Inspection on 18/04/06 for Drey House

This inspection was carried out on 18th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 27 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 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 18th April 2006 10:35 Drey House DS0000064870.V289992.R01.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 Drey House DS0000064870.V289992.R01.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. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 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 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.V289992.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10th October 2005 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 not currently made available for service users or their representatives other than from the CSCI website. The acting manager plans to put copies of these in the reception area of the home, and in the service users’ lounges. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on one day by two inspectors, who were joined during the afternoon by the pharmacy inspector. The Senior Liaison Officer for the company and the deputy manager of Drey House were present for the inspection. Some information was provided by the acting manager during a telephone conversation following the inspection. This summary also includes a summary of additional regulatory activity that has taken place since the last public inspection report was produced following the statutory inspection on 10th and 26th October 2005. Serious concerns about medication administration were identified at the inspection on 10th October 2005 and an immediate requirement notice was left at the home regarding eight breaches of regulations. The pharmacist inspector carried out an additional inspection of all matters to do with medication on 19th October 2005. Serious breaches of regulations were identified. A Statutory Requirement Notice under Regulation 43 of the Care Homes Regulations 2001 was served in respect of poor management of medication practices within the home. An inspection on 1st November 2005 showed that the home had not complied with the Statutory Notice: documents were seized under code B of the Police and Criminal Evidence Act (PACE). Representatives of the Commission for Social Care Inspection (CSCI) met with representatives of Psycare Hostels Ltd on 14th November 2005 to discuss the company’s plans to meet the requirements of the Statutory Requirement Notice served on 20th October 2005. Amongst the issues discussed was the lack of awareness by the staff of the seriousness of the concerns raised by CSCI and of the meaning of the Statutory Notice. CSCI took into account a letter from Psycare Hostels Ltd detailing plans to meet the requirements from the inspection: Psycare Hostels Ltd was required to provide an action plan to meet the requirements of the Statutory Notice. An inspection carried out on 30th November 2005 confirmed that the home had complied with the Statutory Notice. During today’s inspection the pharmacist inspector found breaches of the regulations which showed that compliance with the Notice served in October had not been maintained. Documents were seized under code B of the Police and Criminal Evidence Act (PACE). The CSCI is seeking legal advice. An unannounced additional inspection was carried out on 13th February 2006 to check compliance with the requirements made following the statutory inspection in October 2005. It was pleasing to note that 13 of the 14 requirements had been met. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The inspection in February 2006 showed that requirements made following the inspection in October 2005 had been met. It was therefore extremely disappointing to note at today’s inspection that compliance with a number of those requirements had not been maintained. This inspection has resulted in twenty-seven requirements being made, and in the Commission for Social Care Inspection seeking legal advice on three different matters. This indicates that the management of the home is poor. Neither assessments of service users’ needs nor care plans were adequate and neither showed that the service users have been involved. Risk assessments were not carried out adequately. There was no evidence that service users personal, nursing or healthcare needs are met. The systems in the home for a number of aspects of the administration of medication were poor so that there is a risk to service users. The premises, both inside and outside, looked shabby and uncared for. There was an unpleasant odour in parts of the home, and the home was not as clean as it should be. There was evidence, such as the lack of activities on the day of the inspection and the fact that the home was not clean, to show that not enough staff are employed. Training records, to show that all staff have received adequate training to be able to offer a good quality of care to the service users, were not available. Staff had not received training in the protection of vulnerable adults. Recruitment procedures were poor: information such as references and Criminal Record Bureau checks, to make sure staff are suitable to work with vulnerable people, had not been obtained for all staff. Staff had not received adequate supervision. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 7 A quality assurance system, taking service users’ views into account, has still to be developed. Not all records required by regulation were maintained. For example, reports written by the registered provider following his monthly visits were not available and are not sent to the CSCI; not all staff records were available; and the staff duty roster was not accurate. Several matters regarding safety to the service users were noted, such as a very hot portable heater; trailing wires; tape on carpet seams; and cracked glass in two windows. Some fire doors did not close correctly and one was held open with a wedge of cardboard. 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.V289992.R01.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 Drey House DS0000064870.V289992.R01.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): 2, 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not carry out adequate assessments before a person is admitted to make sure the home can meet the person’s needs. EVIDENCE: Files for two service users were checked. Both files contained detailed health needs assessments carried out by health service staff some time prior to admission. The pre-admission assessments done by the home were poor and contained little information: the majority of the documents were not signed or dated. There was no evidence that the service users had been consulted on whether the home could meet their needs. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no clear or consistent care planning system in place to adequately provide staff with the guidance they need to meet service users’ needs. EVIDENCE: The files of two service users were checked. For one person no needs had been identified by the ‘needs assessment’ document. Two ‘needs’ had been put into care plans: these had been reviewed but there was no evidence that the service user had been involved. It was of concern that the only document indicating this person has an allergy to penicillin was found in the ‘funeral arrangements’ section of the file. For the second person, one care plan was written regarding “further orientation and register with GP”: it was documented that this had been completed within two weeks of admission (October 2005), yet this had been reviewed in February 2006 and “no changes” recorded. There was no evidence that either of the service users had been involved in writing or reviewing the care plans. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 11 The only risk assessments on one file were not completed by the home. On the second file the document in place was the same one that the inspectors had discussed with the Senior Liaison Officer following a previous inspection: this document is considered inadequate as it contains only historical information and does not identify current risks. There was no evidence of any meaningful risk management in place on either of the files seen and yet risks could be identified from pre-admission information and from daily records. Daily notes written by staff were descriptive and detailed. Drey House DS0000064870.V289992.R01.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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff said that the number of activities available to service users is improving. EVIDENCE: One staff member spoken to said that now there is a vehicle available, quite a lot of outings are organised. He said service users who wanted to go out had been to the animal shelter, garden centres, Speedway and other places. He said there has also been improvement in the number of activities in the house undertaken by the service users. On the afternoon of the inspection three service users were going to have a drive out in the house vehicle with the staff member who was collecting prescriptions from two doctors’ surgeries. Records to evidence what activities had been undertaken were not available. There was no information on service users’ files to indicate that they are given the opportunity to develop personal relationships, nor that their rights and responsibilities are recognised. There was little information to show that service users’ independence is encouraged, other than a record that each person has been offered a key to their room. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 13 The week’s menu is displayed on a whiteboard in the dining room. There is one main course and one pudding but the support worker cooking on the day of the inspection said that alternative meals are available if requested. A service user who is vegetarian confirmed that he is given a variety of vegetarian food. The record of food eaten was being maintained in great detail for each service user. For several service users, “DNA” had been recorded: the deputy manager explained this as “did not arrive”. The inspectors were concerned that one service user had missed several meals. Drey House DS0000064870.V289992.R01.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, 19, 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The systems for the administration of medication are poor and potentially place service users at risk. EVIDENCE: Information on care plans was not adequate for staff to know what personal support service users prefer and require. The Senior Liaison Officer said that all the service users had remained with the clinical teams who supported them before they moved to Drey House. The company has been having discussions with local GP practices, and all service users at the home will be registered with a practice in St Neots. The Senior Liaison Officer said that GPs have visited the home when needed, and service users have been to the surgery. Evidence was not seen on the two files inspected that these service users have seen other healthcare professionals such as optician, dentist, chiropodist and so on. Serious concerns about medication administration were identified at the inspection on 10th October 2005 and an immediate requirement notice was left at the home regarding eight breaches of regulations. The pharmacist inspector Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 15 carried out an additional inspection of all matters to do with medication on 19th October 2005. Serious breaches of regulations were identified. A Statutory Requirement Notice under Regulation 43 of the Care Homes Regulations 2001 was served in respect of poor management of medication practices within the home. An inspection on 1st November 2005 showed that the home had not complied with the Notice: documents were seized under code B of the Police and Criminal Evidence Act (PACE). Representatives of the Commission for Social Care Inspection (CSCI) met with representatives of Psycare Hostels Ltd on 14th November 2005 to discuss the company’s plans to meet the requirements of the Statutory Requirement Notice served on 20th October 2005. Amongst the issues discussed was the lack of awareness by the staff of the seriousness of the concerns raised by CSCI and of the meaning of the Statutory Notice. CSCI took into account a letter from Psycare Hostels Ltd detailing plans to meet the requirements from the inspection: Psycare Hostels Ltd was required to provide an action plan to meet the requirements of the Statutory Notice. An inspection carried out on 30th November 2005 confirmed that the home had complied with the notice. During today’s inspection the inspectors had concerns about administration of medication and requested assistance from the pharmacist inspector who arrived at the home at 2 p.m. The pharmacist checked the records of nine service users and found discrepancies on six of them. He identified that there were breaches of the regulations indicating that compliance with the Notice had not been maintained. Documents were seized under code B of the Police and Criminal Evidence Act (PACE). The CSCI is seeking legal advice. Drey House DS0000064870.V289992.R01.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, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training in the Protection of Vulnerable Adults is not adequate to ensure that service users are protected from abuse. EVIDENCE: The acting manager said that when service users are admitted to the home they receive a leaflet which explains how they can complain. The home’s complaints record was not inspected. Staff have not received training in Protection of Vulnerable Adults: the acting manager reported that he has been unable to access training. Following the inspection in October 2005 the home acquired a copy of Cambridgeshire County Council’s POVA protocol which is kept in the policy file. Drey House DS0000064870.V289992.R01.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, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Maintenance and housekeeping in this home are poor so that service users do not have a comfortable, clean and safe place to live. EVIDENCE: The inspectors were disappointed by the condition of the building, both inside and outside. The impression is of a place that is not cared for and is becoming shabbier and dirtier. The entrance lobby outside the front door was littered with piles of dead leaves, and although some of the cobwebs had been cleared, there were still black cobwebs hanging from the windows and porch and the windows were not clean. The home has a very large garden which is mainly lawn with shrubs and trees. The grass had been neatly mown. The patio outside the lounge and the enclosed garden were very untidy. Seams in the dark blue carpet in the downstairs corridor had been covered with bright orange tape. The inspectors were told that there has been a problem with the way the carpet was laid and in the longer term the carpet is Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 18 to be replaced. All the strip lights in the corridors were full of dead flies. Fire doors were not all operating correctly. A pane of glass in one of the bedroom windows had a crack across it, and so did one of the panes in the lounge. There were two bolts on the outside of one of the doors into the lounge: the deputy manager explained that these had been fitted to prevent the door being used. These must be removed. Seats and backs of the chairs in the dining room have been re-covered since the last inspection and are much improved, although could have been improved even further if the wood frames had also been refurbished. The inspectors noted that two rooms upstairs, originally designated as lounges, had been furnished with beds and bedroom furniture. These rooms have no washbasins or ensuite facilities and cannot be used as bedrooms until at least a usable washbasin has been fitted in each room. The Senior Liaison Officer said that there have been difficulties with maintenance at the home but that a maintenance person has now been employed to work across the company’s homes to sort out maintenance issues. One toilet in one of the bathrooms was very dirty and there was an unpleasant smell in one part of the downstairs corridor. The home was generally not as clean as it should be. Drey House DS0000064870.V289992.R01.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): 32, 33, 34, 35, 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are not enough staff to ensure that the needs of the service users are met. The procedures for employing staff are poor and do not ensure the safety of the service users. EVIDENCE: At the time of the inspection there were three staff on duty, including the deputy manager who is a registered nurse, plus the Senior Liaison Officer. The home does not employ a cook, so one of the staff spent the majority of the time in the kitchen. The lack of activity during the morning, and the lack of cleanliness of the home, indicated that not enough staff are employed to meet the needs of the service users. There are two staff on duty at night: it was seen on the staff roster that sometimes both members of staff are male. Daily records showed that this results in one of the female service users having to wait for assistance with personal care until a female member of day staff arrives. Although there were some records of training on one of the files seen, there was no clear record of which training courses had been undertaken by which staff, and when. There was some confusion over whether one of the staff on duty was employed by an agency or by Psycare. This support worker told the inspectors that she Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 20 had worked at the home through an agency for some time but the day of the inspection was her first day of being employed by Psycare. Her staff file did not contain any information other than an application form and records of some training accessed through the agency. The Senior Liaison Officer explained that because the documentation was not available, she was still employed by the agency. Not all staff files were available for inspection (see standard 41). The files of two new staff were inspected. Each file contained an application form and a ‘Big Five Report’, and a note “refs and CRB check in progress”. There was no information on the files as to whether either individual had commenced employment, but both were listed on the staff roster as having started work on 03/04/06 with two days induction, then on the roster unsupervised. The CSCI is taking legal advice regarding this. Staff rosters were not accurate (see standard 41). Another staff file seen included an induction programme: only a few of the items were ticked and were marked as “discussed at interview”. There were two records of supervision on file: one dated 24/11/05, the second one had had the original date of 29/09/05 blocked out with correction fluid. There were also two ‘Personal Development Planning Process appraisal’ forms on this file dated 25/11/05: one was for another staff member. The majority of documents required by regulation were available on this file, including a photograph, proof of identity, application form, medical declaration, interview questions/answers and training certificates. There was no evidence that a POVA check had been undertaken or that a Criminal Records Bureau check had been received. This person commenced employment at the home on 05/09/05: one reference was dated 07/11/05 and one was dated 12/03/05. The contract of employment was dated 04/11/05. Training records on one file showed that training in Fire Safety in a Care Setting; Basic Food Hygiene at Work; Moving and People Handling; and Basic First Aid – appointed person, had been undertaken by this employee. Drey House DS0000064870.V289992.R01.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): 37, 39, 41, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users cannot be confident that the home is managed well enough to meet their needs and keep them safe. EVIDENCE: The number of requirements made following this inspection indicates that the management of the home is poor. The acting manager said that service users’ meetings take place monthly and the minutes are kept in a folder in the lounge. He said that everyone is encouraged to join in and express their views. No formal means such as questionnaires are used at present to get service users’, relatives’ or other professionals’ views of the home. The Care Homes Regulations 2001 require the provider of the service to undertake monthly, unannounced visits to the home and produce a report. A Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 22 copy of the report must be sent to the CSCI and a copy sent to the manager of the home. A requirement was made regarding this following the inspection in October 2005. At today’s inspection it was noted that the last report in the file was dated 10/02/06: this was not signed or dated. The last report received by CSCI was received on 08/02/06. The CSCI is taking legal advice regarding this. The staff file for the acting manager was not available for inspection. Staff rosters were not accurate as the acting manager’s name did not appear on the roster. Staff surnames were not written on the rosters seen. Records of tests of the fire alarm and emergency lighting systems showed that tests had been carried out as required. Records showed that a fire drill had taken place on 18/01/06. Not enough attention is paid to health and safety to ensure service users are safe. For example, a portable heater in the lounge was very hot and could pose a hazard to service users; there was a quantity of electrical flexes and a large electrical extension box near to the television in the lounge which could be a hazard to the safety of service users and staff; and the tape over the carpet seams in the corridor could be hazardous. Glass in two windows was badly cracked. Several fire doors on the upstairs corridor did not close fully and one was wedged open with cardboard. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 1 3 1 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 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 1 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 1 X 1 X 1 X 1 2 X Drey House DS0000064870.V289992.R01.S.doc Version 5.1 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 Standard YA2 Regulation Requirement Timescale for action 31/05/06 14(1)(a) & (b) The registered person shall not provide accommodation to any service user until a full assessment of their needs has been undertaken. 14(1)(c) & (d) Appropriate consultation regarding the needs assessment must be undertaken with the service user or representative. The registered person must confirm in writing to the service user that the home can meet his needs. The registered person must prepare a written plan of care for each service user, detailing how the service user’s needs are to be met. 2 YA3 31/05/06 3 YA6 15 30/06/06 4 YA7 12(2) The registered person must 30/06/06 enable service users to make decisions regarding the care they receive and the way they live their lives. Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 25 5 YA9 13(4)(c) The registered person must make arrangements to enable service users to take responsible risks. Risk assessments must be carried out so that unnecessary risks are identified and minimised. The registered person must continue to develop the programme of activities for service users. 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. 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 healthcare needs of service users are met. The registered person must make proper provision for the health and welfare of service users. A suitable supply of prescribed medication must be available at all times. This was a requirement following the pharmacy inspection in October 2005: compliance has not been maintained. Legal advice is being sought. 30/06/06 6 YA12 16(2)(m) & (n) 30/06/06 7 YA18 12(1) 31/05/06 8 YA19 12(1) 31/05/06 9 YA20 12(1)(a) 12/05/06 Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 26 10 YA20 13(2) Arrangements must be made for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This was a requirement following the pharmacy inspection in October 2005: compliance has not been maintained. Legal advice is being sought. The registered person must make arrangements to prevent service users being placed at risk of harm or abuse. All staff must receive training in the protection of vulnerable adults. 12/05/06 11 YA23 13(6) 30/06/06 12 YA24 23(2)(b) The registered person must 31/07/06 ensure that the premises are kept in a good state of repair both internally and externally. The registered person must ensure that all parts of the home are kept clean. The registered person must keep the home free from offensive odours. The registered person must ensure that staff receive training appropriate to the work they are to perform. This was a requirement following the inspection in October 2005: compliance has not been maintained. The registered person must ensure that at all times suitably qualified, competent and experienced staff are DS0000064870.V289992.R01.S.doc 13 YA24 23(2)(d) 31/05/06 14 YA30 16(2)(k) 31/05/06 15 YA32 18(1)(c) 30/06/06 16 YA33 18(1)(a) 31/05/06 Drey House Version 5.1 Page 27 working at the care home in such numbers as are appropriate for meeting service users’ needs. 17 YA34 19(1) & schedule 2 Full information as detailed in Schedule 2 must be obtained before a person commences employment at the home. This was a requirement following the inspection in October 2005: compliance has not been maintained. Legal advice is being sought. All new staff must complete a full induction programme. Evidence must be available to demonstrate that this has taken place. Arrangements must be made for all care staff to receive supervision at least six times a year. All staff must receive at least one session within the timescale. This was a requirement following the inspection in October 2005: compliance has not been maintained. The registered person must ensure that the person employed to manage the home has the qualifications, skills and experience necessary for managing the care home in a way that provides a quality service for service users. 19/05/06 18 YA35 18(1)(c) 30/06/06 19 YA36 18(2) 30/06/06 20 YA37 9 31/07/06 21 YA39 24 The registered person must 31/07/06 establish a quality assurance system in accordance with this regulation, and ensure that reports of quality reviews DS0000064870.V289992.R01.S.doc Version 5.1 Page 28 Drey House are supplied to the Commission and made available to service users. 22 YA41 17(1)(a) & sch 3 The registered person must maintain in respect of each service user a record of all medicines kept in the care home for the service user, and the date on which they were administered to the service user. This was a requirement following the pharmacy inspection in October 2005: compliance has not been maintained. Legal advice is being sought. A record of all persons employed at the care home must be kept in the care home and available for inspection. An accurate copy of the duty roster must be maintained. 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 inspection in October 2005: compliance has not been maintained. Legal advice is being sought. The registered person must ensure that all parts of the home accessible to service users are free from hazards to their safety. The matters DS0000064870.V289992.R01.S.doc 12/05/06 23 YA41 17(1)(a) & sch 4 31/05/06 24 25 YA41 YA41 17(1)(a) & sch 4 26 & schedule 4 31/05/06 19/05/06 26 YA42 13(4)(a) 30/06/06 Drey House Version 5.1 Page 29 noted in “Conduct and Management of the care home” above must be rectified. 27 YA42 23(4)(c) Fire doors must not be held in the open position other than by a means approved by the fire authority. Fire doors must close correctly. This was a requirement following the inspection in October 2005: compliance has not been maintained. 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Drey House DS0000064870.V289992.R01.S.doc Version 5.1 Page 30 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.V289992.R01.S.doc Version 5.1 Page 31 - 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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