Inspection on 23/07/07 for Drummond Court

This inspection was carried out on 23rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Drummond Court 16/06/08

Drummond Court 27/06/06

Similar services:

Claremont House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Firstlings

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

CARE HOME ADULTS 18-65 Drummond Court Mill Road South Bury St Edmunds Suffolk IP33 3NN Lead Inspector Julie Small Key Unannounced Inspection 23rd July 2007 11:00 Drummond Court DS0000063432.V346766.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 Drummond Court DS0000063432.V346766.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. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drummond Court Address Mill Road South Bury St Edmunds Suffolk IP33 3NN 01284 767445 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) Active Care Partnerships (Drummond) Ltd Mrs Christine Ellen Fryer Care Home 36 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (26), Learning disability over 65 years of places of age (10) Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for one named service user with dementia (DE(E)) as described in variation dated 22/03/05. 27th June 2006 Date of last inspection Brief Description of the Service: Drummond Court is a residential care home for a maximum of 36 adults with learning disabilities. Drummond Court provides a variety of accommodation with varying levels of support. Accommodation offered includes bungalows, houses and flats. Drummond Court is situated in pleasant surroundings, close to the centre of Bury St. Edmunds. Bury St Edmunds offers a small town and has a range of services, which residents of Drummond Court may use. The home’s manager is Mrs Christine Fryer. At the time of the inspection the manager reported that fees ranged from £420 to £1165 per week, dependant on the levels of care required by each service user. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Monday 23rd July 2007 from 11.00 to 17.10. The inspection was a key inspection which focused on the core standards relating to adults and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The home’s manager Mrs Christine Fryer was present during the inspection and provided the requested information promptly and in an open manner. The manager said that service users were referred to as residents and this term will be used throughout this report. During the inspection a tour of the building and observation of work practice was undertaken. Several residents and staff were met and four residents and four staff members were spoken with. Records viewed included three resident, three staff recruitment, training, fire safety and accident records. Further records viewed are detailed in the main body of this report. Prior to the inspection an annual quality assurance assessment (AQAA) questionnaire and staff, visitors and residents surveys were sent to the home. The AQAA was returned to CSCI (Commission for Social Care Inspection) and seven staff surveys were returned. What the service does well: What has improved since the last inspection? Staff administering medication adhered to the medication procedures. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 6 Carpets seen in the houses and flats during the inspection were clean and well maintained. The care plans viewed included dates of when they had been reviewed. 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. The summary of this inspection report can be made available in other formats on request. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 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 Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with the information they need about living at the home, that their needs and aspirations will be assessed and met and that they are provided with the opportunity to visit the home before moving in. EVIDENCE: The home’s statement of purpose was viewed and included details such as the name and address of the organisation, the manager’s name and qualifications, who lives at the home and how the home meets resident’s needs. The manager said that they were going to update the statement of purpose to reflect smoking legislation. The service users guide was viewed and included details of the accommodation and facilities provided, fire procedure, terms and conditions and consultation with residents. A resident was spoken with, who had recently moved into the home, and said that they had received information about the home and said that they visited the home and met other residents and staff before they moved in. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 9 Three resident’s records were viewed and each held a comprehensive assessment of their needs which was undertaken prior to them moving into the home. The assessments had been put into the organisation’s assessment and care plan documentation. The needs assessments included details regarding communication, behaviours, their disability, personal care, leisure interests and health. The records detailed how the resident’s needs were to be met. The needs assessments and care plans were regularly updated to meet with resident’s changing needs and preferences. Resident’s records held an ‘agreement to occupy’, which was in picture and text format and explained the terms and conditions of the home. The home had policies and procedures regarding the new admission of residents. The AQAA stated that prospective residents were provided with home visits where a full assessment is undertaken. They were provided with the opportunity to visit the home prior to moving in to ensure compatibility between residents. Staff were trained to meet the needs of residents. Drummond Court DS0000063432.V346766.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they have an individual care plan, that they make decisions regarding their lives and that they are supported to take risks as part of an independent lifestyle. EVIDENCE: Three resident’s records were viewed and they contained individual care plans which identified how their needs were met at the home. The care plans included details of support they required in all aspects of their daily living. The documents included information taken from the needs assessments which had been undertaken prior to admission and were regularly updated with changing needs and preferences. The records included an ‘additional disability profile’ which included information of the support that staff should provide residents with, such as personal care, Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 11 independence, life skills and activities. The document provided details of the day services that they attended. The resident’s records included risk assessments which included personal safety and vulnerability to abuse, road danger and challenging behaviour. The risk assessments identified the risks in their daily living and methods of minimising them. One resident’s records held a behaviour plan which had been undertaken by a community nurse. The staff survey asked if they were provided with up to date information about the needs of people they supported and seven answered yes. Daily records were maintained and identified individual residents’ actions, activities and support that they had been provided with on a daily basis. The records identified how each individual had made choices in their daily living, such as activities they wished to participate in and what they wanted to eat. There were monthly reports which summarised the resident’s wellbeing and actions throughout each month. Resident’s spoken with confirmed that they made choices in their daily life and the staff listened to what they said. They said that they had chosen the décor in their bedroom and as a group in their accommodation. A resident was observed speaking to the manager regarding their preferences regarding their day services. Their views were listened to and discussed and a solution was negotiated and the resident said that they were happy with the outcome. Resident’s were observed to make choices during the inspection regarding what they wanted to eat and activities they wished to participate in. Resident’s satisfaction questionnaires were regularly undertaken and were used in the home’s quality assurance activities. The AQAA stated that residents were ‘encouraged to make choices in their lives by promoting independence within the home, via the care planning process and in terms of consultation both individually and as a group’. Drummond Court DS0000063432.V346766.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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with opportunities for personal development, that they are supported to participate in appropriate activities, that they maintain contacts, that their rights are respected and that they are provided with a healthy diet. EVIDENCE: Three resident’s records viewed clearly explained the day services they attended and activities they participated in. Residents attended day services which met their needs and preferences. The records identified interests of each resident, their usual daily routines and the support they requires to maintain their independence. There were several comments in the ‘what the home does well’ section of the staff surveys which stated that the home promoted residents’ individuality and Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 13 independence. Examples included ‘caters for our clients every need and promotes individuality and independence’, ‘looks at each individual and works towards independence’ and ‘promote independence, listen to service users, make people feel comfortable, have a good rapport with outside agencies’. The AQAA stated that staff were provided with training in person centred planning which was incorporated in care documentation and that residents are encouraged to make decisions about how they live their lives. One resident was observed discussing issues regarding their day service and their preferences with the manager. They said that they did not enjoy one of the aspects of the service and they agreed a way forward which met with their wishes. The manager said that the home had good relationships with the various day services and maintained regular contact. There was a good range of activities available for residents to participate in, both in the community and in the home. Activities included in the community included a drama group, swimming, bus trips, shopping, cinema, theatre, exercise at a local sports centre, eating out, religious establishments, disco, snooker and bowling. During the inspection two residents were observed preparing to go to a drama group. They were spoken with on their return and said that they enjoyed the group. They said that there were lots of activities which they enjoyed, particularly a disco, which was held in a community venue. There was a range of materials for activities available in the home which included arts and craft materials, books, television, music and films. Resident’s bedrooms had their personal belongings which they used for entertainment including music, television and computer games. There was an attractive garden area with seating and flower beds where residents could sit and enjoy or do some gardening if they wished to. The AQAA stated that staff encouraged resident to access the local community in accordance with their assessed needs. Interaction between staff and residents was observed to be positive and respectful. Staff were observed including residents in their discussions. There was lots of laughter and friendly chat observed. Staff were observed to knock on bedroom doors before entering and they asked permission for the inspector to view their home or bedroom. The AQAA stated that residents were treated with respect and dignity to ensure that they felt at home. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 14 A resident spoken with said that they had a key for their bedroom, which they kept locked when they attended their day service. Residents spoken with said that they were assisted by staff in the housekeeping tasks in their home. They said that they kept their bedroom clean, shopped for food and tidied up. Resident’s records viewed included details of contact they maintained with their families and friends, which included telephone calls and visits. The records identified the people who were important in their lives and how they wished to maintain contact with them. There was information which explained how residents expressed their sexuality, if they were vulnerable to abuse and methods of ensuring their safety. Resident’s records viewed included a detailed description of their likes and dislikes regarding food and the support they required in eating and drinking. Staff said that residents told them what their preferences were with regards to food. When residents had limited communication skills, their families advised staff of their likes and dislikes. A staff member explained how they observed different behaviours, which residents displayed, that indicated if they liked the meals. If they did not like the food that was served then they would be offered an alternative. Staff spoken with said that residents chose what they wanted to eat on a daily basis and their chosen meals were recorded in a menu. Residents and staff were observed preparing for their evening meals in their houses or flats. There was a range of various nutritious meals being prepared in resident’s homes. Each unit provided fresh fruit and residents said that they could help themselves to when they wanted. Residents said that the food was good and they had enough to eat. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with personal support in the way their prefer, that their health needs are met and that they are protected by the homes medication procedures. EVIDENCE: Resident’s records viewed included details of the personal support they required and preferred, including their preferred routines. The AQAA stated that individual care plans were in place regarding personal care and support, that residents were consulted about how they wanted to be cared for and the care plans were reviewed in six monthly reviews. It stated ‘staff provide sensitive support while observing service users dignity and independence’. Records identified medical care and healthcare support that they had received, which included psychological, optical, dental, chiropody and support from community nurses. There was a behaviour plan in one resident’s records which Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 16 had been completed by the community nurse. The records clearly identified the specific support each resident required with regards to their condition, such as dietary needs, and their preferences. One resident spoken with said that they were diabetic and were supported by the staff to ensure that they were ‘eating properly’. One resident said that they had been eating healthier and explained the weight that they had lost. They were proud of their weight loss and the manager praised them. The home had a detailed medication procedure. Training records viewed evidenced that staff had received medication training. The home used a MDS (monitored dosage system). Medication was securely stored in each unit. The MAR (medication administration records) charts viewed were completed appropriately, staff had signed to evidence that medication had been administered. The MAR charts included a photograph of the resident and what medication they were prescribed. In one house it was identified that there was a gap in one resident’s MAR chart for one weekend. When asked about the gap the staff member explained that the resident always went on home leave during weekends. The MAR charts included a code for home leave for every other weekend and the staff member checked the resident’s records which evidenced that they were on home leave for that weekend. The code was added to the MAR chart. Where residents self medicated, records were maintained on a weekly basis and residents were provided with a dossette box with their medication on a weekly basis. Their records explained the procedure for the support they required. The staff survey asked if staff administered medication, if they had received training to do so. Six answered yes and one answered N/A and stated that they had received training such as in house training, Boots medication training and NVQ (National Vocational Qualification) training. During the inspection two staff members were observed returning to the home from medication reviews with two residents. They reported the outcomes to the manager and recorded them in the resident’s records. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 17 Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their views are listened to and acted upon and that they are protected from abuse. EVIDENCE: The home had a detailed complaints procedure, which included contact details of CSCI. There had been three complaints since the last inspection and records viewed clearly detailed that the complaints had been dealt with appropriately and in a timely manner. The records evidenced that the home had maintained contact with the complainant throughout the investigations and that follow up work had been actioned, such as counselling staff and replacing missing items. Two residents spoken with said that they knew what to do if they were unhappy with something in the home. The staff survey asked if they knew what to do if someone wished to make a complaint about the service and seven answered yes. The AQAA stated that they managed complaints objectively and effectively with the aid of a robust company procedure and that they ensured that residents were listened to. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 19 Training records viewed evidenced that staff were provided with training for POVA (protection of vulnerable adults). The AQAA confirmed that staff were provided with adult protection training was delivered to staff to ensure the protection of residents from any form of abuse. The home had policies and procedures relating to the protection of residents including whistle blowing, receiving gifts and abuse. Resident’s records detailed how each individual may be vulnerable to abuse and methods of protecting them, for example if they were friendly to strangers. Seven staff surveys said that they knew about the procedure for safeguarding adults, which is sometimes called POVA. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 20 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, 25, 26, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they live in a homely, comfortable, safe, clean and hygienic environment which meets their needs. EVIDENCE: A tour of the building was undertaken, it was noted that the home was clean, attractively decorated and well maintained. There had been efforts to ensure that the units had a homely feel, with pictures and ornaments displayed in areas around the home. Communal areas of each unit reflected the group of people living there, for example their photographs and memorabilia were displayed in the lounges. Residents spoken with said that they liked their home and that they could choose the décor and furnishings. One lounge had an area on the wall, where the wallpaper had been peeled off, a chair was placed in front of the area which concealed it. The manager said that there were plans to redecorate. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 21 Each unit provided a communal lounge, kitchen and area where they could eat their meals. There was a communal area in the main building of the home, where residents could participate in arts and crafts activities. The room held a large soft drink dispenser, where residents could purchase cans of soft drinks. Resident’s bedrooms viewed during a tour of the home, each reflected the resident’s individuality. Bedrooms were very different from each other. Furnishings provided met with resident’s needs and included a bed, wardrobe, set of drawers and seating. Residents confirmed that they were provided with a key to their bedrooms and one resident said that they always kept it locked when they went to their day services or attended activities. Residents spoken with said that they were comfortable in their bedrooms and they had everything they needed. They confirmed that they had chosen their personal memorabilia, which were displayed in their bedroom such as photographs and stuffed animals. They confirmed that they chose the décor and the furnishings of their bedrooms. Residents were complimentary about the environment and said that they enjoyed the views of the grounds. There were no offensive odours in the home during the inspection. There was one bedroom which smelled a little, however, the room was not accommodated and the windows were open to ensure that the room was kept aired. The AQAA stated that residents were consulted about their individual homes and how they would like to furnish them and that all residents had been provided with new curtains and bedroom furnishings in the past twelve months. It stated that the home was suitable for purpose, accessible and well maintained. The home provided vehicles which residents could use and local bus services could be accessed by a short walk from the home. Each unit provided suitable bathing and toilet facilities to meet the needs of the numbers of residents living in them. There were laundry facilities in each unit. Staff spoken with had an understanding of infection control and confirmed that they supported residents to do their laundry. The home had detailed infection control policies. Staff had been provided with training on infection control. Hand washing facilities were provided and there was hand wash liquid, disposable paper towels and disposable gloves viewed during a tour of the building. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 22 Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 23 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, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are supported by staff who are competent, appropriately supervised and trained and that they are protected by the home’s recruitment procedures. EVIDENCE: Staff were observed undertaking their usual work routines during the inspection, it was noted that they were respectful towards residents. Residents spoken with said that staff were nice to them. Training records viewed evidenced that staff were provided with a Skills for Care (formerly TOPSS) induction programme. The staff survey asked if the induction covered everything they needed to know to do the job when they started. Five answered yes and 2 answered mostly. Three staff recruitment records were viewed and contained all required documentation which included a photograph of the staff member, identification such as a copy of their passport and birth certificate, application form, two Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 24 written references and CRB (criminal records bureau) check. The staff records viewed included a job description, and written evidence of regular supervision meetings. The AQAA stated that the home had a robust recruitment procedure which promoted experienced people to join their team and based on equal opportunities. The supervision plan was viewed and showed that staff were provided with a supervision meeting every two months. The manager said that staff could be provided with supervisions more frequently if required. Staff were provided with annual appraisal meetings. The staff survey asked if the manager provided them with enough support to discuss how they were working. Six answered yes and one answered sometimes. There were records of training undertaken which included medication, manual handling, food hygiene, POVA, infection control and person centred care. The records of staff who had achieved NVQ awards was viewed. There were forty nine care staff and twenty four had achieved a minimum of NVQ level 2 and twelve were working on their awards. The home had achieved the target set down in the National Minimum Standards for Adults, that 50 of staff to have achieved a minimum of NVQ level 2 by 2005. The deputy manager had achieved their NVQ registered manager award and the day care coordinator was working on their award. The staff survey asked if they were given training which was a) relevant to their role, seven answered yes. b) Helps them to understand and meet the individual needs of residents, six answered yes and one did not answer. c) To keep them up to date with new methods of working, six answered yes and one did not answer. The staff survey asked if the staffing levels on each shift gave enough time to meet the assessed needs of residents. Five answered yes and two answered sometimes. The manager said that the home was fully staffed and that they had maintained a stable team for some time. The staff rota was viewed and evidenced that there was staff support available to support residents needs. Staff spoken with said there was sufficient staff on duty to support residents. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 25 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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they benefit from a well run home, that their views underpin development of the home and that their health, safety and welfare is promoted and protected. EVIDENCE: The Statement of Purpose, which was viewed, identified that the home’s manager had achieved an NVQ level 4 registered manager award, which was confirmed in the AQAA. They had made an application for their Registered Manager status with CSCI which had been successful. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 26 There was a good quality assurance process within the home and residents were regularly consulted regarding the care they received and the running of the home. There were regular Regulation 26 visits, undertaken by a senior manager. The visits included the monitoring of records and the environment and discussion with staff and residents, points for action were made during the visits if required. The visit reports were routinely forwarded to CSCI. There were regular resident and relative satisfaction questionnaires. The resident questionnaire was in a format which was accessible to residents. The outcomes of the questionnaires were included in the planning for the development of the home. The manager explained that the questionnaires were forwarded to the organisation’s head office and the accumulated results from Drummond Court and other homes were used to inform the development of the service as a whole. The manager said that if there were any concerns identified in the questionnaires, then the manager contacted the individuals with an aim to resolve the issues and to ensure that they were satisfied with the actions taken. The manager provided documentary evidence of regular audits and checks that they made in the home on a monthly basis, including resident’s records and medication. Their bi-monthly home audits were validated by a senior manager who attended the home on the months between the completion of the audits. During a tour of the building it was noted that the home was clean and there were no offensive odours. The toilets, bathrooms, laundry held hand washing facilities which included hand wash liquid and disposable paper towels. There was a stock of disposable gloves. The accident and incident records were viewed and provided a clear explanation of all incidents. The records of monthly accident and incident audits were viewed. The manager explained that they audited the reports on a monthly basis and the outcomes were forwarded to the head office for audit. The home’s health and safety procedures were viewed and included issues such as manual handling, infection control, risk assessments and clinical waste. Regular health and safety meetings were undertaken to ensure that the safety of the environment was maintained. Each unit had their own health and safety representative. Records of an assessment of the safety of the windows in the home were viewed and as a result window restrictors had been fitted on all first floor windows. The home had a fire risk assessment and each unit had a fire risk assessment. The fire procedures were viewed and there was documentary evidence of Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 27 regular fire safety checks. Fire safety checks were undertaken regularly in each unit and a central fire safety check was made on a weekly basis. The weekly checks had been routinely undertaken, however there was a gap of fire safety checks identified in the central checks. The accommodation checks continued to be undertaken to ensure the safety of residents. Training records viewed evidenced that staff were provided with health and safety related training such as health and safety, infection control, food hygiene, fire procedures and first aid. The electrical appliance testing was booked in the diary for 26th July 2007. The home’s handy person was due to attend training to enable them to undertake the electrical appliance testing. Records of water temperature checks were viewed and temperatures ranged from 37 to 40 degrees. Records were viewed which evidenced that the contents of first aid boxes were regularly checked and refilled. Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 28 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 29 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA42 Good Practice Recommendations It is recommended that records of central fire safety checks make reference to the records of fire safety checks which are maintained in the houses and flats to ensure that the information can be cross referenced. It is recommended that the wallpaper in the lounge in The Lodge be made good. 2. YA24 Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Drummond Court DS0000063432.V346766.R01.S.doc Version 5.2 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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