CARE HOME ADULTS 18-65
Drayton Wood Drayton High Road Drayton Norwich Norfolk NR8 6BL Lead Inspector
Mrs Judith Last Unannounced Inspection 14th June 2007 02:30 Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 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 Wood DS0000027499.V343749.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 Adults 18-65. 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 Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Drayton Wood Address Drayton High Road Drayton Norwich Norfolk NR8 6BL 01603 409451 01603 426568 bennellcare@tiscali.co.uk 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) Benell Care Services Limited Ms Sonja Serruys Care Home 29 Category(ies) of Learning disability (29) registration, with number of places Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. In total twenty-nine (29) people of either sex, who have a learning disability, may be accommodated. Nine (9) people, of either sex, with a learning disability may be accommodated in Drayton Wood main house. Six (6) people, of either sex, with a learning disability may be accommodated in Cedar Lodge. Seven (7) people, of either sex, with a learning disability may be accommodated in Holly Lodge. Seven (7) people, of either sex, with a learning disability may be accommodated in Honeysuckle Lodge. 21st June 2006 Date of last inspection Brief Description of the Service: The home is registered to provide services to adults with learning disabilities who are between the ages of 18 and 65 years. Drayton Wood is set in seven acres of landscaped gardens and forty acres of woodland. In the grounds there are pens for pygmy goats and chickens and there is an aviary. At the present time there are, on the site, four houses accommodating service users. Drayton Wood is original building and dates back to Victorian times. There are three much more recent purpose-built houses known as Holly Lodge, Cedar Lodge and Honeysuckle Lodge. Although the four units are registered as one, they function almost independently of each other with separate staff teams and service users with different needs. The main house, Drayton Wood, provides accommodation for up to nine service users. There is one shared bedroom that is used for couples wishing to share, and seven single bedrooms. Seven of the eight rooms have en-suite facilities. There is a large lounge and dining area and a dedicated busy colourful day care centre. Cedar and Holly Lodges each provide accommodation for six and seven service users respectively, in single bedrooms with en-suite facilities. Honeysuckle Lodge was registered in January 2006 to accommodate 7 people. One further unit for 7 people, Spruce Lodge, remains yet to be completed. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 5 The home is located within easy access to the City of Norwich and other nearby towns and villages. Drayton Wood was awarded the Investors in People Award in December 2004. Fees are from £1798 to £3983.44 per month, dependent upon needs and dependency, with additional charges for hairdressing, chiropody, transport and personal spending. The manager says that the inspection report is made available to people who ask for it, but not left accessible as it would be destroyed. Following an earlier inspection, the manager wrote to all relatives to tell them how they could access the inspection report. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. We made two visits to the home to look at things and spent over 8 hours there in all. We spoke to the manager, one relative, some of the staff, and to four people living at the home. We also looked at the records the home keeps including people’s care records. We got other information from 21 written comment cards sent to us by people living at the home (with support from staff), and from four relatives. We also spoke to one relative on the telephone. We used this information and looked at our rules to see how well the service was doing. People are having an adequate service at the moment. However, this is only because of a few things that need to be improved. People generally have a good quality of life at the home and the manager and staff team have worked hard to do this. What the service does well:
People living at the home are supported to make decisions and choices about their care and their daily lives. They have lots of opportunities for activities, inside and outside the home and staff work hard to make these enjoyable. This includes taking people on holiday. Care plans set out the sort of support people need, so that staff are clear about what they need to do to help meet people’s needs. People are happy with the care they get. Staff work hard to help them keep well and to see other people like the doctor or nurse, who can help with this. Staff also take care to make sure that they explain things to people and have a good understanding of what support people need. Ms Serruys has started to make sure her management team look in some detail at how they meet the standards and can use this information to help look at how well the service is doing. She already asks people living at the home what they think of the way their home is run. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
There are only two things that need to happen by law. These are to do with the way medicines are handled, to make sure this is consistently fully recorded. The records kept about medication need to improve to match regulations in all cases. This is so that if there is a problem, this can be picked up easily and quickly. These improvements are also needed to provide an extra check on dosages so that everyone can be confident people have the medication they need in the right strengths at the right time. There are some other things that could happen and would be good practice. Some of these are to do with the level of detail and consistency in care plans, making sure that all the available information is included and that there are contingency plans in place where this is appropriate. Although staff are aware of much of the information, it would be better clearly set down in one place. The way new staff are allocated to the units needs to be looked at. If several new staff are completing their induction in one of the houses all at the same time, it makes it very difficult to be sure they are supervised on a day to day basis as they need to be. The manager can tell you about the other things that are in the report. 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 Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are proposing to move to the home generally have access to information to enable them to make informed choices and will have their needs assessed so they can be sure these will be met. EVIDENCE: There are full assessments on file for people newly admitted and dates show these are completed before people arrive. There was also evidence that information is obtained from relatives and other interested parties. One file also contained a specific pre-admission plan showing the programme of visits, including a tea visit and overnight stays, so that the person could get used to the service. Daily records for newly admitted people show that staff take care to explain any routines and responsibilities. Files all contained statements of terms and conditions and where possible these were signed by service users and the manager. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 10 There were letters on file showing that the complaints procedure is sent out to representatives/relatives of people who are newly admitted to the service. One said that the Statement of Purpose had been sent, as a matter of course. In others, it was unclear whether the Statement of Purpose or Service User Guide had been given to representatives. A recommendation has been made. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents know their needs and the things they would like to do are reflected in their individual plans. They are supported to make decisions and to take reasonable risks. EVIDENCE: We checked three care plans for people who have moved in since the last inspection. Care plans are generated from assessments and produced using a computer system known as “Resicare”. They contain information about a wide range of needs and how staff are expected to meet them. These include people’s preferences and preferred routines, need for support with personal care, mobility, communication, social needs and domestic abilities. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 12 All of the 21 service users responding in comment cards say that they have care plans. Two people spoken to say that they know what is in them and that staff help them with the things they want to do. One person told us about some of their problems at present and this matched the staff account and the care plan showing the emotional support they needed. The process of review has taken place where needs have changed. Some aspects of care are due for routine reviews at the present time. There are minor inconsistencies in information contained in files although staff spoken with or listened to at handover showed that they were aware of current need. For example, notes of discussions at review in April for one person say that their independence in shaving has improved since the acquisition of an electric razor. The care plan itself, dated for February, shows that the person needs assistance to shave. Similarly, one staff member spoken to was aware of information about someone’s mental health state, although the care plan did not totally reflect the interventions considered as successful by relatives. A recommendation has been made. Risks within each area of care are identified on the plan and the “treatment” section sets out what staff are to do to support people. Staff say that this part is to minimise the risk. However, contingency plans are not clearly identified. For example one person is identified as having mental health problems. Although a staff member and the manager consider this well controlled by medication, the care plan does not contain clear information about the actions to take in the event of a crisis and what the warning signs of a developing crisis would be. A recommendation has been made. On another file seen, there were clear risk assessments to do with mobility and continence management. Service users are encouraged to sign some information in their files. There are sheets to record what staff have done to make people’s care plans accessible, recording when they were explained to the person and by whom. This is good practice. The service is in the process of arranging additional training for a communication coordinator as one of the units is currently without a staff member with this training. 19 out of 21 service users completing comment cards say that they feel well cared for and are well treated by staff, (Over 90 .). Two people responded that they feel well cared for “sometimes”. All four relatives sending written comments say that they are consulted about care. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a range of appropriate activities, including opportunities to make choices and to practice or learn skills. EVIDENCE: One relative specifically writes in a comment card that the manager and staff do everything possible to make people’s lives as full and enjoyable as possible. There are people trained as communication coordinators in the main home, Cedar Lodge and Holly Lodge. One of the small homes does not currently have someone who has completed training to support people with this, although there are plans to do so. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 14 Records show people have access to a range of opportunities, including formal day care, work at nurseries, and a variety of leisure opportunities. One person told us they were completing a course at Easton College and will go to the presentation to receive their certificate. We saw that people had chances to go out with staff or on their own according to risk. This included a trip to Yarmouth, a shopping trip, walking in the grounds, and going out to buy magazines. People also go on holiday and one showed us a photo diary of what they had done when they were away. One care plan we saw showed that the person had a relationship that was important to maintain having moved to the home. The person told us they see their friend regularly and share meals and that they can go and visit their friend in their own home. Records show that support given to maintain contact with family members matches what care plans say is needed. All four relatives completing comment cards say that they are welcomed into the home at any time and can visit in private. One person told us they had cleaned and tidied their bedroom. They say that staff do the washing, but that they are supported to do their own ironing. Terms and conditions of residence set out that people are encouraged to participate in domestic routines. Just over half of service users completing comment cards say they have keys for their rooms and two people confirmed this although they did not necessarily keep their rooms locked. All of the people answering the question in comment cards say that they can keep things that are theirs private. Care plans record people’s decision if they wish staff to open their letters on their behalf. The person concerned had signed the one seen. Each house plans its own menus and there are records in notes from residents’ meetings that food and menus is one of the things they discuss. Everyone completing comment cards says that they get to choose what they eat. Almost two thirds of people say that they are involved in shopping for food from time to time. People told us they like the food. Records show that people are weighed regularly so that any developing problems with nutrition can be identified, although they are not routinely screened. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good support with managing their personal and health care needs. Outcomes would have been good had medication systems been more robustly implemented in line with good recording and management practice, to show service users are properly protected from error or misuse. EVIDENCE: Records in care plans show what personal care people need and how staff are to support them with maintaining personal hygiene. This includes the goal for such support to be given with privacy and dignity. They are clear about people’s abilities to make decisions about the clothes they wear and about the encouragement people need to retain or develop some independence and responsibility for their routines. There are mixed staff groups in most of the “units” and so, dependent upon the duty roster, people could have some choice in who supports them with personal care. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 16 One person has been equipped with the mobility aids. The person told us that they wished for a change in arrangements. Staff and records confirm that the person’s wishes were being acted upon. They also told us about the kind of support they needed. This matched what was set out in the person’s care plan. Care plans set out how often health care appointments are needed and show when these take place. There is a sheet in each file listing health professionals who are involved in people’s care and how or where they can be contacted. One relative writing to us says that members of the family are impressed with the standard of care at the home. One person spoken to on the telephone says that staff are very good and caring and that they are very happy with the standard of care their relative receives. All four people writing to us say that they are satisfied with the overall standard of care their relatives receive. The local pharmacist is providing training in managing medication and there are workbooks for staff to complete. The manager says that staff do not give medication until they have had training, (but they do not have to have completed the workbooks). The confidence of staff is taken into account in the process. However, there are no records to show that practical abilities rather than self expressed confidence, are assessed to make sure people are able to carry out the process. A recommendation has been made. Staff have access to information about medication and care plans say what medication people have. The person showing us the system knew what conditions the medicines we asked about had been prescribed for and told us what checks would be made when giving it. Medication brought into the home is not consistently recorded on the MAR charts. This meant that, when checked, there were discrepancies in the amounts recorded as supplied by the pharmacy, doses given, and stock left. There was no evidence of a management audit or check that would have identified this as an issue. The strength of some medication supplied via a dentist and the amount received had not been recorded. There was an omission of signature for one of the antibiotics and no alternative coding meaning that it was not possible to determine the person had been given the medication as prescribed. Most medicine is in monitored dosage packs. These were being used appropriately and doses remaining corresponded to those not yet given. There is policy guidance for administration. Care plan files record people’s consent and agreement to have medicine s administered to them by staff. These are signed by the service user and by the staff member explaining the information. This is good practice.
Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People feel safe at the home, know their concerns (or those of their representatives) will be taken seriously and there are measures in place to help prevent abuse. EVIDENCE: Copies of correspondence from the manager to the relatives of people moving into the home show that the complaints procedure is sent to them. All four relatives writing to us about the service say that they know how to complain, but that they have not had to. One relative specifically commented that any issues or concerns are dealt with promptly and with consideration to both service users and their relatives. Service users comment cards say that they all feel safe at the home (one person did not answer). Two care plan files seen contained a copy of the complaints procedure simplified with Widget symbols. The people concerned sign these. However, one file did not show on the sheet provided that the procedure had been explained to the person or that they had any copy of the information. One person completing a comment card says that they do not know who to talk to if they have concerns. However, the remainder say they do. A recommendation has been made. Staff have regular training in the protection of vulnerable adults. Service users spoken to say they like the staff, staff are good and that they have no complaints or concerns.
Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 18 Staff are checked against the list for the protection of vulnerable adults before they start work and references are taken up. (See staffing section). There has been one referral to the adult protection team and this arose from some aggression between service users. There were notes supporting that the home had acted appropriately and promptly in referring to the adult protection team for advice and respecting the rights of the people concerned. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, service users benefit from an environment that is safe, homely and clean. EVIDENCE: Major redecoration has taken place since the last inspection to rectify the damage caused by the replacement of the heating system in the main home. Three people told us they were very happy with their rooms and one relative writing to us was very happy with the standard of accommodation. There have been no concerns relayed to the Commission by the fire service or by environmental health. There is rotten wood to the office window in the main building. This is flaking away in pieces. Water had been leaking into the office on our arrival on the first visit and there was a bucket on the desk area. The woodwork to close to the main front door in this building is also in poor condition and poorly painted. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 20 There has been some damage to the wall of the “quiet” lounge cause by a leak in the porch. This has not yet been made good, being slightly bubbled and stained. The manager told us the leak has now been repaired. Neither of these areas impacts greatly on the environment for people living at the home. Other areas of the homes seen showed reasonable maintenance and décor, and that staff work hard to try and keep them clean. There is guidance for staff about hand washing and training in infection control as well as food safety. However, the training matrix shows that some of this training has passed the “expiry date” shown on the matrix and that many food hygiene certificates will need renewing in July. During our visit, the training coordinator told us that she has arranged for basic food hygiene training to take place. The laundry has been redecorated. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good progress is being made towards staff achieving the necessary qualifications, although there are issues about the practical day to day supervision of staff completing induction when new staff are all recruited to work in one unit. EVIDENCE: Not all people in possession of NVQ qualifications were shown on the training matrix. The manager identified more people who have this and these were added to the matrix. However, taking into account the updated information, and the revised matrix provided, 13 people were shown with at least NVQ level 2 or equivalent. This represents under 50 , although there are, from the matrix, people either already in progress or awaiting enrolment for the training which would allow the ratio of 50 set out in standards to be exceeded. A random sample of names were checked and evidence of certificates seen on file. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 22 The training matrix shows that staff in one unit do not have mental health training despite accommodating someone who has difficulties in this area. However, there are staff in another unit who have training and could provide support or advice, based on the matrix. A recommendation has been made. The training coordinator told us that she oversees with team leaders, the delivery of induction training and the supervision of staff during this process. The training manager and a home leader spoken told us the names of people responsible for supervising staff while they complete their induction, but the roster does not support these people are always able to share shifts with new staff completing induction. As new staff have been recruited to work predominantly in the same unit, this compounds the difficulty. A recommendation has been made. Staff files did not contain evidence of responses to interview questions for applicants to help show equality of opportunity in the process if challenged. Because the responses are not there the manager cannot also show that she has explored any queries with references or employment histories. However, she gave an account of doing so and contacted one person during the visit to tie up loose ends. A recommendation has been made. Files show that enhanced Criminal Records Bureau checks are applied for before people start work and checks against the list for the protection of vulnerable adults are made. Supervision has improved – based on records and schedules seen. Mostly records show this as individual although some group supervision, (for example of team leaders), takes place where there are common issues needing to be addressed. One relative writing to us specifically commented that staff are always very approachable and very friendly. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home benefit from a service that is run with regard to their welfare, safety and taking into account their views. EVIDENCE: The manager is qualified. Management responsibilities are delegated within an appropriate structure. The manager has a deputy manager and each home has a home leader. Surveys of people’s views are carried out and results published in a report. The manager says there have been poor responses from relatives and care professionals. A system of checking and grading performance of individual units within the home against individual standards has been brought in via management meetings, although these are not consistently completed for all the care units on the site. Currently the manager says she is using this as a Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 24 means of ensuring team leaders are aware of the content of standards and not to feed into the quality assurance process. 85 , (17), of service users in comment cards say that they have meetings from time to time to talk about what is good and what can be changed. There are no concerns with checks in place for safety; records show regular servicing and testing in sample seen and stickers posted on appliances etc. Guidance about health and safety is available in the policy manual (and posted with reference to hand washing for example). There are COSHH manuals for each small home and health and safety training offered. First aid and health and safety training is out of date for some people based on the training matrix. For example, for one person first aid training was undertaken in a previous job and ran out in the middle of 2004. However, taking into account this slippage, all staff have had training at some point in first aid, health and safety, food handling and infection control. The training coordinator acted to rectify some of this during our visit. Drayton Wood DS0000027499.V343749.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 Adults 18-65 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 3 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Drayton Wood DS0000027499.V343749.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 YA20 Regulation 13.2 Requirement Timescale for action 31/07/07 2. YA20 17.1.a, Sch 3.3.i Systems for recording medication must provide for a clear audit trail. This is to ensure errors can be easily and promptly identified to protect service users from misuse The administration of medicines 31/07/07 and the strength of dose must be consistently recorded to comply with regulations and to show that people have their medicines administered as prescribed. Drayton Wood DS0000027499.V343749.R01.S.doc Version 5.2 Page 27 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 YA1 Good Practice Recommendations Records should be used to confirm that people or their representatives have been given a copy of the service users’ guide before they move into the home. This is so they can make an informed choice about whether it is suitable. Staff should make sure that information from all sources, and any progress made is used to update care plans. This is so they show more fully in writing, what kind of support people need and how well they are being supported to attain skills, independence and control of their lives. Care plans should record information about signs that mental health is deteriorating so that staff can respond promptly to a developing crisis and make sure people are safe or get any extra help they may need. The manager should satisfy herself that staff are able to apply the training they have had to manage medication. This is so she can rely on staff to carry out the process safely. Records should be reviewed so that the staff and management team can be confident each person has had every effort made to explain to them what they should do if they have any concerns about their care. This is so they can be confident about how to raise concerns if they are able to do so independently. Staff who are offering support to people with mental health difficulties in addition to learning difficulties, should be provided with training in this area. This is so they could be confident they understood the person’s condition and needs should problems surface. The manager should keep notes of interviews to show she has explored any queries arising from references or employment histories, and so that she can demonstrate how equal opportunities are upheld in recruitment. Duty rosters should show how people are supervised during induction, taking into account the possible need for temporary moves to allow for this properly. This is show it is clearer how the process is being used to protect people.
DS0000027499.V343749.R01.S.doc Version 5.2 Page 28 2. YA6 3. YA9 4. YA20 5. YA22 6. YA32 7. YA34 8. YA35 Drayton Wood Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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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