CARE HOME ADULTS 18-65
Drayton Wood Drayton High Road Drayton Norwich Norfolk NR8 6BL Lead Inspector
David Welch Unannounced Inspection 4th January 2006 4:15 Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 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.V275999.R02.S.doc Version 5.1 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.V275999.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Drayton Wood Address Drayton High Road Drayton Norwich Norfolk NR8 6BL 01603 409451 01603 426568 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 Care Home 29 Category(ies) of Learning disability (29) registration, with number of places Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 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. The age gap between the youngest and the oldest person accommodated in Honeysuckle Lodge will be no more than 25 years. 26th July 2005 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 ornamental goats and chickens and there is an aviary with zebra finches. At the present time there are on the site four houses accommodating service users. Drayton Wood is the main building. This was constructed in 1900. 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 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 a very busily colourful, day care centre. Cedar and Holly Lodges each provide accommodation for six or seven service users in single bedrooms with en-suite facilities. Honeysuckle Lodge was registered only very recently and at the time of inspection had yet to admit any service users. When fully operational it will provide accommodation for up to 7 younger adults with an age range not exceeding 25 years between the youngest and oldest persons. One further unit for 7 people, Spruce Lodge, remains yet to be completed. 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.
Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection was timed to take place as service users were returning from their day care services, preparing for their evening meal and relaxing in their different houses. The purpose of the visit was as follows: • • • • • • • • To fulfil the Commission’s responsibility to inspect the home on at least two occasions in a 12-month period To check on progress in complying with 9 requirements made following the announced inspection in July last year To check on progress in introducing 5 good practice recommendations made following the announced inspection To check on how the home has began to introduce people to the new house, Honeysuckle Lodge To view evening routines To speak to as many residents as possible To speak to as many staff on duty as possible To inform senior staff of the likely changes to the way the Commission will operate in the short and medium term The visit lasted for four and a half hours during which time there was an opportunity to talk at length with the Deputy Manager and to speak with 14 of the people living in three of the houses. The two young people who were visiting Honeysuckle Lodge prior to moving in the following week were also spoken with. And six of the care staff on duty. Service users were engaged in a number of relaxing pastimes such as watching television, writing a letter, with careful and sensitive assistance from a member of staff, looking at catalogues or playing board games with staff. In the Main House two people were washing and drying up while two others were taking time to finish their meal. One person was helping to sweep the laundry area in preparation for the arrival of the heating engineers the following week. Everybody seemed very willing to chat and in one case to make a drink. Most people living in the houses appeared happy and settled. The two young people who were visiting Honeysuckle Lodge had chosen their bedrooms and were getting to know the people who would help to look after them. Some very nice interactions were observed between staff and the people living in the houses. It was clear that visiting from one house to another was a regular occurrence. Even the house cat went from one house to another! One person said that he liked his bedroom in the Main House. Several residents described what they had been doing during the daytime and seemed pleased with the activities provided for them and proud of their efforts. The staff explained what duties they were doing, when they were expected to sleep in and when next they were on duty.
Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection?
The Statement of Purpose, while needing some further fine-tuning, has improved to provide information about what each individual house offers. The Service User Guide is going through development to provide information in ways that people living here have a chance of understanding. The potential risks that one person might run in living where she does have been looked into. Ms Serruys has contacted placing authorities to try to find out if the cost of an annual holiday is included in the fee. However, while she has fulfilled her responsibility, she has not been successful in most cases where Norfolk County Council supports residents. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 7 Relatives, social workers and Learning Disability Teams have been reminded about the home’s Complaints Procedure. Relatives have responded to questionnaires with comments about how they see the home’s operation. Work is to start soon on replacing the heating system in the Main House. 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 Wood DS0000027499.V275999.R02.S.doc Version 5.1 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.V275999.R02.S.doc Version 5.1 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 the following standard(s): 1 and 2. Once some fine-tuning has been done on the Statement of Purpose the information given will provide a good indication of the services on offer. The Service User Guide is being developed in a way that the people living here have a much better chance of understanding. EVIDENCE: The home had been required to provide a Statement of Purpose that included all the information detailed in National Minimum Standards and Care Homes Regulations 2001. This was increasingly important, as Ms Serruys had made an application to vary the conditions of the home’s registration to include a newly built house, Honeysuckle Lodge. The Statement of Purpose had been amended to include the required information, but some aspects still need to be changed. For instance, the ages of the youngest and oldest people living in the different house has been given. This is not necessary as the information will be out of date as soon as somebody has a birthday. In the Main House and in Cedar and Holly Lodges, no reference to age needs to be given. In Honeysuckle Lodge only the maximum age range needs to be stated. A good start had been made to providing the Service User Guide in a colourful picture and symbol format that people are likely to understand, i.e. not simply word based. There is still some work to do in this respect and the home might still need an audio version or maybe even a video or DVD version of the Guide depending on the capabilities of the people living in the houses. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 10 The Deputy Manager said that nobody new had come to live at Drayton Wood since the last inspection, but arrangements were being made for people to move into Honeysuckle. The people concerned had been visited in their own homes, their families spoken to and the people themselves had visited Honeysuckle Lodge to familiarise themselves with the set-up. The Deputy Manager said that the staff had gathered a lot of vital information in considering the home’s suitability to care appropriately for the new people. This included from day service staff, who tended to know the people well. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 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 the following standard(s): 9. While risk assessment is an on-going process, in the main case in point good efforts have been made to identify and respond to potential dangers. EVIDENCE: During the last inspection, one person who lived in a first floor bedroom with a balcony appeared not to have a risk assessment that took account of the potential for an accident to happen. The home was required to consider the risks inherent in this situation and take any appropriate steps to minimise them. This unannounced visit provided a chance to see what the home had done in this regard. The person’s Care Plan showed that staff had considered the person concerned to be very capable and safe to live in the bedroom. Ms Serruys had assessed the possibility of the person concerned jumping or falling off to be very low indeed. Such issues as an understanding of the privacy of other residents with access to the balcony from their own room had also been considered. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 12 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 the following standard(s): 14, 16 and 17. There are quite good opportunities available for residents to lead fulfilled lives. But, some work remains to be done to ensure that the people living here have everything to which they are entitled and to inform them of what, exactly, the home’s approach is to certain matters. Issues to do with diet are considered. EVIDENCE: At the last inspection, residents did not have in their contracts any information about whether the cost of an annual holiday was covered in their fees if the local authority supported them financially. Ms Serruys was asked to check with placing authorities and following receipt of the draft report she did so. At this visit the matter was discussed again. The home’s Deputy Manager said that Ms Serruys had received only one reply - from Suffolk County Council, who, she said, believed that the cost of an annual holiday was covered in the fee charged. Norfolk Care Services had not responded in respect of any of the people they support in the home. The owner must re-negotiate the terms and conditions of residence to ensure that fees cover the cost of an annual holiday for all service users. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 13 People are asked what they want to be called and they are offered a key to their bedroom. Both things are recorded on Care Plans. People living in the home all have an ‘at home’ day when staff assist them with things like their washing and ironing and other household chores. On the evening of the unannounced visit one couple were doing the washing and drying up and putting away the crockery. One person routinely helps with small cleaning and maintenance jobs around the house. Residents help with preparing vegetables, laying up the tables and loading the dishwasher. The Deputy Manager confirmed that this was a non-smoking establishment for staff and only one resident currently smokes tobacco. She confirmed that there is nothing at this time in resident contracts about smoking, consuming alcohol or drugs. The home must decide on its approach to these issues and show it clearly in contracts. In this way, people making decisions about living in Drayton Wood do so armed with the knowledge of where the home stands on the issues. One person currently has a pet. The Deputy Manager said that she is responsible for its food and any vet’s bills. Staff assisted when the cat’s food was purchased and if it needed to see the vet. One person is vegetarian and another has multiple allergies. Their dietary needs are taken care of. One person is insulin dependent and another has Type-2 diabetes that involves careful consideration of diet. Presently, staff assist with injections using a ‘pen’ syringe. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 14 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 the following standard(s): 18 and 20. Although staff have made efforts to resolve one issue of privacy and dignity, they do not provide an altogether satisfactory conclusion. It is important that training in the administration of medication is handled by a trained and competent person, and preferably delivered through an ‘accredited programme’. EVIDENCE: At the previous inspection it was clear that the chiropodist routinely carried out care in a communal area, which might compromise privacy and dignity. Ms Serruys was asked to arrange a more private location for the chiropodist to practice. At this inspection the matter was again discussed. The home’s Deputy Manager said that no alternative arrangements had been made. In one case a resident had felt it was not necessary to, say, go to his bedroom for foot care when the chiropodist visited. The Deputy said that there really was nowhere in the Main House that would serve as a private place when the chiropodist came. Staff had drawn the curtains in the lounge and placed a notice on the door saying that the lounge could not be used when the chiropodist was here. This is not acceptable as it means the lounge is then not available for other service users. Screening off an area might provide an alternative that preserves the privacy and dignity of the people having their
Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 15 feet checked. In the newer houses the Visitor’s Room is used when the chiropodist visits. No controlled medication is prescribed. No resident self medicates. All care staff administer medication after training and they are not allowed to do so until senior staff feel that they are competent. Currently, the Training Coordinator does the medication training. The Commission’s view is that this is unlikely to meet the requirement for this important training to be ‘accredited’ and it might be more appropriate if Boots, who provide the monitored dosage system, do it. The Deputy Manager was advised to negotiate with Boots so that any training was geared to National Minimum Standard 20. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 16 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 the following standard(s): 22 and 23. It is clear that concerns raised are listened to and acted upon appropriately. The provision of POVA training for all staff will further enhance their understanding of the issues involved. EVIDENCE: Following the last inspection Ms Serruys was asked to inform all relatives and other stakeholders of the home’s Complaints Procedure. At this inspection, the Deputy Manager said that all relatives, social workers and Learning Disability Teams had been sent a copy of the procedure. The Deputy Manager confirmed that she, the home’s manager, Home Leaders, the Day Care Manager and the Training Co-ordinator had attended a day seminar recently on the Protection of Vulnerable Adults. She was reminded of the requirement for all staff to be trained in this important aspect of care by 31st January 2006. There have been two Protection of Vulnerable Adults (POVA) investigations since the last inspection. These followed, in one case, concern raised by a relative of bullying of one resident by another. In the other case one resident complained of being hit by another resident and of being ‘pushed’ by a member of staff. One particular resident was common to both complaints. Both incidents were thoroughly investigated following strategy meetings. In both cases of alleged unkindness between residents, the complaints were upheld in part. The member of staff was exonerated. Steps had been put in place to minimise the potential for particular residents to bully others. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 17 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 the following standard(s): 24 and 30. The installation of a new heating system, hopefully within three months, will provide safe and regulatable temperatures in the Main House. And security lighting will make the movement between houses during the hours of darkness a less intimidating experience for staff and residents. Full implementation of the home’s very comprehensive infection control procedures in regards to laundry can only be possible once the planned refurbishment of this area takes place. EVIDENCE: A requirement remains outstanding for all residents to be able to control the temperature of radiators in their bedrooms and to be protected from any hot surfaces. At the previous inspection the Commission had been told that a new heating system was to be installed in the Main House that would take account of these requirements. At this inspection, we were told that work on installing the new heating system was due to start shortly. The laundry had already been cleared to enable the work to begin. There are to be new boilers in the Main House. Staff have been assured that the home will not be without heating and hot water. Work will only take place when residents are out at their day service. The Deputy said that protocols had been discussed with the heating engineers and work was likely to take 12 weeks.
Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 18 During a joint visit to the home when Ms Serruys’ application to vary the conditions of registration was being considered, the Commission felt that the site required some security lighting, as some areas between houses were dark. Service users, and staff, might find walking between houses at night intimidating. The laundry area was checked. It would not meet the requirements of the National Minimum Standards - for the floor to be impermeable and the walls to be easily cleanable. The Deputy said that once the proposed heating work is finished the laundry would be furbished to comply with all requirements. The home’s written infection control procedure was looked at. It was comprehensive and covered all aspects well. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 36. A tightening up of recruitment checks is vital to ensure that only the most suitable people are employed. EVIDENCE: On the evening of the inspection, the home’s Deputy found herself having to do a double shift, finishing quite late at night, after a colleague called in sick. She was due to be on duty again within 9 hours. The home should have a suitable relief or bank system so that staff are not called upon to work very long hours. Four new staff had been employed since the last inspection – all to work in the new house. Their recruitment was checked. In one case only one written reference had been obtained and this from a family member and friend. In two cases one written reference was from a ‘friend’ and not from somebody who knew the applicant in a professional capacity. In all cases there was a CRB certificate, but in one case there was a covering letter from the CRB to say that a mistake had occurred and the disclosure was inaccurate and would be done again. The home’s Deputy said she was not aware of the situation. The new carer remained in post while this was happening. Following the last inspection, a recommendation was made that a training matrix was kept so that it was clear where each member of staff stood in terms of their own personal development. The Deputy Manage said that this
Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 20 had been done, but she could not put her hand on it. She agreed to forward a copy to the Commission’s Norfolk Area Office as soon as possible. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39. Some very useful feedback on the way the home is operating has already been obtained from relatives, but every effort should be made to encourage all stakeholders to take part in the process. EVIDENCE: The Deputy said that comments on the way the service operates had been obtained through a questionnaire sent to relatives, social workers, partner agencies and other professionals. Twelve relatives had responded, but no professionals. There had been some feedback on the washing and ironing of service users’ clothes and the availability of activities. The Deputy Manager said that these had been followed up with staff. A recommendation that the home should seek service users’ views about the home and record them in the Service User Guide had not been done and this will now elevate to a requirement. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 22 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 3 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X 2 X X X 2 X X X X Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 23 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 Requirement Timescale for action 31/01/06 2. YA1 3. YA14 4(1a)(b)&(c) The Registered Persons must provide some ‘fine-tuning’ to the home’s Statement of Purpose to reflect services offered in each house. This is a repeat requirement. 5(1)(a) - (f) The Registered Persons must continue work on the Service User Guide, to provide information in a variety of formats. Following receipt of the draft report, Ms Serruys said in a letter dated 14th February 2006 that the Service User Guide is now available in written, ‘Widget’ symbol and picture format. 5(3) The Registered Persons must negotiate again with placing authorities about including in the contract price for each user a sum to cover the cost of a seven-day annual holiday. This is a repeat requirement. In her letter that followed receipt of the draft report, Ms Serruys said that she had written again to the placing authorities, but had only received two replies. When
DS0000027499.V275999.R02.S.doc 31/01/06 31/01/06 Drayton Wood Version 5.1 Page 24 4. YA16 5. YA18 6. YA20 7. YA23 new service users are referred the cost of an annual holiday is now included in the fees. 5(1)(b) The Registered Persons must develop an approach to smoking, the consumption of alcohol and drugs by residents and include this information in the terms and conditions of residence document or contract. In her letter that followed receipt of the draft report, Ms Serruys said that she has now included the home’s approach to the use of alcohol and drugs in the contract. 12(4)(a) The Registered Persons must identify a suitable area where specialist healthcare services such as chiropody can be carried out without compromising the privacy and dignity of residents or denying others proper access to communal areas. This is a repeat requirement. In her letter that followed receipt of the draft report, Ms Serruys said that the home does not have a private area where chiropody can be provided. She confirmed that residents preferred the living room to be used. 18(1)(c)(i) The Registered Persons must ensure that training in the administration of medication is ‘accredited’. 18(a)& (c)(i) The Registered Persons must ensure that all staff receive Protection of Vulnerable Adults (POVA) training. In her letter that followed receipt of the draft report, Ms Serruys confirmed that all staff had received training in ‘Vulnerable Adults at Risk Basic
DS0000027499.V275999.R02.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 Drayton Wood Version 5.1 Page 25 Awareness’. 8. YA23 18(a)&(c)(i) The Registered Persons must ensure that all members of staff receive training in physical control and restraint. In her letter that followed receipt of the draft report, Ms Serruys said that staff are receiving training in the ‘Prevention of Aggression’, which is accredited. The Registered Persons must ensure that the new heating system in the Main House allows service users to control the heating in their bedrooms and protects them from hot radiator surfaces. This is a repeat requirement. The Commission is aware that work to replace the heating system in Drayton Wood Main House is due to start shortly. In her letter that followed receipt of the draft report, Ms Serruys confirmed that the work to refurbish the heating system should be completed by 30th April 2006. The Registered Persons must install suitable security lighting in areas between houses that require it. In her letter that followed receipt of the draft report, Ms Serruys said that security lighting has been installed between the houses. The Registered Persons must ensure that once planned heating work is carried out the laundry is refurbished to meet environmental standards. Following receipt of the draft report, Ms Serruys confirmed that the laundry room would be refurbished to meet environmental standards as soon as the other heating work
DS0000027499.V275999.R02.S.doc 31/01/06 9. YA24 13(4)(a)& (c) 30/04/06 10. YA24 23(2)(o) 31/01/06 11. YA30 16(2)(j) 30/04/06 Drayton Wood Version 5.1 Page 26 has been finished. 12. YA34 19(b)(i) The Registered Persons must ensure that the homes recruitment procedures fulfil 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. This is a repeat requirement. The Registered Persons must seek service users views, analyse the results and record them in the Service User Guide that is available to people living in the home. This is a repeat requirement. 26/07/05 13. YA39 24(3) 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA33 YA36 YA39 Good Practice Recommendations The Registered Persons should put in place an effective relief or ‘bank’ system so that staff do not have to work very long hours to cover colleagues. The Registered Persons should encourage the person employed as the homes Training Co-ordinator to develop a training matrix for staff. Regulation 18 refers. Having canvassed their views once beforehand, the Registered Persons should follow up enquiries with partner agencies and other professionals, such as Community Nurses, GPs, social workers, off site day care staff etc for their perceptions of how the service is being delivered. This is a useful quality assurance tool. Regulation 24(3) refers. Drayton Wood DS0000027499.V275999.R02.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispin’s Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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