Inspection on 31/01/07 for WCS - Drayton Court

This inspection was carried out on 31st January 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

WCS - Drayton Court 31/03/09

WCS - Drayton Court 02/11/05

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 Deborah Shelton Unannounced Inspection 31st January 2007 09:50 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.V326839.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 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.V326839.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service WCS - Drayton Court Address Cedar Road Camp Hill Nuneaton Warwickshire CV10 9DL 02476 392797 02476 393020 admin@draytoncourt.f9.co.uk 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.V326839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 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 promotes 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. Telephone points are not fitted in bedrooms, service users wishing to have a telephone can do so at their own cost. The current scale of charges are £370 - £437 per week. Additional charges are made for taxis, chiropody, hairdressing, newspapers/magazines, toiletries, alcohol, cigarettes and outings/holidays. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place on Wednesday 31 January 2007 between the hours of 09:50am and 6.40pm. The Home manager was on duty along with the care manager, six care assistants, one housekeeper, a kitchen domestic and four domestics (including one laundry assistant), two catering staff and an administrator. Forty people were living at Drayton Court; a further three were in hospital at the time of the visit. Two residents were ‘case tracked’, this involves finding out about the individual’s experience of living in the care home by meeting with them, talking to them and their families (where possible) about their experiences, looking at their care files, looking at their environment, discussions with staff on duty and reviewing staff training records to ensure training is provided to meet resident’s needs. Documentation regarding staffing, health and safety, medication and complaints was also reviewed. The inspector was introduced to a majority of the people that live at Drayton Court and conversations were held with ten people. The inspection process enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. The inspector dined with residents during this visit. Commission for Social Care Inspection comment cards were sent out to residents and relatives. One response was received from a relative and sixteen from residents. Their comments are included in the main body of this report. The inspector wishes to thank the manager and her staff for the hospitality on the day of inspection. What the service does well: Residents are cared for at Drayton Court in individual “units” of fourteen people. Each unit has a kitchenette area for preparation of snacks and drinks, a lounge and a dining room. Individual units were homely and well maintained. The atmosphere throughout the Home was relaxed and friendly. The relationship between staff and residents was good. Both management and staff had a good understanding of the wants and needs of those under their care. Residents were at ease in the company of staff and chatted freely asking questions about activities, the hairdresser and meals. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 6 The manager and staff are dedicated to meet the needs of residents encouraging independence as much as possible. Systems in place are well established, work well and staff have a good understanding of them and their role within the Home. Residents were complimentary about the Home. Some of the comments made are recorded below: “This was the only room available in this area when my family were asked to move me from George Eliot Hospital. Although I knew nothing about the Home I have found it such a pleasant place, am really content and thankful every day that fate brought me to Drayton Court”. “All my visitors are made very welcome. Tea or coffee and biscuits are served with pleasure if desired”. “I have been pleased with Drayton Court. They are very good and considerate. The staff are approachable and always make my family feel welcome”. “nothing is too much trouble for the staff” “quite happy and grateful for the care received here”. “I am happy and I feel safe” The ongoing programme of decoration and renewal of fittings continues to ensure that the Home is well maintained and in good decorative order. What has improved since the last inspection? What they could do better: Two new issues for action were identified at this inspection. The care manager was informed of the issues during the inspection and committed to address the issues immediately. The Home are using a controlled medications register to record medication usage, they do not record the new stock in the register until the old stock has run out. There is therefore no correct record of the number of controlled medications on the premises at any one time. The care manager said that a WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 7 senior carer would be requested to update the controlled medications register immediately. The other issue identified related to mandatory training. The training matrix seen shows that a majority of staff have undertaken mandatory training, however some staff require refresher training in first aid, basic food hygiene and fire safety. The manager was aware of this and agreed to organise training for these staff as soon as possible. A majority of those residents spoken to in the bedrooms said that although they do not wish to join in with the activities that take place in the lounge and most do not wish to socialise in the lounge, they get bored and want some form of stimulation. One resident said that “it is just an existence, day after day” and another resident commented, “it is boring”. During a discussion with the manager it was noted that various activities are available for residents to undertake in their rooms. However one resident commented that “staff ask me what I want to do and I say I don’t know, I seem to have lost all motivation to do anything”. The manager confirmed that she would speak to all residents who prefer to stay in their rooms and will discuss activities available and the activities that individual residents may wish to undertake. 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. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 8 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.V326839.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The pre-admission process provides staff with the information needed to meet the health and social care needs of residents. EVIDENCE: The care file of the most recently admitted resident was reviewed to evidence whether pre-admission assessments are undertaken and to review the documentation used during this process. Standardised documentation is used and that seen was fully completed and easy to read and understand. Additional notes made by the manager were also available. Care plans provided by Social Services form part of the pre-admission process when applicable. Sufficient information is gathered before agreeing a placement at Drayton Court. Information obtained during the pre-admission process is then transferred onto initial care plans. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 10 The manager confirmed that potential residents and their relatives are invited to look around the Home, stay for a meal and meet staff and other residents. Feedback received from the Commission for Social Care Inspection questionnaire sent to residents before this inspection is detailed below. The question relates to pre-admission information and sixteen residents responded. Yes 10 No 3 COMMENTS We were given information and a tour before we decided. My daughter looked at the Home and explained everything. Can’t remember Can’t remember Did you receive enough information about this Home before you moved in so you could decide if it was the right place for you? WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The recording of resident’s health, personal and social care needs are good and give staff detailed guidance to enable them to meet the care needs of those that live at Drayton Court. Residents have good access to a wide range of health professionals which results in their healthcare needs being met. Systems and practices regarding storage and administration of medicine are good. The Home’s policies and procedures for dealing with medicines protect residents from risk of harm. Residents are treated with respect and their rights to privacy and dignity are maintained WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 12 EVIDENCE: Two residents were case tracked, this involved looking at their care plans, reviewing their living accommodation, talking to staff and the residents where possible. Both care plans contained comprehensive information to enable staff to meet health and social care needs. Standardised documentation is used in the care planning process. Information is also obtained from the Social Worker where applicable before admission to Drayton Court. Care needs are noted and the type and level of assistance required by staff is recorded in detail. Strengths and weaknesses are noted and risk assessments developed as required. Each care file contained a very detailed life history including details of the residents daily routine before moving in to Drayton Court i.e. time of getting up, going to bed, lunch and dinner, whether the person preferred a bath or shower and hobbies enjoyed are recorded amongst other things. A summary of retained skills and abilities and things to try is recorded. Details regarding preference of male or female care, religious needs, family contacts are all noted in files. Daily entries were very detailed and include pictures of residents undertaking activities. Social activity records are also available and record activities such as family visits, hairdresser, and attendance at a church service. Evidence was available in care files to demonstrate that residents have access to external professionals such as dentists, chiropodists, GP, District Nurse and optician. Involving these professionals ensures that resident’s health care needs are being met. There was documentary evidence of regular management reviews of care plan information taking place. The manager is auditing this documentation to ensure it is up to date and contains sufficient detail. Care files contained evidence of ongoing quality assurance practice. Residents are asked a quality assurance question on a monthly basis and their response recorded. Care plans were reviewed on a monthly basis and details updated as required. Short-term care plans were available for short-term health needs such as a urine infection, chest infection etc. The information detailed gives guidance to staff of additional assistance required on a short-term basis. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 13 Details of likes and dislikes were recorded, adaptations required, religious beliefs etc. Overall those care files reviewed were up to date, easy to read, in good order and contained comprehensive details to enable staff to meet the health and personal care needs of residents. Residents sign the front of care files to demonstrate that they have read and agree with the contents of care plans. The resident or their representative signs the quality assurance questionnaire. One resident commented, “everyone is able to see the GP, optician or dentist whenever they need. The Home have a stock of everybody’s tablets and we all have our medication at the same time each day which is really good”. Another resident commented, “if you feel a bit under the weather they call the GP, all of my care needs are met here. I am fit and healthy at the minute, my only problem is that I am getting old”. The commission for Social Care Inspection forwarded a questionnaire to the residents of Drayton Court before this inspection took place. Sixteen residents responded. The results of the questions relating to health and personal care are detailed below: Always Usually Sometimes Never Do you always receive the care and support you need. 15 1 Comments I feel very well looked after. Care is fantastic. Everything is fine. Do you receive the medical support you need 9 4 2 I never require GP visits. The District Nurse could be better. Changing GP at the moment as own GP out of the area. Medication receipt, storage administration and disposal was reviewed. The systems in place were discussed and it was noted that a copy of the prescription is obtained and checked against Medication Administration WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 14 Records (MAR). Mar charts are signed and the amount and strength of medication received into the Home is recorded. Medication audits are completed two or three times per month. Records are also randomly audited and medication is checked to ensure the correct stock is available. A new risk assessment has been developed for PRN (as required) medication. This is considered to be good practice. There is a medication room per floor and medications are kept securely. Each MAR chart contained a photograph of the resident to enable staff to double check a resident’s identity when necessary. There is a medication fridge on each floor and the temperatures of the fridge are taken to ensure medication is stored within the required temperature range. The temperatures of medication rooms are also taken. Consideration is being given to fixing air vents to the doors in these rooms to reduce temperatures. Controlled medications were checked and found to be satisfactory. However, staff are not recording controlled medications in the controlled medications register as soon as they are received on the premises, they wait until they run out of stock to record the new balance. This does not give a true picture of the amount of controlled medication on the premises at any one time. The care manager confirmed that this would be addressed immediately. Staff were seen to have an excellent relationship with those under their care. Residents chatted freely with staff and were at ease in their company. Staff were caring and patient and treated residents with respect and dignity. Staff were seen to knock on bedroom doors before entering their room and were sensitive when offering personal care. Residents were complimentary about staff, some of the comments are detailed below: “staff are patient, kind and don’t rush you, they never shout and are always friendly” “the staff are nice, I have a call bell and call staff if I need to” “staff treat you with dignity” WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The lifestyle experience in terms of meals and social/leisure activities meets the expectations of most residents. The service ensures that visitors are made welcome and the residents’ benefit from visits from family and friends. Residents were happy that they still had some control over their lives and the choices that they make which improves their sense of wellbeing. Residents receive suitable meals in pleasant surroundings which promotes social interaction and wellbeing. EVIDENCE: Details regarding likes and dislikes regarding social and leisure activities and hobbies and interests participated in before moving into the Home are recorded in care files. Information regarding any retained strengths and abilities is recorded along with the action that staff can take so that the resident is able to maintain a level of independence. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 16 For example if a resident enjoys cross-stitch staff are to ensure that the resident has supplies of equipment i.e. thread and needles, staff are to offer to thread needles if the resident appears to be in difficulty etc. Bingo was taking place on the afternoon of the inspection and a vicar had visited in the morning to see some of his parishioners. The vicar spoke to the inspector and was complimentary about the Home, the staff and the management. The hairdresser was doing ladies hair. Some of the ladies spoken to praised the hairdresser saying how nice and friendly she is and said that they always enjoy seeing her. One resident described the hairdresser as a “ray of light” and said that everyone enjoyed her company and wished they could see her more often in the week. An activity list is on display to enable residents to choose whether they wish to participate in an activity or not. A majority of those residents spoken to during the visit preferred to stay in their bedrooms and not join in with the usual activities such as games, bingo etc. One of these residents said that she did not like to join activities or sit in the lounge, however she did get lonely in her room by herself. Another resident said that she also “did not join activities or go into the lounge but needed to do something to pass the time and occupy her mind”. A discussion was held with the manager regarding activities/hobbies that are available for those that prefer to stay in their room. The manager discussed activities such as talking books, large print books, knitting, cross stitch, music tapes and chats with staff. The manager confirmed that she would speak to all residents who prefer to stay in their room and discuss activities and remind them of the activities available and discuss any new activities that they may wish to do. One resident spoken to said that although she does not like joining in activities she enjoys watching them. Another resident said, “there is always a little activity taking place every day – its all good”. The inspector dined with three residents, one of these residents confirmed that “there is a little something going on most days which I join in with, these help to pass the time, if nothing was going on I would be really bored”. Another resident asked staff to change the time of her hair appointment so that she could play bingo first. The resident said that she enjoyed having busy days. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 17 Feedback from the Commission for Social Care Inspection questionnaire relating to activities is detailed below: Always Usually Sometimes Never 12 1 2 Comments I do not wish to attend activities. There are always a lot of activities going on if I wanted to attend them. I Would like to go shopping in the town centre. I can’t do the ones where you have to lift your legs up. I do not wish to take part in them. I Enjoy participating when able to do so. There are activities but I don’t want to go to them. I enjoy participating. I prefer to stay in my room at present setting in. Two residents confirmed that visitors are welcome at any time and are always made to feel welcome by staff. The manager discussed the activities that residents enjoy that occur outside of Drayton Court. Some residents apparently regularly attend the tabletop sale that is held at a local church, other residents attend Bingo at a youth club and it was noted that residents still enjoy visiting local churches to attend services. Are there activities arranged by the Home that you can take part in? WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 18 The choices made by residents regarding daily routines are recorded in care files, i.e. time for rising, retiring, food likes and dislikes, choice of male or female carer, bath or shower. Residents confirmed that they are able to eat their meals wherever they wish in the dining room, their bedroom or the lounge. One resident was seen eating her evening meal on a seat in the corridor. The resident said that she enjoys sitting here in the afternoon so that she can see all that is going on. One resident said “it is pretty perfect here, I can do pretty much what I want there are no problems at all. I can get up when I want, go to bed when I want, I have as much choice as possible in this setting. They encourage you to be independent but help whenever you need”. Residents meetings are held on a monthly basis. Advocacy Alliance have recently been invited to chair the meeting. Minutes of resident’s meetings are on display on the notice board in large print. The inspector dined with residents on this occasion. The meal served was appetising and well presented, portion sizes were large and residents appeared to enjoy their meal. The dining table was nicely laid out with condiments and flowers. A menu on each table displays the choice of meal available. Residents said that you can eat whatever you want, the food is always good. The cook came into the dining room to chat to residents. Feedback from the Commission for Social Care Inspection questionnaire regarding meals is detailed below: Always Usually Sometimes Never 11 2 3 comments Very good. Would like a bit more gravy. Excellent. Like the food here. The food is good a wide choice is available. I didn’t enjoy the dinner on 30.10.06. Do you like the meals at the Home WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 19 Other comments made by residents on the day of inspection regarding the meals are detailed below: “the food is good” “the food is excellent, I have a cooked breakfast, two wheetabix and toast. The main lunchtime meal is lovely” “the food is always good and there is plenty of it”. “you can have snacks whenever you want”. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Complaints are handled objectively and service users are confident that their concerns will be listened to and acted upon. Systems are in place to protect residents from the risk of abuse, increasing their feeling of safety and their quality of life in the home. EVIDENCE: The complaints and adult protection policies have been reviewed and updated since the last inspection and are now satisfactory. No complaints have been received by the Commission for Social Care Inspection since the last inspection to the Home. The manager reported that fifteen complaints have been received by the Home within the last twelve months. All have been responded to within twenty-eight days. The complaints folder records details of complaints received, investigation and action taken. All relevant paperwork is kept in the complaint file. The main complaints logbook is kept in the manager’s office. Staff also have a book to log complaints, which are then passed on to the manager who records the details in the main logbook and continues with the investigation process if necessary. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 21 A comments, compliments and concerns book is available on each unit and residents or visitors are able to log comments or concerns in this book. Sixteen residents responded to the Commission for Social Care Inspection feedback questionnaire. Their comments regarding comments and complaints are detailed below: Always 16 Usually Sometimes Never Comments Sometimes Sometimes They are very good They do listen Oh yes Do you know who to speak to if you are not happy? Do you know how to make a complaint 14 2 Any staff member Would tell keyworker 13 Never had to complain but would if required. Have no complaints Write in the complaints book Have been told how to complain There have been no allegations of abuse at this Home. Some of the staff have recently undertaken Protection of Vulnerable Adults Training. The Adult Protection Policy also now includes reference to the Warwickshire Vulnerable Adults Protection Committee Multi Agency Policy. The Home’s policy is comprehensive and guides staff regarding types of abuse, signs to look out for and the action to take should abuse be suspected. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 22 Do the staff listen and act on what you say Protection of Vulnerable Adults is discussed with staff at induction and on an ongoing basis during supervision and staff meetings. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of the environment within this Home is generally well maintained providing an attractive, hygienic and homely place to live therefore improving the quality of life for residents. EVIDENCE: A tour of the premises took place, communal rooms and some bedrooms were viewed. The Home is divided into three housegroups each providing a lounge with kitchenette, dining room and bedrooms. Bedrooms are located on three floors, these can be accessed via a shaft lift. Those bedrooms seen had been personalised with pictures and ornaments and residents are able to bring pieces of their own furniture if space and fire regulations allow. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 24 An ongoing programme of routine maintenance and decoration ensures that the Home is maintained to a good standard. Grab rails are provided throughout corridors to aid those with mobility difficulties. Assisted bathing facilities are provided and residents are able to shower if they prefer. The music room and lounges were clean, hygienic and comfortable. A laundry assistant works seven days per week. The laundry was clean and hygienic and infection control measures such as disposable hand towels and liquid soap are in place. All equipment in the laundry was in good working order. In general Drayton Court provides a homely atmosphere with fixtures and fittings that are in a good state of repair. Some of the comments made by residents regarding the facilities at Drayton Court are detailed below. The table below records the feedback received from the Commission for Social Care Inspection questionnaire sent to residents before this inspection took place. “the Home is always exceptionally clean” “the Home is clean” “the laundry service is good” “it is always clean and tidy” “I love to sit outside in the summer and I can’t wait to go outside again” Always Usually Sometimes Never 16 comments The Home is clean and comfortable. Very clean and Spotless. Is the Home fresh and clean WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 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. The number of care staff with an NVQ 2 qualification will help to ensure that the skill mix of staff on duty will support meeting the needs of residents. Staff recruitment and selection procedures ensure that only those individuals deemed to be suitable are employed to work at Drayton Court. EVIDENCE: At the time of this inspection there were six care staff, catering, domestic and laundry staff on duty. The manager works in a supernumerary basis and receives support from a care manager and administrator who were also on duty during this inspection. The number of staff on duty throughout the daytime hours remains the same and reduces to three staff who work throughout the night. The staff numbers and skill mix were satisfactory on the day of inspection. Comments received by residents regarding staff are detailed below: WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 26 “the staff help me with everything that I need” “the staff are lovely” “staff chat to me when they can” Comments received from the Commission for Social Care Inspection feedback questionnaire sent out before the inspection are detailed below: Always 11 Usually 4 Sometimes 1 Never Comments Staff come as soon as they can. Most of the time. Staff can sometimes be busy. The staff are very good but due to their workload they don’t always have time to chat, more staff would be ideal. Three staff files were reviewed to evidence whether the recruitment and ongoing training processes at the Home are satisfactory. All required documentation was in place to demonstrate that appropriate pre-employment checks are undertaken. All staff have a criminal records bureau and protection of vulnerable adults check, two written references, application forms, curriculum vitae etc were in place. Copies of training certificates were also available. It was noted at the last inspection that the Home’s recruitment policy does not refer to the requirement to obtain a satisfactory criminal records bureau and protection of vulnerable adults check before employment. This policy was amended in July 2006 and now mentions that these checks must be undertaken before an employee is able to work at the Home. Are staff available when you need them WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 27 Thirty-two care staff are employed, nineteen of these have already achieved NVQ level 2, two are currently doing this training. Three staff have achieved NVQ level 3 with three others still doing NVQ level 3 training. The Home have well over 50 of care staff trained to NVQ level 2, which is the required minimum standard. The induction process takes approximately 12 weeks but can take longer. DVDs are used to assist with the induction process and are used during refresher training. Induction training is in line with the Skills for Care Council. Each staff member is given an information booklet as well as a personal development plan. Staff spend approximately one week shadowing another member of staff. Training records were reviewed and demonstrate that a small few staff require refresher training. The manager was fully aware of the training required and confirmed that this training will be booked in the very near future. Various training courses such as infection control, moving and handling, health and safety, medication and other mandatory training has been undertaken recently. Resident focussed training such as loss and bereavement, pressure areas and sores, stoke care and pain management were undertaken during 2006. The manager provided a list of thirty-six training courses that have been undertaken by some staff during 2006. Induction and foundation training meet the national training organisations standards. Staff spoken to felt that the amount of training available is sufficient. It was noted that both mandatory training such as moving and handling, fire and first aid and resident focussed training such as caring for a person with a stroke, continence and catheter care, equality and diversity take place on a regular basis. Staff are apparently able to request to attend other training of interest i.e. dementia. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home has an experienced manager who has an in depth knowledge of the needs of those under her care. There are systems in place to ensure that the quality of the service provided meets the needs and expectations of the Service users who live at the Home. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff is promoted and protected. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 29 EVIDENCE: The Registered Manager has completed the Registered Manager’s Award and undertakes any update training that is appropriate to her role. There are clear lines of accountability within the Home and within the wider organisation. The manager reported that she has regular supervision sessions with her line manager and support is available as needed. Both staff and residents said that the manager is approachable and they would discuss any problems that they may have with her. The manager is fully aware of any areas that require improvement and is proactive in her approach to managing the Home. The manager has knowledge of the needs of those residents in her care and is dedicated to meeting these needs. A comprehensive quality assurance system is in place. Various audits are undertaken such as care plan, medication, environment, catering, laundry, domestic, gardens. A management matrix is also completed on a monthly basis this enables the manager to review and compare management issues such as dependency levels, staffing and complaints. The results are then forwarded to the company head office for further review. Care plans contain a monthly quality assurance question i.e. “do staff always knock on your room door and wait for an answer”, “how do you rate the way the Home cares for and respects your laundry”. Different questions are asked each month about various aspects of life at Drayton Court. These are completed and signed by the resident or their relative. An annual questionnaire is sent to relatives and a separate questionnaire sent to staff. The results of questionnaires are sent to headquarters. An annual review is completed and the results of the annual surveys are compared. Observed practice takes place to enable the manager to ensure that staff are working to the policies and procedures of the Home. Residents meetings take place and the minutes of these meetings are available for review. The Home handle the personal allowance monies for those residents that request this service. Receipts are kept for all income and expenditure. There is a limit to the amount of funds held on behalf of residents. Residents are able to keep their own funds if they wish and lockable facilities are available in each room. Advocates are involved in financial matters if the resident requests this service. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 30 The funds of those residents being case tracked were checked and found to be satisfactory. Funds are held in line with the Home’s policy, which ensures that resident’s financial interests are safeguarded. Various records were audited to evidence whether health and safety documentation is kept up to date. Fire service and test records were all up to date and in good order, lift service records, portable appliance test records and water disinfection records were all in good order and up to date. No health and safety issues were identified during this inspection. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 31 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 32 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 (2) Requirement The Registered Manager must ensure that all controlled medications are recorded in the controlled medications administration book as soon as they are received on the premises. The Registered Manager must ensure that all staff receive regular updates regarding mandatory training. Timescale for action 20/03/07 2 OP30 13, 19 27/03/07 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 OP12 Good Practice Recommendations The manager should ensure that activities are arranged suited to the wants and needs of all residents including those who wish to stay in their bedrooms. These activities should be available on a regular basis. WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 WCS - Drayton Court DS0000004263.V326839.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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