Inspection on 02/11/05 for WCS - Drayton Court

This inspection was carried out on 2nd November 2005.

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

The inspector 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

WCS - Drayton Court 31/03/09

WCS - Drayton Court 31/01/07

WCS - Drayton Court 10/06/05

WCS - Drayton Court 15/12/04

WCS - Drayton Court 11/08/04

WCS - Drayton Court 13/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE WCS - Drayton Court Cedar Road Camp Hill Nuneaton Warwickshire CV10 9DL Lead Inspector Patricia Flanaghan Unannounced Inspection 2nd November 2005 10:30 X10015.doc Version 1.40 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 WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service WCS - Drayton Court Address Cedar Road Camp Hill Nuneaton Warwickshire CV10 9DL 02476 392797 02476 393020 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) Warwickshire Care Services Limited Mrs Shirley Ann Randle Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th June 2005 Brief Description of the Service: Drayton Court is situated next to the church of St Mary and St John in Cedar Road, Nuneaton. It is located approximately 50 yards from the local amenities including post office, chemist, newsagent, supermarket, florist, greengrocer and hairdressing salon. Drayton Court is located close to Stubbs Park and pool, with water lilies, ducks, swans and children’s play area, all of which are adjacent to a landscaped area, which provides pleasant walks. Drayton Court is a three-storey building, which was comprehensively refurbished in 1997 in order to meet the needs of 45 older people. All corridors are fitted with handrails, all doors are wheelchair accessible and there is a shaft lift to all floors. The home offers a range of adaptations and equipment, which assist service users in attaining greater independence and also promote their health and safety. All bedrooms are single rooms, 22 having en-suite facilities. All bedrooms have washbasins, call bell systems to call for assistance, central heating, wardrobe and dressing table as standard. Service users can, if they choose, furnish and redecorate their room to their own taste if they wish. Telephone points are not fitted in bedrooms, service users wishing to have their own telephone can do so at their own cost. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second visit of the inspection year and took place over six hours. The inspector spent time talking to the manager, deputy manager, examining records, policies and procedures, talking to residents, visitors, a visiting healthcare professional and observing staff working practices. The inspector observed the care being delivered and the excellent interaction between staff and residents. A discussion took place with a number of care staff on duty, who were able to describe how they were meeting the needs of the residents. Following the inspection the manager was asked to distribute questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but prove useful in assessing the various views that are held. Seven responses from residents have been received to date. Questionnaires received were positive about staff and the care provided in the home. Comments made include “I am very content and happy here” and “it is like staying in a hotel.” What the service does well: The home has a group of well trained care staff, some of whom have worked at the home for a long time. Residents spoken to said that their relationships with the staff were good and staff were caring and hard working. The layout allows care to be delivered in spacious surroundings, with residents benefiting from communal areas that are bright and airy. Residents and relatives said that the home had a comfortable homely atmosphere and staff were approachable. The house is well maintained, clean and comfortable. The decoration and furnishing are attractive and suitable for the purpose. The residents have good access to medical care and other health professionals and a visiting healthcare professional confirmed the high standards of care delivered in the home. Staff have good access to training and this is encouraged and supported by the managers. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed at this visit. Standards 3, 5 and 6 were reviewed at the inspection of 10/06/05 and found to be met. EVIDENCE: WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 There was a safe system for the receipt, storage, administration and disposal of medicines. EVIDENCE: The medication written policies and procedures require review. The manager said that all the organisation’s policies are in the process of being reviewed. The medicines within the home, medication administration records, controlled drugs book and drugs returned book, were all checked and no errors were noted. All unused/unwanted medicines returned to the pharmacist for disposal are entered in a returns book. At present, the returns in the book are not receipted by the pharmacist to demonstrate that there is no mishandling of medication. Controlled drugs were checked and the stock reconciled with the accurate records seen. The documentation seen evidenced that only senior staff administered medicines. No resident was ‘self medicating’, but locked facilities were available. There is no policy in place to address self-medication, however, a risk assessment would be completed and there is an agreement for residents to sign if they choose to administer their own medication. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive suitable meals in pleasant surroundings, which promotes social interaction and wellbeing. EVIDENCE: Meals are served by care staff in the individual units presenting a homely environment, which encourages socialising between residents. Lunch was seen to be nutritious and well presented and the residents were seen to eat heartily and really enjoy their meals. Individual menus were displayed on the tables and care staff ask residents what they would like to eat from the two choices available each day. The cook is familiar with individual residents likes and dislikes and any special meals required. A number of residents spoken with on the day of the inspection commented positively on the quality of the food served in the home. One resident said that ‘the food is always wonderful’. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are taken seriously and residents and relatives are confident that any of their concerns or complaints will be taken seriously and action taken. The home has systems in place to protect residents from the risk of abuse. EVIDENCE: An examination of the complaints record, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with. The complaints policy has not been reviewed since 2001 and the manager said all policies are in the process of being reviewed and rewritten, if necessary. Since the last inspection no complaints had been recorded or brought to the attention of the commission (CSCI). No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. The policy and procedure seen is not in line with local guidelines and should be updated. Documentation seen and discussions with staff evidenced vulnerable adult protection had been discussed at length during staff induction, training and on-going supervision. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 Facilities and equipment, supported by staff training, ensures that the risks of cross infection are kept as low as possible. EVIDENCE: The laundry was clean and in good order and provided with liquid soap and paper towels for staff to hygienically wash their hands. Laundry staff are employed 7 days a week and one resident commented that her clothes are always washed and returned to her daily. Measures were in place to reduce the risks and control the spread of infection. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29 Drayton Court is adequately staffed by a team who are committed to ongoing training. This means that the needs of this vulnerable group of people are understood and met. There are robust recruitment practices in place, which protect the residents. EVIDENCE: The records of three staff members were examined, which included recently appointed staff members. The files contained evidence of suitable Criminal Record Bureau disclosures (CRB), references and all other information as required by this standard. Interview forms are completed at the time of interview demonstrating that recruitment is based on equal opportunities. Although the home clearly demonstrated a robust recruitment practice, the written recruitment policy and procedure must be more robust to ensure that service users are protected from harm by the people caring for them. For example, it makes no reference to the requirement to obtain a satisfactory CRB check prior to employment and refers to the Registered Homes Act (1984). WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The quality management systems in this home are developing, with evidence that residents’ views are sought and acted upon. Residents financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: A comprehensive quality management system linked to resident assessment and care planning has recently been implemented by the organisation. A management matrix is completed monthly, which enables the homes manager and senior managers to monitor aspects of care and staffing throughout the home. This includes dependency levels and staffing, accident/incidents and complaints. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 15 Residents are asked one quality question each month and the responses are recorded. Throughout the year this will give an overall indication on residents views of the home. Resident meetings are held regularly with records of this seen at inspection. In addition to this there is a compliments/complaints book on each floor. Many positive comments were seen from appreciative relatives in the comments/complaints book kept in the entrance hall. Comments seen included “coming here is like a ray of sunshine” and “it is like a home from home.” Policies are produced corporately and the manager advised that these are currently under review. Monies held at the home on behalf of residents are handled in line with the homes policy of handling residents’ money, ensuring their financial interests are safeguarded. A sample was checked and found to be satisfactory at the inspection visit. Evidence was seen to confirm that staff receive regular training in moving and handling, fire safety, first aid, food hygiene and infection control. Fire alarm tests, emergency lighting tests and fire drills have been carried out at the required intervals. Staff spoken to confirmed that they received training on safe working practice topics during their induction. Appropriate risk assessments have been carried out. No health and safety hazards were observed at this inspection. Certificates were seen during the inspection for the maintenance and service of most major systems. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 17 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 OP9 Regulation 13 Requirement Timescale for action 31/12/05 2 OP16 22 3 OP18 12(1) 4 OP29 19, 26 SCH 2 The home must ensure that there is a robust policy in place for the receipt, storage, administration, recording, handling and disposal of medication The home must ensure there is a 31/12/05 simple, clear and accessible complaints policy in line with Regulation 22. The home must review the Adult 31/12/05 Protection Procedure. It must be in line with the Local Authority procedure and the Department of Health guidance, No Secrets. The manager must ensure that a 31/12/05 robust recruitment policy and procedure is developed in line with Schedule 2 of the Care Homes Regulations 2001. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 18 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 OP9 Good Practice Recommendations It is recommended that the pharmacist signs the returns book to acknowledge receipt of medication returned for destruction. WCS - Drayton Court DS0000004263.V264705.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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. 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