Inspection on 10/10/05 for Drey House

This inspection was carried out on 10th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drey House 05/02/08

Drey House 17/08/07

Drey House 15/11/06

Drey House 18/04/06

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Drey House Cambridge Road Eynesbury Hardwicke St Neots Cambridgeshire PE19 6SR Lead Inspector Nicky Hone Announced Inspection 10th and 26th October 2005 13:40 Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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 Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Drey House Address Cambridge Road Eynesbury Hardwicke St Neots Cambridgeshire PE19 6SR 01480 880022 01480 880112 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) Psycare Hostels Limited Care Home 33 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (33), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (33) Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5 May 2005 Brief Description of the Service: The home is set slightly back from the main A428 main road in grounds of over three acres, and a detached house and outbuildings form part of the property. The busy market town of St Neots is within a few minutes drive, the city of Cambridge is within 20 miles and there are good local road and rail links to London. Originally an Edwardian House, Drey House was extended some years ago and accommodation is offered on two floors. There are 32 single bedrooms. There are two large lounges plus a visitors’ lounge and a dining room on each floor, as well as bathroom, toilet, kitchen, laundry, office and staff facilities. The expansive gardens at the rear of the house back on to fields and offer a private and peaceful setting. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was undertaken by two inspectors on the 10th and 26th October 2005. The inspectors spent 8 hours in the home and spoke to two of the service users, the staff on duty and the Senior Liaison Officer. Documents were read and a tour of part of the home was undertaken. A pharmacy inspector employed by the Commission for Social Care Inspection also undertook an unannounced inspection of the medication system on 19th October 2005. The acting manager completed a pre inspection questionnaire and sent this to the Commission for Social Care Inspection before the inspection was undertaken and some of the information contained in the questionnaire has been used to write this report. Psycare Hostels Limited became the registered owners of Drey House on 1st July 2005 and this is the first inspection of the home since the home was purchased by the company. Three of the directors of the company have a wide range of qualifications in Psychiatry and all have a least 20 years of experience of working in mental health care in a wide range of settings. The acting manager also has over 20 years experience of working in Mental Health Care as a qualified and registered mental health care nurse. All of the service users accommodated when the sale was completed have remained in the home and a further two service users have been accommodated. Staff also had the option of remaining in employment at the home. What the service does well: What has improved since the last inspection? Since the previous inspection all areas of the home occupied by service users have been kept warm. This was a requirement from the previous inspection. A programme of maintenance has been submitted to the Commission for Social Care Inspection and at the time of this inspection the maintenance programme was well underway. An acting manager is currently in post. He is the registered manager of a home in Hertfordshire and has worked with the client group for many years. The assessment and care planning documentation is of Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 6 a high standard ensuring the staff know the needs of the service users and how to meet these needs. 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. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 7 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 Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 8 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): 1,2,4,5 The inaccurate information contained in the Service User Guide does not ensure that prospective service users are clear about the services the home provides to meet their needs. The assessment process is thorough and ensures that only service users whose needs can be met are accommodated at the home. EVIDENCE: The home has a statement of purpose which sets out the aims, objectives and philosophy of the home. This document provides all of the information required by the Care Homes Regulations 2001. The Service User Guide which is provided to service users and their representatives is a comprehensive document but does not provide accurate information. An example of inaccurate information is that the guide states that ‘there is a large old stable to the side of the house and this has been converted to provide an activities room and a gym area’. At the time of this inspection the stable did not provide these facilities. The Senior Liaison Officer stated that she meets with service users before they move into the home and provides them with a brochure which contains accurate information. She also talks to them about the home. She stated that the Service User Guide is ‘aspirational rather than factual’. Pre admission information is obtained about service users before they are offered a place at the home and staff from the home also assess the service user. Potential service users have the opportunity to visit Drey House several times during the assessment process. These visits may also include overnight Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 9 stays. Service users are admitted to the home for a six week trial period and a review is held during the fifth week. The contract of the most recent service user who moved into the home was seen. This did not contain all of the information detailed in standard 4 and the contract referred to the Registered Homes Act 1984 rather than the Care Standards Act 2000. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 10 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): 6, 7, 9 Comprehensive care plans are in place which detail how the needs of the service users are to be met. Further work is required to be taken by staff to ensure that the risk assessments detail the actual risks to service users. EVIDENCE: The inspectors looked at two care plans. An initial care plan is drawn up from the assessment information and the inspectors were informed that service users are involved in drawing up their care plans. The care plans seen contained detailed information about how to meet the needs of the service users. Care plans are reviewed at least every three months and also when the needs of the service user change. Risk assessments were seen on the service user files but these did not contain information about current risks. Each file contained information about a number of risks including self-injurious behaviour, fire safety and substance abuse but the information was historical and there was no information about current risks. The ‘Missing Person Procedure’ was seen but it was noticed that several pages were missing and that although the procedure was very detailed it did not Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 11 name the Commission for Social Care Inspection as an organisation that must be contacted if a service user is missing from the home. The home must also ensure that there is a shorter policy detailing the main points of the procedure which staff can refer to when a service user is noted to be missing from the home. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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): 13,14,15,16,17. Although service users are encouraged to pursue their own hobbies and interests the lack of transport means that service users’ links with the local community are restricted. Service users have a varied menu. EVIDENCE: The home is situated in a rural setting and is about three miles from the market town of St Neots. Public transport cannot be accessed from the home so the service users rely either on taxis or transport provided by the home to access St Neots and the surrounding areas. The home currently has the use of two ‘pool vehicles’ which belong to the company and are also used by the other homes owned by the organisation. A vehicle solely for the use of Drey House has been ordered and the inspectors were informed that this should be arriving ‘shortly’. One of the service users spoken to stated that because there is not a bus or house transport ‘there is not a lot to do’. All service users are registered on the electoral roll. Service users are encouraged to pursue their own hobbies and interests and the home has an activities room. A member of staff stated that service users enjoy quizzes and developing their art skills. One service user enjoys listening to Classical Music and another is a keen photographer. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 13 The home has two visitors’ rooms and as the home is not fully occupied there are lots of alternative rooms available for service users to entertain their visitors in private. The Service User Guide states that ‘family and friends are permitted to visit Drey House between the hours of 9am to 9pm. Prior arrangements outside of these times may be made in discussion with staff though please remember to give staff adequate notice’. The acting manager stated that there are no set times for service users to get up or go to bed and that staff only enter service users’ bedrooms and bathrooms with their permission. All bedroom doors are lockable but at the time of this inspection none of the service users had a key to their bedroom door. The acting manager stated that all service users would be offered a key unless their risk assessment suggested otherwise. Menus were seen during the inspection. Service users plan the menus and their likes and dislikes are taken into account. Catering staff are not currently employed and the acting manager stated that when additional service users are accommodated in the home a cook might be employed depending upon the needs of the service users. It is envisaged that service users will develop their catering skills and a kitchenette for the use of service users is currently being refurbished. The meal seen at the time of the inspection looked appetising. The acting manager stated that on occasions service users will request a meal that is not on the menu and that this request is accommodated. A record of food eaten by the service users was not being maintained. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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): 18,19,20 Unsafe practices that operate in relation to the recording, handling, safekeeping and safe administration of medicines mean that service users are put at risk. EVIDENCE: The two care plans inspected contained detailed information about service users preferences and how their needs would be met. Times for getting up/going to bed are flexible. There was evidence that service users choose their own clothes, hairstyle and make up. None of the service users currently accommodated in the home required technical aids and equipment to assist their independence. A key worker system does not currently operate in the hone: this will commence when more service users are accommodated. All service users are registered with a local G.P Practice. Service users usually visit the local GP surgery accompanied by staff when required, but if the service user was too unwell to visit the surgery a GP would be requested to visit the home. The home currently uses two GP practices, one in St Neots and one in Papworth. The inspectors were informed that service users are not currently registered with a dentist. A Chiropodist visits the home every 12 weeks and arrangements are being made for an Optician to visit the home. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 15 During the first day of the inspection the systems used by the home for the storage, receipt, administration and disposal of medication were inspected. It was noted that records of medication administered contained gaps, that there had been occasions when medication had not been administered because it was not available, that medication was not being administered as prescribed, that the Controlled Drugs register had not been completed correctly when medication had been administered, that the date when medication had been opened had not been recorded, that the records of staff who administer medication was not complete and that the name of the pharmacy who supplied the Controlled drugs was not recorded in the Controlled drugs register. These issues were brought to the attention of the Acting Manager during the inspection and before the inspectors left the home an immediate requirement notice was left detailing the action that the home had to take in respect of the issues identified. A Pharmacist Inspector employed by the Commission for Social Care Inspection was requested by the inspectors to visit the home and he undertook an unannounced inspection on 19th October 2005. During his inspection the pharmacy inspector noted that the home had not made arrangements for the recording, handling and safe administration of medication and that records required to be maintained by the home were still not accurate. A notice was served on Psycare Hostels Limited in accordance with Regulation 43 of the Care Homes Regulations 2001. This notice detailed breaches in respect of Regulation 12(1)(a) 13(2) and 17(1) Schedule 3(i) of the Care Homes Regulations 2001 and stated that action must be taken by 31 October 2005 to ensure suitable procedures are in force for the recording, handling, safekeeping and safe administration of medicines. The Commission for Social Care Inspection has received a response from Psycare Hostels Ltd detailing the action that they have taken to comply with the regulations and the Pharmacy Inspector will be undertaking a further unannounced inspection to check compliance shortly. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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): 22,23 A robust complaints procedure is in place to ensure that complaints are responded to and investigated appropriately. EVIDENCE: The home has a complaints procedure which details all of the information required by the Care Homes Regulations 2001. The acting manager stated that a leaflet detailing the complaints procedure is given to all service users when they move into the home and the procedure is also contained in the Service User Guide. A record of complaints made, details of any investigation undertaken, any action taken and the outcome is recorded in a complaints log. The complaints are recorded on sheets of paper and the paper is stored in a file. It is recommended that a hardback book is used to record complaints. The home has a policy detailing the action to be taken when there is a suspicion or evidence of abuse or neglect. The home also has a copy of Cambridgeshire County Council’s Adult Protection Procedures. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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): 24,25,28 Service users are provided with a spacious and comfortable environment. EVIDENCE: At the time of the inspection the home was undergoing major maintenance. The flat roof repairs have been completed, work has been carried out on the electrical system, the fire alarm system and extinguishers have been checked and certified, and the cold water system has been drained, disinfected and refilled. Further plans include installing further showers, filling in the swimming pool and making it into a horticulture areas, having a pathway to the back entrance and fixing TV aerial sockets in bedrooms and day areas. A tour of the whole building was not undertaken during this inspection but areas seen were clean and well maintained. It was noted that several dining room chairs were in need of repair/replacement. One bedroom occupied by a service user was seen and it was noted that it did not have a mirror. The first floor of the home is not currently occupied by service users. A fire door on the first floor was wedged in the open position. All areas of the home toured were warm. The previous inspection report required that all areas occupied by service users must be maintained at a satisfactory temperature. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 18 All of the bedrooms are now single rooms and service users are assisted to personalise their rooms. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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): 33,34,35,36 Full information must be obtained before a staff member commences employment to ensure that service users are not put at risk. Training and supervision must be provided to staff to ensure that they have the skills and receive the necessary support to undertake their roles. The number of staff available is appropriate to meet the needs of the service users currently accommodated at the home. EVIDENCE: Staff rotas showed that there is a minimum of two staff on duty at all times and that one of these staff is always a registered nurse. At the time of the inspection the care staff were responsible for the catering and domestic duties in the home but domestic staff will be employed once more service users are admitted to the home. There was no evidence to suggest that there were insufficient staff on duty to meet the needs of the service users. All staff employed in the home are at least 18 years of age and staff left in charge of the home are at least 21. Staff files were inspected and it was noted that some members of staff had been recruited without all of the required checks having taken place. Psycare Hostels Ltd had not obtained evidence that staff were physically and mentally fit before they employed them and a reference in respect of one member of staff had not been obtained from the staff member’s previous employer. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 20 The inspectors were informed that new staff receive a structured induction which is designed to take six weeks to complete. Training and development plans for members of staff were not seen but the inspectors were informed that mandatory training for all staff is currently being arranged. As a minimum all staff must receive training in Fire Safety, First Aid, Infection Control, Moving and Handling and Basic Food Hygiene. Records showed that the majority of staff had not received this training. A system of formal supervision is not fully operational. A supervision record in respect of one member of staff was seen. The inspectors were informed that this was the only member of staff who had received formal supervision. It was noted that the areas discussed during the supervision session did not include any of the areas that are outlined in Standard 36. The supervisor had not received training in the supervision of staff. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 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): 37,40,41,42 Accurate records must be kept in the home to ensure that service users are safe. EVIDENCE: Mr Russell Fletcher is currently ‘acting’ as the manager of the home until a permanent manager is recruited. Russell is registered as the manager of a home owned by the company in Hertfordshire. He is a first level nurse and holds a number of qualifications including the Registered Manager Award. Information provided by the acting manager in the pre-inspection information notes that policies and procedures are reviewed at least yearly. Staff spoken to indicated that they were aware of the policies and procedures and how to refer to these when needed. As stated previously in this report a full copy of the Missing Persons Procedure was not available in the home. Not all policies and procedures were signed by the manager and/or dated. Records seen other than those discussed in the report included records of accidents, records of visitors to the home and copies of duty rotas. These Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 22 were satisfactory. The reports written by the Registered Provider following their visit to the home were seen. These had not been signed by the person undertaking the visit and copies of the reports had not been sent to the Commission for Social Care Inspection. Information provided by the acting manager in the pre-inspection information notes that the most recent fire drill was undertaken on 2 September 2005. The same document provided information about service checks to include checks on the central heating system and electrical wiring. Records for emergency lighting and fire alarm tests were seen. The records were not clear. For example, the records dated 7 and 14 October 2005 stated ‘not working’. The record did not state what was not working or any action taken in respect of the fault. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 23 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 2 3 X 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 2 14 3 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X X 3 1 2 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Drey House Score 3 2 1 X Standard No 37 38 39 40 41 42 43 Score 2 X X 2 2 2 x DS0000064870.V250658.R01.S.doc Version 5.0 Page 24 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 2 Standard YA1 YA9 Regulation 5(1) Requirement Timescale for action 30/11/05 18/11/05 3 YA16 4 5 YA17 YA19 6 YA20 7 YA24 The Service User Guide must contain accurate information. 17(2)Schedule 4(16) A complete Missing Persons Procedure must be available to staff. A statement of the procedure must also be available. 12(4)(a) Service users must be offered a key to their bedroom door unless a risk assessment suggests otherwise. 17(2)Schedule 4(13) A record of food eaten must be maintained. 13(1)(b) All service users must be registered with a dentist unless there is written evidence that they do not wish to receive dental treatment. 12(1)(a)13(2)S3P3(i) 17(1)(a) Suitable procedures must be in place for the recording, handling, safe keeping and safe administration of medicines. 24(4)(c)(i) Fire doors must only be kept in the open position DS0000064870.V250658.R01.S.doc 18/11/05 26/10/05 30/11/05 31/10/05 26/10/05 Drey House Version 5.0 Page 25 by a means approved by the Fire Safety Officer. 8 9 YA24 YA34 23(2)(c) 19(1) Schedule 2 The damaged dining room chairs must be repaired or replaced Full information as stated in Schedule 2 must be obtained before a person commences employment at the home. Arrangements must be made to ensure that all care staff receive training in Fire Safety, First Aid, Infection Control, Moving and Handling and Basic Food Hygiene. Arrangements must be made for all care staff to receive supervision at least six times a year. An application by the person proposing to be registered as the Manager of the home must be submitted to the Commission for Social Care Inspection. Reports written as required by this Regulation must be signed and a copy must be sent to the Commission for Social Care Inspection. The fire and emergency lighting records must contain full details of any faults noted and the action taken to rectify the fault. 31/12/05 26/10/05 10 YA35 18(1)(c)(i) 30/11/05 11 YA36 18(2) 30/11/05 12 YA37 8(1) 31/01/06 13 YA41 26(5)(a) 30/11/05 14 YA42 17(2) Schedule 4,p4 31/10/05 Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 26 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 4 5 Refer to Standard YA5 YA22 YA26 YA36 YA40 Good Practice Recommendations The contract should include all of the information detailed in this Standard. All complaints should be recorded in a hardback book. A mirror should be provided in each bedroom. All staff who supervise staff should receive training in supervision. Policies and procedures should be signed by the registered manager and dated. Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Drey House DS0000064870.V250658.R01.S.doc Version 5.0 Page 28 - 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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