Drayton Village Care Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The provider had made improvements to the recording of incidents and accidents with the identification of action to reduce risks. Staff and people living at the home stated that they felt there was not always enough staff on duty on the ground floor unit. This was discussed with the management of the home and an additional staff member was added to the daytime rota. Incidents and accidents were recorded and information on how to reduce risk was identified. This information was included in the person’s care plan and risk assessment. The provider had a robust recruitment process. Staff followed the infection prevention and control procedure.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff explained an analysis of incidents and accidents, which had occurred in the previous month, were discussed at the monthly staff meetings. This included how many incidents had occurred, types of issues, if there were any trends identified and the actions taken. Staff told us they found this information useful and helped them identify possible risks.

People told us they knew how to raise a concern when needed with 2 people telling us “I just shout and say oi. If you want to make a proper complaint, you have to see the people in charge. Never had to, we’re too busy laughing” and “Oh yes I do but never had to.” There were procedures for reporting and the investigation of complaints with information on how to raise any concerns provided when a person moved into the home. The relatives for one person said they had not received any information when their family member moved into the home. This was raised with the registered manager who confirmed they would ensure this information was provided to the relatives as soon as possible.

The provider had a system for staff to record incidents and accidents. Staff completed a form with detailed information including what had happened, who was involved, the immediate actions taken by staff and what additional actions were taken to reduce further risk of the issue happening again. The registered manager or another senior staff member reviewed each form to ensure they were detailed and included the identified actions. People’s care plans and risk assessments were updated following an incident or accident with details of what happened, and the actions identified to reduce the risks.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider had a procedure for safeguarding people. When a concern was identified, the provider communicated with the local authority to ensure the concern was investigated and appropriate action taken. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. There was a clear process to ensure care was being provided in line with the principles of the MCA so that it was provided in the least restrictive way possible. Mental capacity assessments and best interest decisions were completed for a range of aspects of care to ensure it was provided in the person’s best interest.

Staff we spoke with demonstrated a good understanding of safeguarding processes and whistleblowing. The staff members explained who they would speak to within the home if they had concerns. They also told us how they would escalate any issues to external organisations such as the local authority and CQC if they felt their concerns were not being responded to appropriately. Staff explained how they would support people with making decisions.

People told us they felt safe living at the home and when they received care. Their comments included, “Yes, their expertise, competence and genuine concern make me feel safe” and “I do, the fact there’s always somebody here. You’re not allocated a particular one but there’s always someone to look after you.”

People’s risks related to their care and any medical conditions were identified in their care plans and risk management plans had been developed. There were a range of risk assessment completed which included oral health, continence care, falls and pain management. When an incident of aggression occurred, staff recorded information as part of the care plan including how they supported the person. Each person had a personal emergency evacuation plan (PEEP) which provided guidance on the support they needed if they had to be evacuated from the home. Staff recorded daily checks on pressure relieving mattresses to ensure they were functioning correctly to meet the person’s needs and reduce the risk of possible skin issues developing.

Staff were aware of people’s care needs, and we saw them support people so that they were kept safe. Staff told us they reviewed people’s care plans regularly as they could access them on a hand held electronic device. They also said they were told about any changes to a person’s support needs by senior staff and during handover meetings to ensure people received safe and appropriate care to meet their needs.

Risks to people associated with their health and wellbeing were identified and staff supported people to reduce the risks, whenever possible. People told us they could access their call bell if they needed to use it. They commented, “I’m supposed to wear it, look, around my neck” and “I do and I can reach it when I need it.” One person told us that the staff usually pin the call bell to their clothes when in bed as they visually impaired so they can easily find it but sometimes it falls on the floor and they cant reach it. People with a visual or hearing impairment commented they sometimes found it difficult to take part in resident’s meeting as they could not hear or see clearly. This was raised with the registered manager during the assessment and they confirmed they would discuss with staff on how to ensure people could engage during meetings and activities. The director purchased a portable hearing loop to be used around the home.

Staff ensured people had the appropriate support and equipment to ensure they were cared for in a safe manner. We saw that staff supported people to use mobility aids such as walking frames so that they could maintain their independence as much as possible. The activity coordinator told us that they were looking to decorate people’s frames to make it easier for them to identify their own frame.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

There were not always enough staff to provide support for people. During the inspection we identified that there was only 1 senior care worker and 3 care workers providing support for 27 people in the ground floor unit. During busy periods of the day when care workers were busy supporting with personal care, people were in the lounge and there was not always a care worker available to provide support when required. People were asking for support to go to the bathroom and staff had to be located around the unit to provide the required support.

People provided mixed feedback when asked if they felt there were enough staff to support them. Some people felt there were enough staff on their unit with other people thinking they required more staff. Their comments included, “It depends on the shifts but I haven’t had any problems so far” and “No, definitely not. Any time is not good, In my opinion there aren’t enough. They’ve just said your lunch will be here soon, it’s 1.20, I like mine at 1pm (arrived at 1.40).”

Staff on the ground floor unit told us they felt there were not enough staff on duty during the day to enable them to support people in communal areas when they have to provide care for people in their bedrooms. This was discussed with the registered manager, regional manager and managing director who added an additional care worker to the daytime rota for this unit. This meant there was a specific care worker with the responsibility of caring for people in the lounge and their bedrooms while other care workers provided personal care support. Staff confirmed they had completed a range of mandatory training as well as training to meet specific care needs which included dementia, end of life care and catheter care which they all felt were useful.

The provider had a robust recruitment procedure to enable them to identify if new staff had the required skills for the role. We reviewed the recruitment records for 4 staff members. The records included at least 2 references, the applicants right to work in the United Kingdom and the Disclosure and Barring Service check for criminal convictions. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff members completed an induction before they started their new role. Staff had regular supervision meetings and discussions with a senior staff member. Staff completed a range of training courses which included dignity, dementia, falls prevention and palliative care. Competency assessments were completed for a number of aspects of the care provided including infection control, wound management and safeguarding to assess the staff member’s knowledge and understanding of the impact on care.

Staff confirmed they had completed infection prevention and control training and this was supported by training records.

The home was clean, tidy and, in general, free from malodour. Staff had access to personal protective equipment (PPE) around each unit including gloves, aprons and hand gel. During the inspection we observed housekeeping staff were cleaning communal areas and bedrooms in each unit. They were following best practice by using different equipment when cleaning specific areas to prevent cross contamination.

Staff had completed infection control training and had access to personal protective equipment (PPE), such as aprons, masks, and gloves to help reduce cross infection risks. The provider had an infection control policy and a policy for managing an outbreak of infection within the home in place, which was up to date and provided direction to staff on reducing the risk of the spread of infections, including COVID-19. The provider completed a range of quality control audits on a regularly basis, to help prevent the spread of an infection within the home .

Staff who administered medicines confirmed they had regular competency assessments to monitor their skills and knowledge of best practice when managing medicines. This was supported by completed competency forms we reviewed. They confirmed they had completed training including courses on specific clinical needs which enabled them to build their confidence in relation to practice and skills.

People were supported by staff in a kind and caring manner when they received their prescribed medicines. Staff ensured medicines were administered in a safe way and explained to people when they were supporting them with medicines.

Medicines were kept securely and according to manufacturer’s instructions. Where a medicine needed to be kept at a specific temperature, they were stored in a fridge which had the temperature regularly checked. Where a person had been prescribed a medicine to be administered as and when required (PRN), staff were provided with guidance on when the medicine should be administered. The medicines administration record (MAR) included information on the medicines prescribed, their dosage, when they should be administered and staff recorded when they administered people’s medicines.