Inspection on 15/11/06 for Drey House

This inspection was carried out on 15th November 2006.

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 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 13 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 18/04/06

Drey House 10/10/05

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 Key Unannounced Inspection 15th November 2006 11:00 Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drey House Address Cambridge Road Eynesbury Hardwicke St Neots Cambridgeshire PE19 6SR 01480 880022 01480 880805 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 Mr Simon Eric Belfield 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.V320113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 2006 Brief Description of the Service: The home is set slightly back from the main A428 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. All service users at Drey House are funded by local or health authorities. Information from the acting manager on 01/05/06 was that fees for accommodation and care at the home range from £1050 to £1250 per week. Inspection reports are made available for service users or their representatives in the reception area of the home, and in the service users’ lounges. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over several days by two inspectors, and included meetings with the registered manager and with some of the Directors. The CSCI Pharmacist Inspector was present for part of the first day and gave full feedback to the senior nurse on duty. Part of the inspection, and the meeting with the Directors, was taken up with looking at concerns that had been raised about whether some of the people who had been admitted to Drey House were outside the home’s registration categories. The discussions that took place, and advice taken, indicated that the concerns were unfounded and all the service users were within the home’s registration categories. There is still a concern however about the arrangements for meeting service users’ mental health care needs, as the local Mental Health Trust is currently not involved. Discussions continue to take place between Drey House and the MHT. On the first day of the inspection there were twelve service users living at Drey House. What the service does well: Management of the home is much better and the staff team are to be commended for the hard work they have done to try to make sure this home keeps moving forwards. Information about the home is provided to new service users and full, detailed assessments are carried out so that the service users know their needs can be met. New service users have the opportunity to have overnight stays at Drey House to see whether they would like to live here. Each service user has a Service User Plan based on the assessment of their needs and the staff are working hard to make sure the service users are involved in decisions about their lives. There are more opportunities for service users to join in fulfilling and stimulating activities, relationships with families and friends are encouraged and a good range of healthy, nutritious meals are provided. Complaints are dealt with well and staff are being trained in the Protection of Vulnerable Adults. Improvements are being made to the premises and the by the second day of the inspection the home was clean and comfortable for the service users to live in. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 6 Recruitment of staff is improving and there are plans for all staff to receive training in a range of topics, including having the opportunity to work towards a National Vocational Qualification in care. Service users are being involved in giving their views on the running of the home and we found no major issues to give us concern about health and safety. What has improved since the last inspection? What they could do better: This inspection has resulted in thirteen requirements being made, four of which have been requirements following previous inspections. Six of the requirements relate to issues around medicines. Records of the administration of medicines to residents must be more accurate and complete. Records of controlled drugs in use must be made accurately. Records of the results of blood tests and clinical investigations could be more up to date. The home must continue to improve the number and range of activities available to service users, and care plans need more detail about the way in which each service user’s personal support and healthcare needs are to be met. There must always be enough staff on duty to meet the service users’ needs. Staff must receive training appropriate to the work they are to perform, and regular supervision. It is of serious concern that an immediate requirement had to be made regarding the visits to the home required by Regulation 26. It was a requirement following the inspections in October 2005 and April 2006 that reports of the provider’s visits to the home must be sent to the manager and a copy sent to the CSCI. A Statutory Enforcement Notice was served on Psycare Hostels in April 2006 and although the company complied with the notice initially, compliance has not been maintained. The last report available was dated June 2006. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is good. The home collects full information about each service user to make sure it can offer the support each service user needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the first day of the inspection the information in the service users’ guide was not up to date. The manager amended this and sent a copy to the CSCI. This is generally satisfactory. Full assessments of the needs of each service user were on the files we looked at. These assessments are very good, giving detailed information for each person which is then used to develop a Service User Plan. There was a record on one of the files we looked at that showed when the service user had visited the home, and when he had stayed for the night, before being admitted. On the first day of the inspection two service users arrived for a two-night stay to decide whether they would like to move to Drey House. The manager said he will now be sending a letter to new service users to confirm that the home can meet their needs. Each service user agrees a contract with the home which is kept on their file. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is good. Risk assessments and Service User Plans for each service user are developed so that each person knows his/her needs will be met by staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users now have an individual Service User Plan in place which is developed from pre-admission assessments and risk assessments undertaken when the person arrives at the home. This is referred to as an Action Plan at Drey House. The format for these is very good and the way the information is collected and used is being developed well. The assessments of risk/need are updated approximately monthly by the consultant psychiatrist who visits the home. Examples of risk assessments seen include money, keys, smoking, violence and community access. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 11 One person has indicated that he wants nothing to do with the information in his file and will not sign any documents. The manager will make sure there is an entry in the file to show this. The daily records completed by the staff are excellent, giving details of the way the person has spent their day, including any activities they have taken part in, and what the day has been like for them. Service users have a copy of their file in their room, and all information about them is kept securely in a locked office. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. Staff are working hard to develop opportunities for service users to have a fulfilling life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The company employs an occupational therapist who works at Drey House for two days each week. The OT sent us a very good report detailing the group activities which take place on the two days she is at the home, and providing an analysis of how many sessions had taken place and how popular they were. Sessions include making breakfast smoothies, a current affairs group, a games group, a cookery/baking group, a creative writing/art and craft group, and a relaxation group. She wrote that the groups were happening more regularly and gradually more service users were wanting to join in. She also said that other staff were beginning to have more confidence about organising activities when she was not around, and quite a few ad hoc sessions had been taking place. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 13 On the first day of the inspection, in mid-November, there was little evidence that there were any meaningful activities going on for service users to take part in. The photographs of people enjoying outings had been on the board for several months, and the lists on the board of activities taking place referred to June and July. During the morning one staff member was involved in assisting one of the service users with some sewing. There was nothing else for the other service users to do, and we were told that no-one could go out as the mini-bus was being used to take one of the service users to a hospital appointment in London. Staff we spoke with said that the service users are bored much of the time because there is nothing to do. The manager said that the current service users all want to do different activities to each other: he feels that once the top floor is opened it will be easier to arrange things that people want to do. In one service user’s file we found a detailed check-list of activities that the person was interested in or would like to try. This is excellent information on which to develop activities that each individual wants to pursue. However, this had been completed when this person had been admitted to the home (about nine months ago) and nothing further had been done with the information. The manager said that when people who have been in hospital for a long time move to Drey House they take time to settle and take time to accept that they are able to have more freedom of choice in all aspects of their lives than they had before. One person had recently said that “it’s the first time since 1984 I’ve been able to ask someone to visit me”. The home encourages service users’ families and friends to visit as much as possible: all had been invited to a Christmas party. We spoke with the cook who felt that things were going really well in the kitchen, with lots of new equipment. The cook spends time with the service users to write the menus. A greater choice is being offered to a vegetarian service user as meals are being cooked and individual portions put in the freezer. The menus we saw showed that service users are offered a good choice of nutritious and healthy meals. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. The systems in place for handling of medicines, offering personal support and meeting healthcare needs are not robust enough to ensure that service users’ needs will be met and they will be safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The storage facility provided for medicines is satisfactory and the temperature monitored regularly. This ensures the quality of medicines in use. The controlled drug cabinet was not fixed to the wall in a way that complies with the Misuse of Drugs (Safe Custody) Regulations. Subsequent correspondence from the provider states that the cabinet is now fixed with the appropriate bolts: this has not been checked and will be subject to further examination at the next inspection. The record book used for controlled drugs carries recording errors and omissions. The recorded stock balances do not reconcile with the amount of medication in stock. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 15 Records of the administration of medicines carried an unacceptable number of gaps giving no clear record of whether medicines had been administered or a reason for their omission. Medication for one resident was not administered as prescribed and an immediate requirement was made about this on the first day of the inspection. A satisfactory response was received from the providers. This was not checked on the other days of the inspection and will be the subject of further inspections in the future. There were a number of examples where medication had been changed, either the dose or the timing, without a clear record of the prescriber’s instructions to do so made in the care notes. Records of the results of blood tests were not made in the care notes. Stock levels of medicines were reasonable but one medicine for a resident had been recorded as out of stock for two days. Supplies of medicines are acquired from a location which is at a considerable distance to the home which has resulted in residents being left without medication on this and previous occasions. Serious consideration must be given to the use of a local General Practitioner who may be able to provide a more responsive service. The date of receipt of medicines into the home is not always recorded and so it is difficult in some cases to properly audit the medication used. One resident whose medication records indicate he self medicates did not have a complete risk assessment or management plan in the care notes. In fact the entry in the care notes in July 2006 indicated concerns about his ability to continue to self administer his medicines. The majority of the service users at Drey House manage their own personal care, so there were no guidelines for staff in the care notes of the files we looked at. We suggested that guidelines regarding personal care are needed to make sure that all staff know what each individual service user’s needs are. There was evidence available that service users are supported to attend GP, optician, and emergency dentist appointments when needed. Arrangements are in place for service users to be supported regarding their mental health needs by the clinical teams in the area of the country they came from. For some people this means a long drive to attend an appointment, as was happening on the first day of the inspection when one person had been driven to London to meet with his consultant. One person’s clinical team is in Dorset. This is not considered satisfactory and was the main topic of discussion at the meeting with the Directors and during the other two days of the inspection. Discussions between the company, Psycare Hostels Limited, and the local Mental Health Team are continuing. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. Service users know that systems are being developed so that their concerns will be listened to and they will be kept safe from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has introduced a hard-backed book to log complaints and was working out a system to ensure that all information about each complaint is kept secure and confidential, but available for inspection. Two complaints made by one of the service users had been investigated and responded to appropriately. The senior nurse has attended a ‘train the trainer’ course for Protection of Vulnerable Adults (POVA) and is awaiting approval. Meanwhile, all except two of the staff have already attended POVA awareness training, and we were told that the company training and development officer has provisionally booked further sessions during December and January. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. Improvements are being made to the building, and in keeping it clean, so that service users have a pleasant, comfortable place to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The company have spent a lot of money on Drey House, repairing and replacing a wide range of items such as windows, the boiler, carpets, non-slip flooring, damp course, flat roofs and much more, not all of which is visible but has been essential in improving the building. A kitchen has been installed on the first floor so that service users will be able to have cookery sessions and be involved in producing their own meals. There are also plans in place to continue to improve the environment for the service users, including using the old stables for a gym, computer room and activities centre. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 18 French doors have been put into the lounge replacing a large window so that service users can have easier access to the garden, and it is planned that an extractor will be put into the smoking room so that smoke does not drift out into the dining room. On the first day of the inspection the home was not clean in several areas. We were told that the home had been let down by the agency cleaning staff. By the second and third days a cleaner had been employed for four days a week and the home was looking much cleaner. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. Staff recruitment, training and supervision are all being improved so that staff are equipped to offer service users a better quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing at Drey House consists of a registered manager, trained nurses, and Care Path Facilitators (CPF), as well as kitchen, domestic and maintenance staff. The senior nurse told us that four new staff had been employed since August. Agency staff who know the home are also employed. Agency staff do the cleaning, although on the first day of the inspection there were no domestic staff as the agency had let the home down. By the time of our second visit cleaning staff from an agency had been employed. Staff we spoke with said that it is a good staff team but that sometimes, especially at weekends, there are not adequate staff to meet the service users’ Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 20 needs. They felt that the work was very task-driven and they had little time to spend with the service users. Training records sent to us following the inspection show that all staff, except those who are newly employed, have received training in the mandatory topics (fire safety; food hygiene; moving and handling; first aid; infection control). All except two staff (who were on sick leave at the time the training took place) have also had training sessions in Protection of Vulnerable Adults (POVA). Several staff have received training in Care of Medicines, and Health and Safety. All staff recruited already have training and experience in mental health issues. We were told that training sessions in the mandatory topics, plus POVA, had been provisionally booked during December and January for all staff who need to attend. The consultant psychiatrist has held a case-discussion session with two staff, and one of the senior nurses plans to talk to staff about managing violence and aggression. We spoke with three staff who were on duty on the first day of the inspection. Generally they were happy to be working at Drey House. One person confirmed that she had received mandatory training, and said she would like the opportunity to do more client-based training, such as managing challenging behaviour. The other two staff were newly employed and had not received training, other than during their induction, since arriving at Drey House. Induction is carried out over a two-week period and includes working alongside experienced staff as well as completing an induction workbook. The workbooks, based on Skills for Care induction, plus Psycare induction, were seen on all three staff files. The records showed that five of the seven staff (CPFs) who are eligible to do this course had been registered to undertake a National Vocational Qualification level 2 in care, which was due to start imminently. The personnel files of three staff members were checked. These contained the majority of documents required by the regulations. Some of the references seen had not been signed by the referee, nor verified by the home. Staff meetings are held monthly and one-to-one supervision sessions should take place every two months. The last recorded session seen on one person’s file was in June 2006. New staff are closely supervised during the first three months as this is considered an induction period. No records of these sessions were seen on the files of the two new members of staff whose records were checked. The manager told us that formally recorded supervision starts after this three month period. On the third day of the inspection a new document Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 21 had been introduced for both supervisor and supervisee to sign to show when supervision has taken place. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate. Service users are beginning to benefit as the management of the home improves. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was registered with the CSCI in July 2006. He and the staff team have worked hard to move the home forward. Some of the improvements they have put in place are beginning to show good results. Service users are being encouraged to participate as much as they can and want to in the running of the home. As mentioned earlier, this is new to some people who have spent many years in hospital settings so will take time to develop. Fortnightly residents’ meetings are held: minutes of the meetings are Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 23 taken and kept in a folder in the lounge. Any ideas are discussed and introduced whenever possible. The manager told us that two service user surveys were carried out in 2006, in June and October. The results were collated and published. The regulations require all homes to keep certain records. Some of these were checked. Records of tests of the fire alarm system showed that tests had been carried out weekly as required, although on the first day of the inspection it had been eleven days since the last recorded test. The emergency lighting had been tested almost every month but there was a gap of six weeks since the last recorded test. The manager must make sure the tests are carried out at the intervals required by the fire service. Staff rotas are much improved and include staff’s full names and the hours worked by the manager. A representative of the registered provider is required to visit the home unannounced at least monthly and send a report of the visit to the manager and the CSCI. A statutory enforcement notice was served on the home on 20/04/06 regarding this and although the provider complied with the notice by sending a report, compliance has not been maintained. The last report on file at the home was dated June 2006. An immediate requirement was left at the home on 12/12/06, requiring the provider to submit a report by 15/12/06. There were no health and safety issues that gave us any cause for concern, other than the slight lapse in records of tests of the fire safety systems as detailed above. Drey House DS0000064870.V320113.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 2 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 2 X 3 X 2 3 X Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA12 Regulation 16(2)(m) Requirement The registered person must continue to improve the number and range of opportunities for service users to participate in fulfilling and meaningful activities. The registered person must promote and make proper provision for the health and welfare of service users. Evidence must be available to show that the personal support and nursing care needs of service users are met. This requirement was only partly met. The timescale has been extended for the second time. The registered person must ensure that service users’ healthcare needs are met. The Registered Person must ensure that medication is administered in accordance with the prescriber’s instructions. An immediate requirement Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 26 Timescale for action 31/05/07 2 YA18 12(1) 28/02/07 3 YA19 13(1) 31/05/07 4 YA20 12(1) 13(2) 16/11/06 notice was served. 5 YA20 13(2) 17(1)(a) The Registered Person must ensure that records of medicines prescribed, administered (or not administered) are accurate and up to date. The Registered Person must ensure that medicines controlled under the Misuse of Drugs Act 1971 are stored and recorded in accordance with the Act and associated Regulations. The Registered Person must ensure that results of clinical investigations are recorded accurately. The Registered Person must ensure that records of medicines received into the home are accurate. The Registered Person must ensure that risk assessment and risk management procedures are in place for those service users who self medicate. 31/12/06 6 YA20 13(2) 31/12/06 7 YA20 17(1)(a) 31/12/06 8 YA20 13(2) 31/12/06 9 YA20 13(2) 31/12/06 10 YA32 18(1)(c) The registered person must 31/05/07 ensure that staff receive training appropriate to the work they are to perform. This requirement was partly met. The timescale has been extended for the second time. The Registered Person must 28/02/07 ensure that staff are employed in adequate numbers to meet the needs of the service users. Arrangements must be made for 31/03/07 all care staff to receive supervision at least six times a year. All staff must receive at DS0000064870.V320113.R01.S.doc Version 5.2 Page 27 11 YA33 18(1)(a) 12 YA36 18(2) Drey House least one session within the timescale. This requirement was not fully met. The timescale has been extended. 13 YA41 26 and schedule 4 The registered provider must visit the care home at least monthly as required by this regulation, and prepare a report. A copy of the report must be sent to the CSCI and a copy kept in the care home. This was a requirement following the inspections in October 2005 and April 2006: compliance has not been maintained. An immediate requirement was left at the home on 12/12/06. 15/12/06 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 Refer to Standard YA32 Good Practice Recommendations The registered person should consider what training should be offered to staff to deal with situations that might arise due to the challenging behaviour of some of the service users. This recommendation is carried forward. The registered person should consider the use of a local general practitioner for the prescribing of all medicines in current use. 2 YA20 Drey House DS0000064870.V320113.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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.V320113.R01.S.doc Version 5.2 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. 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