storage facilities are provided to ensure that if such drugs are prescribed for any resident they will be properly stored. It is again recommended that to ensure the home is properly equipped a Controlled Drug Register be obtained for use if at some future date such drugs are prescribed. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Some residents are not satisfied with the lifestyle at the home; they frequently feel bored and lonely. Residents receive sufficient to eat but are not provided with a choice of meals and do not all consider the meals to be appetising and well prepared. There were unacceptably low safety standards of foodstuff storage. EVIDENCE: Comments received from residents during conversations with the inspector included: “no activities at all…just dead and alive…not told anything (about activities)...(in the lounge other residents) don’t say anything, just sleep…”, “there’s a lot of boredom…I sometimes hear the ladies say “I’m just fed up”…”. At the time of the inspector’s first visit a visiting therapist was leading the regular music and movement activity in a lounge. Comments included “same old thing”; residents said no other activities are arranged “just sit and talk, and watch the telly…”. During the other two visits the inspector noted that a number of residents were asleep in the lounges, usually without staff present in these rooms. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 13 With the exception of the weekly music session the home does not provide a regular programme of recreational and social activities; a requirement has been made to address this shortfall. Residents indicated that although the quantity of food provided at mealtimes is adequate they are not offered a choice and the presentation and food quality is not always good. Comments regarding food provision included “they bring my food up and take it away…today I had mince, and batter on top of it…(choice?) Oh Lord, No…” and “Choice? No, just what they give you”. A number of dry foodstuffs including sugar, flour and sponge mix were in opened bags without any attempt having been made to close them in a room used also to store cleaning machinery and products. A bag of dried coconut bore a ”best before 04/05” label. The door to the room was wide open, although clearly labelled “Keep locked shut”. An Immediate Requirement was issued for the proper stock rotation and storage of foodstuffs. The written procedure for the management of dying residents and actions to be taken by staff after the death of a resident makes numerous inappropriate references to the provision of palliative care, which Drayton House is not registered to provide, and fails to give appropriate guidance on actions to be taken when an unexpected death may have occurred in the home. It is recommended that the policy be reviewed and amended to ensure the provision of accurate guidance to staff. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The complaints policy and procedure provide residents with information and guidance about making complaints including to whom they can be made. The home does not have written policies and procedures for the protection of residents from abuse or neglect and in consequence has not always taken correct action to deal with events placing residents at risk of harm and has not notified the Commission of these events. EVIDENCE: No complaints against the home have been received or investigated since the last inspection. The manager said that the home does not have written Protection of Vulnerable Adults policies and procedures to provide staff with guidance relating to the understanding and management of abuse. Recently the behaviour of one resident has placed others at risk of harm and injury; the home had not informed Dorset Social Care & Health (DSC&H)and the Commission for Social Care Inspection of these events, and had not adhered to nationally established guidance in dealing with these matters. In consequence, other residents have continued to be placed at risk of harm. The home failed to act on the request of the inspector to report the concerns regarding the Protection of Vulnerable Adults to DSC&H so the Commission has reported them to DSC&H for investigation. (DSC&H are the lead agency for this type of investigation.) Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 15 This report includes a number of associated requirements, including one made for the third time. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 24 & 26 The standard of décor, furnishings and fittings in Drayton House is poor with little evidence of improvement through maintenance or future planning. The home does not present a pleasing, safe and comfortable environment for residents. The standard of premises and equipment hygiene is frequently poor, exposing residents, staff and visitors to potential risks of infection and injury. EVIDENCE: Many bedrooms contained worn, outdated, ill-matched furnishings in poor condition; a number of cabinet doors and drawers could not be closed, some were without handles, some vanity cabinet mirror glass was pitted and unsightly, cloth covered armchairs were dirty and many curtains were disconnected from rails. Beds had been made with damaged, dirty linen and misshapen pillows. Ragged towels were in regular use. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 17 Many bedrooms had only one ceiling mounted pendant light; no bedside light and no light switch within reach of the bed, causing at least one resident to resort to a torch kept in the bedside cabinet. Not all bedroom doors are fitted with locks of approved style enabling residents to hold the key, and suitable for staff to gain rapid access in emergency. Most communal use bathrooms and toilets do not have useable locks on the doors so residents are not assured privacy in these rooms. A first floor bathroom was used to store cleaning fluids and equipment in a wooden cabinet in front of the wash hand basin obscuring its use. The relocation of the cabinet was the subject of a requirement issued at the previous inspection but remains unmet. Bathrooms and toilets are small, cramped and invariably shabby; staff routinely experience difficulty when assisting residents using wheelchairs to use the toilets closest to the lounges, because they are too small to enable wheelchairs to enter, and the corridor is too narrow to enable wheelchairs to be safely turned. One bath was used to contain portable toilet items (commode pans, urine bottles), thereby causing a potential source of infection. Commodes in bedrooms frequently held soiled pans. The décor of many bedrooms is unattractive; one had curtains with bold green and yellow stripes, a heavily worn orange, brown and cream carpet, blue, mauve and cream wallpaper and a bright pink bedspread. The cleanliness and decorative order of many rooms was poor including waterstained ceilings, cobwebs, wallpaper which was damaged and had come loose from the walls, and unpainted exposed pipes. The easily remedied aspects (e.g. soiled commode pans, poorly made beds) were made known to the care worker in charge of the home at the time of the fist visit; some improvements had been made by the second and third visits. The home has not met the recommendation of the previous report to provide written evidence of compliance with the Water Supply (Water Fittings) Regulations 1999 to ensure that all service users have access to a safe water supply; the recommendation is therefore repeated in this report. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Care staff levels meet those recommended by the Department of Health guidance calculation but care staff undertake a variety of housekeeping and other tasks within the home resulting in residents receiving an inconsistent and unsatisfactory service. EVIDENCE: The Staffing Forum calculation indicates that, based on the dependency levels of currently accommodated residents, at least 312 care staff hours should be provided each week; during week commencing 6 August 2005 the home provided care staffing of 395 hours. During most mornings there are 4 staff on duty, during most afternoons there are 2 and at night there are 2 care workers on duty. However, care staff also undertake aspects of cleaning, cooking and laundry work and recent redecoration of some rooms has been voluntarily carried out by the manager and a care worker in their off-duty time. Most residents consider the staff to be helpful and willing but one commented “I don’t consider there’s much looking after”. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 37 & 38 The systems for service user consultation in the home are poor with little evidence that service user views are sought or acted upon. The Commission has not received regular reports about the conduct of the home including notification of recent events which adversely affected the safety of service users. In consequence, risks to residents have been increased. Fire safety equipment is not all properly maintained and staff have not received fire safety training at required frequencies, so in the event of fire in the home, it may not be properly contained and staff may not know what action to take to protect residents and themselves from harm. EVIDENCE: The home does not arrange meetings for residents or their relatives and has not established a system for obtaining their opinions about the home. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 20 To meet a recommendation of the previous report, the home has recently commenced use of a questionnaire to obtain the opinions of service users about Drayton House. 9 completed questionnaires have been returned to the home and indicate general satisfaction although 2 rate the laundry service as ‘fair’ and one rates the home’s “décor and general ambience” as fair. (The options for ratings are ‘Poor’, ‘Fair’, ‘Good’ and ‘Excellent’.) The home has taken no other action to obtain the views of service users about the home and does not carry out a formal system of internal audit to ensure that good general standards are met and maintained. With the exception of those provided for the months of March, April and May 2005 the Registered Person has not provided reports to the Commission at the monthly frequency required by the Care Standards Act 2000. The home has failed to notify the Commission of a number of recent incidents when residents were placed at risk of harm or injury by the behaviour of other residents. The Commission has thereby been unaware of these incidents and in consequence unable to provide staff with necessary guidance and information designed to minimise and properly manage the risks. Records were not all kept in good order; the care records of one resident were incomplete and an accident form had been crushed beneath a recruitment record folder in a filing cabinet. Care records not in current use were not stored in systematic order, being instead randomly placed in folders labelled for individual residents. There are regularly recorded checks and tests of fire safety equipment but records of fire safety training to staff did not reliably indicate that all staff have received training at the required frequencies. For example, records showed that 2 night care workers have received fire safety training on only 2 occasions during the past year; for night care staff Dorset Fire & Rescue Service require training to be undertaken at least 4 times during every 12 month period. A requirement has been issued to address this shortfall. At the first visit an Immediate Requirement was issued regarding the fire door at the top of the main stairs which could not be closed; at the second visit another Immediate Requirement was issued because it did not close to latch. The same door was the subject of an Immediate Requirement issued during the previous inspection. An unlocked cabinet in a communal bathroom held a large container of bleach, which would be extremely hazardous if drunk or in contact with skin. An Immediate Requirement was issued for the safe storage of hazardous products. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 1 x 1 x x 1 x 1 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 x x 1 x x x 1 1 Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? 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 3 Regulation 14(a) Requirement Prior to admission the significant needs/circumstances of each prospective resident must be assessed and adequate records kept of this assessment. A comprehensive care plan must be recorded for each resident. Residents health needs must be fully met at all times. Medicine administration procedures must be properly adhered to at all times. Medicines (including creams, lotions and other medicaments) must be administered only to service users for whom they have been dispensed. Previous timescale of 13/09/04 not met. The home must regularly consult residents about their social interests and must arrange an appropriate variety of activities. At all times food products must be properly stored. The room in which they are kept should not be used to store cleaning and other items unrelated to food storage. Dry stores should be in sealed containers. ‘Best before’ dates must be noted and Timescale for action 16/09/05 2. 3. 4. 5. 7 8 9 9 17 13 13 13 16/09/05 15/09/08 15/08/05 09/08/05 6. 12 16(2)(m) 01/11/05 7. 15 & 38 13(4) 09/08/05 Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 23 8. 18 13(6)&13 (7) 9. 18 & 37 37 10. 19 23(2)(b & d 11. 19 16(2)(c) 12. 19 23(2)(e) 13. 19 & 38 23(4) 14. 21 23(2)(e) 15. 21 23(2)(l) products ‘out of date’ withdrawn from use. The registered person must be able to demonstrate that robust procedures have been developed for responding to suspicion or evidence of abuse or neglect, in accordance with the Department of Health guidance ‘No Secrets’. Previous timescales of 01/07/04 and 01/11/04 not met. The registered person must promptly notify the Commission of any event in the home which seriously adversely affects the well-being or safety of any service user. There must be a written programme of routine maintenance and renewal of the fabric and decoration of the premises. Previous timescale of 14/10/04 not met.. The damaged furnishings described in this report must be repaired or replaced. Previous timescale of 01/11/04 not met.. At all times service user accommodation must be maintained to a satisfactory standard. Previous timescale of 14/10/04 not met. The fire door at the top of the main stairs must be adjusted to fit and close to latch. Previous timescale of 20/09/04 and 11/08/05 not met. The doors of all bathrooms and toilets (including en suite facilities) must be fitted with suitable locks enabling staff access in emergency. Previous timescale of 01/11/04 not met. Separate provision must be made for the secure storage of cleaning equipment. Previous timescale of 01/11/04 not met. 16/09/05 16/09/05 01/10/05 01/10/05 01/10/05 15/08/05 16/09/05 16/09/05 Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 24 16. 21 23(2)(e) 17. 24 23(2)(p) 18. 19. 26 38 16(2)(j) 23(4)(d) 20. 37 26 21. 22. 23. 38 13 The substandard aspects of bathroom and toilet decoration and general conditions described in this report must be made good. Previous timescale of 01/11/04 not met. Bedside lighting must be made available to each service user. Previous timescale of 01/01/05 not met. All parts of the home must be kept clean and in good order. There must be reliable recorded evidence that each member of staff has received fire safety training at the required frequencies; arrangements to provide such training to staff who have received none during recent months must be made. The Responsible Individual must arrange for the home to be visited at least once each month to inspect the premises, interview, with their consent, residents and staff and must provide to the Commission a written report on the conduct of the home. At all times hazardous substances must be securely stored. 01/11/05 01/10/05 16/09/05 15/09/05 16/09/05 09/08/05 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 9 Good Practice Recommendations A Controlled Drug register should be made available. This recommendation is repeated from the previous inspection report. D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 25 Drayton House 2. 3. 4. 5. 11 12 26 26 6. 7. 27 33 8. 37 The written procedure regarding management of death/sudden (unexpected/accidental) death should be improved to ensure accuracy and clarity. A programme of social and recreational activities should be provided and made known to each resident. 15A choice of all meals should be routinely provided from a written menu. The home should have written evidence of compliance with the Water Supply (Water Fittings) Regulations 1999. This recommendation was also included in the report of the previous inspection but remains unmet. Care staff should not be diverted to tasks unassociated with their main purpose of providing personal and social care to residents. An effective quality assurance and self-monitoring system should be introduced (preferably a professionally recognised system) involving service users and taking place at least annually.The home should be able to provide evidence that there is an annual development plan for the home, based on a systematic cycle of planning-actionreview and that there is continuous self-monitoring with annual audit. This recommendation has been repeatedly made in previous reports. Records no longer in current use should be systematically filed to ensure they remain in good order. Drayton House D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole Dorset BH17 0NF National Enquiry Line: 0845 015 0120 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 D55 S36054 Drayton House V243293 090805 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!