Inspection on 26/07/05 for Drayton Wood

This inspection was carried out on 26th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drayton Wood 08/06/09

Drayton Wood 09/06/08

Drayton Wood 14/06/07

Drayton Wood 21/06/06

Drayton Wood 04/01/06

Drayton Wood 18/01/05

Drayton Wood 24/05/04

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

CARE HOME ADULTS 18-65 DRAYTON WOOD Drayton High Road Drayton Norwich NR8 6BL Lead Inspector David Welch Announced 26 July 2005 09:40 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Drayton Wood Address Drayton High Road, Drayton, Norwich, Norfolk, NR8 6BL 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) 01603 409451 01603 426568 None Benell Care Services Limited Ms Sonja Serruys Care Home 22 Category(ies) of LD Learning disability registration, with number of places DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Twenty-two (22) people, of either sex, who have a Learning Disability, may be accommodated. Date of last inspection 18 January 2005 Brief Description of the Service: Drayton Wood is set in seven acres of landscaped gardens and forty acres of woodland. In the grounds there are pens for ornamental goats and chickens and there is an aviary with zebra finches. At the present time there are on the site three houses accommodating service users. Drayton Wood is the main building. This was constructed in 1900. There are two much more recent purpose-built houses, known as Holly Lodge and Cedar Lodge. Although the three units are registered as one, they function almost independently of each other, with separate staff teams and service users with different needs. At the time of inspection, the main house Wood provided accommodation for eight service users (one vacancy), in one shared bedroom and seven single bedrooms. The majority of the rooms have en-suite facilities. There is a large lounge and dining area and a dedicated, and very busily colourful, day care centre. Holly Lodge and Cedar Lodge each provide accommodation for six or seven service users in single bedrooms with en-suite facilities. The home is registered to provide services to adults with learning disabilities who are under the age of 65 years. 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. Two houses, of similar design to Holly and Cedar Lodges, have been built in the grounds, but at time of the inspection the Commission was waiting for an application from the providers to increase the number, and possibly the category, of service users. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. When, in this report, the Commission talks about ‘Drayton Wood’, it means the three houses, Drayton Wood, Cedar Lodge and Holly Lodge. The announced inspection took place during one day in July and lasted for almost nine hours. Service users and staff had been informed prior to the visit that the inspection was due to take place. The Commission had provided the home with posters advertising the inspection and these were displayed on the front doors of both Holly and Cedar Lodges. Comment cards had been sent to the home for completion by interested relatives. The Commission received four comment cards, which were in general quite positive about the care at Drayton Wood. On the day of the inspection, service users and staff in each house were reminded about the visit in notices left by the Commission, inviting people to speak to Mr Welch if they wanted to. During the visit the Registered Manager, Ms Sonja Serruys, was available throughout the day. It was possible to speak in private with three staff on duty. Other staff were spoken with in passing and as they went about their duties. A number of service users were kind enough to agree to private interviews and several others contributed to the inspection when they talked about their lives at Drayton Wood, including what they had been doing that day. The visit provided a chance to talk about what changes there might be to the Commission in the next couple for years and what immediate changes the home will notice in the report format now being used. Hopefully, it will be more user-friendly, jargon free and more accessible to the people living and working in the home. Ms Serruys wanted to talk about the two new houses that were in the process of being finished and how they might be used. Two matters were discussed in depth; firstly, the use of ‘velux’ windows in first floor bedrooms at the back of both houses. People using the bedrooms concerned would not have any view. And secondly, the very austere chain link fence at the back of one house that enclosed what could eventually be a ‘secure garden’ for older people with dementia. At the end of the inspection, a leaflet was left for the relative of one person living at the home asking the question ‘Is the care you get the care you need?’ and on which information about CSCI was given. At the end of the day a short meeting was held with the manager to give feedback on how the Commission views the service being provided at Drayton Wood. A short questionnaire was DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 6 left with the manger on which she could give her views on the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The requirement remains to provide a heating system that residents can control individually and does not put them at risk from hot radiator surfaces. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 7 The Statement of Purpose must be developed as a matter of urgency and, similarly, a suitable Service User’s Guide in different formats. Every person coming to live here must have an assessment of what they need before taking up permanent residence. Staff must have training in the Protection of Vulnerable Adults (POVA) and in an accredited programme of physical control and restraint. Recruitment checks must leave no room for doubt about an applicant’s fitness for the job, or their integrity. To this end, the manager should carefully consider the working patterns of two people already employed. Any risks that service users might be open to must be considered and action taken to minimise them. A more private place should be found for visiting health professionals. Service users, their friends and relatives, partner agencies and other professionals should be canvassed for their views on how the home is doing. 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 WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 In the absence of a suitably detailed Statement of Purpose and a Service User’s Guide in different formats such as sign, symbol, audio and/or video, prospective service users are unlikely to have all the information necessary to make an informed choice about where they want to live. If a full assessment of a resident’s needs has not been carried out in every case before decisions are made about admission, the home will be hampered when considering if it can provide the most suitable care. EVIDENCE: A residential home’s Statement of Purpose is intended to ‘set out its stall’ in terms of the precise service it offers to residents and the way it intends to operate. A recommendation was made at a previous inspection that the home drew up a Statement of Purpose that included all the elements detailed in the Care Homes Regulations 2001. This matter was returned to at this inspection. Ms Serruys kindly provided a copy of the Statement of Purpose updated first on 21st June 2002 and reviewed on 9th June 2004 and again on 4th July 2005. Unfortunately, the document still fails to give the information required under Schedule 1 of the Care Homes Regulations 2001 where the information is clearly set down under different headings and gives a really useful steer to what must be included. The provision of a suitably detailed Statement of Purpose is now overdue and a requirement has been made for immediate attention to be given to this matter. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 10 The home had no Service User’s Guide in different formats so that all service users had a chance of understanding what was being provided at Drayton Wood. This, too, is urgent. The Complaints Procedure had been provided using ‘Widget’ symbols. This is good practice. The most recent admission, a young woman with learning disabilities, had been admitted to the home in what was described as ‘an emergency’. Because the person concerned was known to the home through the in-house day care service, no needs-led assessment had been completed. Despite this, the quality of life of the person concerned appeared to be of quite a high order. In preparation for admission to one of the new houses, an assessment had been started for a prospective resident. This must happen in every case. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. The Commission is confident that at the time of the inspection service users were being helped to make choices about their care and provided with the level of help and assistance they need. In some situations the risks that residents might be exposed to have not been identified and therefore their safety could be compromised. EVIDENCE: Four service users were tracked and three had had a review within the last 9 months. Records for the fourth had been archived, but the person concerned was due another review in August this year. A Team Leader said that responsibility for arranging reviews is largely shared between day care services and the home as many residents do not at present have social workers. The home dealt with challenging behaviour in a number of ways, including bringing in a psychologist for advice, talking 1:1 with the person concerned, removing him or her or other residents or suggesting ‘time out’. Ms Serruys was aware that with early onset dementia the behaviour of one person, at least, was “beginning to be more aggressive”, she said. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 12 One member of staff said that he had discussed with a service user for whom he is a ‘keyworker’ the person’s Care Plan after which it was agreed and signed off. A service user mentioned that he had talked about his Care Plan with a special member of staff. Each service user had a day during which he or she was ‘at home’ and, with the assistance of a keyworker or other member of staff, made decisions about their life. Each resident had a bank or building society account into which his or her money was placed. This is good practice. Any limitations and/or restrictions on the activities of certain service users were discussed. The risks that service users might take in their everyday lives are termed in the home’s records ‘evaluations’. Many aspects had been considered, but not in every case had risks been identified or action taken to minimise them. For instance, three people have bedrooms on the first floor of the main house with access to very attractive balconies overlooking landscaped gardens. No specific risk assessment had been made to take account of the potential for an accident to happen. A requirement that this is done has been made. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14 and 15. The range of activities, outings, day care, community use and family contact was something the home does well. A careful approach has been taken to involvement with friends and who is allowed to visit. EVIDENCE: A number of people have spiritual support and guidance from visiting clergy or attend local churches. They either make their own way, are assisted by members of the church or by staff at the home. One service user confirmed that a sister from the local Roman Catholic church visits him. One resident is made so very welcome at the local Methodist church that they are allowed to stand alongside the pastor when he is addressing the congregation. Four service users, different people from those mentioned above, were tracked and their day care/education/work experience activities were looked at. All had some form of day care activity for all, or some of the week. Service users regularly use the local pub, park, fast food outlet, use buses to go into the city and shop at the superstore. The manager described two people as ‘real party girls’. The contact the four people had with members of their family were DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 14 discussed and the arrangements made for them to have an annual holiday. Ms Serruys was not able to say whether the basic contract price paid by the placing authority included the cost of a 7-day annual holiday. Indeed, she described how each service user saves up to pay for their holiday, but the home contribute by means of additional staff and transport costs. A requirement has been made that Ms Serruys enquires of the placing authority about this matter and, if the cost of a holiday is not included, negotiates with them accordingly. A couple were currently living in a shared room in the home and other residents spoke about their ‘boyfriends’. In some cases, friends visit Drayton Wood, although this could be on a supervised basis. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18. Residents are given proper support and help by staff in line with their wishes and needs. In one respect privacy and dignity could be adversely affected by the care given by a visiting professional. EVIDENCE: In the pre-inspection questionnaire kindly sent to the Commission by Ms Serruys prior to the inspection taking place, she said that a chiropodist visits Drayton Wood every six weeks or so. Foot care is apparently given in a communal area and this is not either private or dignified for service users. She was asked to identify a more suitable place for this care to be carried out. Nobody needed to be hoisted as part of his or her care at the home. People with mental health problems (not their primary need for care) were helped by the involvement of GP’s and, where necessary, by Community Psychiatric Nurses and psychologists. One resident described how he liked to take a daily bath. A member of staff was close at hand, but not immediately present. This gave him some reassurance. Another resident described his one to one relationship with a carer employed to provide individual attention for two days a week. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 16 Four residents were busily engaged in the home’s day care centre. Activities included computer programmes, painting, embroidery, jigsaws, art and crafts, drawing, modelling etc. The centre was bright and cheerful and an extraordinary number of examples of artwork had been displayed. It was a very inspiring place. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The manner in which stakeholders in every respect are able to raise issues could be improved. They might need to be reminded of the process. The Commission harbours some concerns about how management had dealt with a particular matter recently and the way the home’s staff have been made aware of Protection of Vulnerable Adults (POVA) issues. An opportunity has been missed in ensuring residents are protected at all times and in all circumstances through a failure to provide training in physical control and restraint. EVIDENCE: One relative said in their comment card returned to the Commission that they were not aware of how to make a complaint to the home and the manager may wish to remind all relatives and family members with an interest in the home how to do so. The Complaints Procedure for residents had been provided using a symbolbased programme called ‘Widget’. The Complaints Log was looked at and three recent complaints considered. The home had followed Protection of Vulnerable Adults (POVA) protocols in investigating a possible incident of abuse by a family member. However, protocols were not followed in full when a resident complained, with the help of a trusted carer, about care he had received from another member of staff. Advice given by employment lawyers appears to have superseded what should have been done to ensure and protect the service user’s welfare in every DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 18 respect. When two members of staff said that they had not had Protection of Vulnerable Adults training, something confirmed by the home’s training coordinator, the Commission has been prompted to make a requirement that senior staff attend as a matter of urgency and then ‘trickle down’ to others what they have learned. Staff confirmed that they had not been trained in physical control and restraint as a ‘last resort’. Yet they described situations when residents might in certain circumstances need some ‘holding’, steering away or restraint. Ms Serruys said that the behaviour of one person was beginning to cause concern as it was becoming ‘more aggressive’. The trainer said that the approach of the home was one of non-intervention physically and Ms Serruys said that Norfolk County Council were unwilling to provide guidelines for management of behaviour that was physically challenging. All front line care staff must be suitably trained in an accredited programme of physical control and restraint. ‘Trickle down’ is not appropriate in this respect. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24. All three houses are comfortable and homely, and the two newer houses are safe. In the main house the heating installation continues to be a cause of some concern. EVIDENCE: A requirement had been made previously that the home ensures service users must be able to control the heating in their bedrooms and not run the risk of burning themselves on hot radiator surfaces. A timescale for action was given as 30th September 2004. The matter as again discussed at this inspection. Ms Serruys said that she had involved heating engineers and because the heating was now quite old, not compatible with modern sizes and unable to be adapted, the whole of the system in the main house was being replaced this autumn at a cost of £60,000. The new system would comply in all respects. Some redecoration had been done, including the lounge and three bedrooms in the main house. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36. Not in every case are the home’s recruitment procedures sufficiently robust. Staff training is generally OK, but some specific progress is looked for in the next 6 months. Staff support and supervision is satisfactory. EVIDENCE: The person employed to provide training to staff had been in post, she said, about a year. She had yet to compose a ‘training matrix’ for all staff, but has made a start at considering what training each person needed in the individual houses. A training matrix is an important tool in assessing training needs within a home and for keeping track of when updates might be needed and a recommendation has been made that one is worked up as soon as possible. Care staff confirmed that some training was available in-house. One person said that she had recently finished NVQ 3 in Care. A very recently appointed carer was in the process of being mentored until such time as her CRB disclosure is obtained and induction completed. A carer who was the subject of a complaint had been counselled and shadowed until management were confident that the person concerned was able to provide satisfactory care. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 21 Two people were in post and carrying out care duties, involving unsupervised and, possibly, personal care for service users before CRB disclosures had been obtained. In one case, a check had yet to be applied for despite the person being in post for almost a year. Ms Serruys said that this was an oversight. In the other case, the person was a ‘returner’ after leaving the job more than a year previously. Ms Serruys was reminded that CRB checks are no longer ‘portable’, i.e. they must be applied for whenever a person starts a new job where vulnerable people are concerned. She was required to consider the working practice of each of the people until such time as their CRB’s are returned. When looking at the recruitment of staff, Ms Serruys said that one person had left previous employment ‘under a cloud’. At the new employee’s request, no reference had been sought by the home from the previous employer in respect of this person. This is poor recruitment practice and cannot be said to be sufficiently robust. Two written references must be obtained in every case and this must include one from the most immediate previous employer. The employee had subsequently been subject of a complaint by a service user. Staff confirmed regular individual supervision and support available from senior staff out of hours. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42. By talking to residents on a daily basis the manager can sufficiently monitor the way the home is operating in line with what they want and need. Some improvements can be made in satisfactorily reflecting the views of service users, their families and friends and other stakeholders. EVIDENCE: The manager said that she monitors the service by doing what she described as her ‘rounds’, by talking to service uses and staff. Indeed, her good relationship with service users was observed on the day of the inspection. She attends, and sometimes takes, handovers at 3.00pm and will on occasion drop in to the handovers and staff meetings in the two newer houses. She has access via computer to the notes of all service users and has fortnightly meetings with senior staff including Team Leaders. She provides targets for staff and gives individual supervision to senior staff. Ms Serruys said that the home does have simple survey questionnaires for service users and these are occasionally handed out. No attempt had been DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 23 made to analyse the results and no statistics had been compiled. Service user views should be included in the Service User’s Guide (see Standard 1.2 viii). While Ms Serruys said that there was ‘an open door’ policy for relatives who visit regularly, no feedback had been obtained using questionnaires from the wider relative group, partner agencies, GP’s, social workers, Community Psychiatric Nurses, and/or other professionals. The views of families, friends, advocates and other stakeholders should be sought about how they perceive the home is delivering the service. The Fire Safety Log was looked at and found to be in order. Advice was given about only needing to check break glass points weekly in rotation. No fire doors were seen propped open unless held back with a magnetic closer or a Dorguard device. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 2 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 2 3 x x Standard No 31 32 33 34 35 36 Score x x x 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 DRAYTON WOOD Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 25 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 YA1 Regulation 4(1)(a)(b) and (c) Requirement The Registered Persons must provide a Statement of Purpose for the home that includes all of the details in Schedule 1 of the Care Homes Regulations 2001. The Registered Persons must provide a Service User Guide, in a variety of formats, if necessary, that is suitable for all service users for whom the home is intended. The Registered Persons must ensure that a needs-led assessment is carried out in every case prior to the admission of any prosepctive service user. The Registered Persons must ensure that the risks to all service users are identified and action taken to minimise them. The Registered Persons must negotiate with placing authorities about including in the contract price for each user a sum to cover the cost of a seven-day annual holiday. The Registered Persons must ensure that all staff receive Protection of Vulnerable Adults (POVA) training. The Registered Persons must Timescale for action Immediate 2. Ya1 5(1)(a) to (f) By 31th October 2005. 3. YA2 14(1)(a) to (d) On-going. 4. YA9 13(4)(a) to (c) 5(3) Immediate and ongoing. By 30th September 2005. 5. YA14 6. YA23 18(a) and (c)(i) 18(a) and By 31st January 2006. By 31st Page 26 7. YA23 DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 (c)(i) 8. YA24 4(a) and (c) 9. YA34 19(b)(i) ensue that all members of staff receive training in physical control and restraint. The Registered Persons must ensure that service users are able to control the heating in their bedrooms and are protected from hot radiator surfaces. The Commission understands that the Registered Persons have decided to replace the heating system in the main house. The Registered Persons must ensure that the homes recruitment procedures fulfill all the requirements set out in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001. In particular, this includes obtaining two written references, one from the immediate previous employer and a CRB disclosure before the person concerned takes up their post. January 2006. By 31st December 2005. Immediate and ongoing. 10. 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 YA18 Good Practice Recommendations The Registered Persons should provide for visiting health professionals, such as the chiropodist, a private area in which care can be given; one that does not in any way compromise the dignity of users receiving care. Regulation 12(4)(a) refers. The Registered Persons should remind relatives and other stakeholders about the homes Complaints Procedure and, in particular, how to make a complaint, if they wish. Regulation 22(12) refers. The Registered Persons should encourage the person employed as the homes training co-ordinator to develop a training matrix for staff. Regulation 18 refers. I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 27 2. YA22 3. YA36 DRAYTON WOOD 4. YA39 5. YA39 The Registered Persons should seek service users views, analyse the results and record them in the Service User Guide that is available to people living in the home. Regulation 24(3) refers. The Registered Persons should by way of questionnaires canvass the views of relatives, friends, partner agencies and other professionals, such as Community Nurses, GPs, social workers, off site day care staff etc for their peceptions of how the service is being delivered. This is a useful quality assurance tool. Regulation 24(3) refers. DRAYTON WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 WOOD I55 s27499 Drayton Wood V233496 260705 Stage 4.doc Version 1.30 Page 29 - 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. 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