CQC report explained · a residential care home
What the CQC found at Drayton Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks to people's health were not properly assessed, monitored or reflected in care records. Medicine records also had stock discrepancies and did not always give enough guidance for medicines given when needed.
- Effective?
- Requires improvement
- This key question was not inspected at this visit. Its rating was carried over from the previous inspection.
- Caring?
- Requires improvement
- This key question was not inspected at this visit. Its rating was carried over from the previous inspection.
- Responsive?
- Requires improvement
- This key question was not inspected at this visit. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- Checks and management systems did not reliably identify or address risks in care records and medicines. A new manager was committed to improvement, but the home did not have a registered manager in post at the time.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found risks in care records, medicines, staffing at busy times and oversight, with two breaches.
This was an unannounced inspection on 19 May 2022. Inspectors spoke with people, relatives and staff, and reviewed care, medicine, recruitment and management records. They focused on safety and leadership because of concerns about risk management.
The home was not always safe. Some health risks were not properly assessed or monitored, records did not always reflect changes, and medicine records did not show clearly that medicines were given as prescribed. There were also times when staffing levels meant care and call bells were not dealt with promptly.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe and Well-led. Inspectors found no evidence that people had been harmed, but said people were at increased risk. The home remained in breach of Regulation 12 and Regulation 17, as it had at least one breach at the previous inspection.
Safeguarding
People said they felt safe, and staff understood their safeguarding duties. The provider made appropriate referrals when needed.
“People told us they felt protected from the risk of abuse.” from the report
Infection control
Inspectors were assured that infection prevention arrangements were in place, including safe visiting, hygiene, protective equipment and outbreak planning.
“The home was clean, and staff followed good infection control processes.” from the report
Learning from incidents
The provider reviewed accidents and incidents to look for patterns and used learning to improve care. This included action after a serious scald injury.
“Learning from incidents was used to educate staff to prevent reoccurrence.” from the report
New leadership
The new manager was visible and committed to improvement. Staff and relatives spoke positively about communication and the changes they had noticed.
“A new manager had been recently employed and was committed to driving forward improvements at the home.” from the report
Health risk records
seriousSome people did not have clear or up-to-date plans for risks such as diabetes, skin damage, weight loss or choking. Records showed long gaps between repositioning for one person.
“We found no evidence people had been harmed but some risks to people's health had not always been assessed or monitored.” from the report
Medicines
seriousMedicine stock records did not match the medicines held for any of the three people checked. It was not always clear what action was taken to investigate discrepancies or protect people's health.
“The electronic medication administration record (EMAR) did not provide assurance people received their medicines as prescribed.” from the report
Management oversight
seriousThe provider's checks did not consistently identify or correct problems with risks, care records and medicines. Inspectors said the management systems were not effective enough.
“Although the provider had systems and processes to check the safety and quality of the service, oversight of some risks to people's health and wellbeing was not always effective.” from the report
- 01How are you now checking that each person's risks, including diabetes, skin damage, weight loss and choking, are assessed and kept up to date?
- 02How do you check medicine stocks and records, and what happens immediately when there is a discrepancy?
- 03What written guidance is now in place for medicines given when needed, such as medicines for pain or anxiety?
- 04How do you provide enough staff at the busiest times, and how quickly are call bells answered?
- 05What progress has been made with the action plan, and is the manager now registered with CQC?
This was an unannounced focused inspection prompted by concerns about risk management, covering Safe and Well-led; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 21 July 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
Rated Requires Improvement; inspectors found risks, care and leadership were not consistently good, and the rating fell from Outstanding.
This was an unannounced inspection on 25 June 2019. Two inspectors, an inspection manager and an expert by experience visited the home. They spoke with people, relatives and staff, observed care, and checked care, medicine, risk and management records.
The home was not consistently safe. Risks were not always managed properly, medicines and personal information were not always stored securely, and some call bells were not answered promptly. Night staffing was also a concern for some staff.
There were some positive findings. People could access healthcare, food and drink needs were generally met, staff understood safeguarding, and some staff showed kindness. However, activities, mealtimes, care planning, dignity and follow-through on improvements were inconsistent.
The overall rating and all five question ratings were Requires Improvement. The previous inspection, published in April 2016, rated the home Outstanding overall. A new manager had started in May 2019 and was beginning to address the problems.
Safeguarding knowledge
Staff understood different types of abuse and knew how to report concerns. The manager and provider took action after a safeguarding incident.
“Staff were trained and knew about different types of abuse.” from the report
Healthcare access
People were supported to see healthcare professionals, including GPs, dentists and opticians. Referrals were made when choking risks were identified.
“People were supported to access healthcare professionals such as GPs, dentists and opticians.” from the report
Food and drink
The report found that people's nutritional and hydration needs were met, with extra snacks offered and action taken where people were at risk of malnourishment.
“People's nutritional and hydration needs were met.” from the report
Some positive activities
Some people benefited from exercise, hobbies and visits from school children. One person's mobility, confidence and strength improved after joining group exercise.
“Some people experienced positive outcomes.” from the report
New management focus
A new manager had started shortly before the inspection and was identifying and prioritising areas for improvement. Staff said communication had improved.
“A new manager had commenced their employment during May 2019 and was working with the provider's service manager and director of delivery to prioritise areas for improvement.” from the report
Unsafe risk management
seriousSome known risks had not been reduced. Inspectors found an entanglement risk, accessible alcohol and unlocked hazardous cleaning products, as well as unclear moving and handling guidance.
“Risks were not always well managed.” from the report
Medicine security and records
seriousMedicines and prescribed items were not always stored securely. Inspectors also found one incident where legal requirements for administering and recording a medicine were not followed.
“Staff did not consistently follow the provider's policy on the safe storage, handling and administration of medicines.” from the report
Staffing and call bells
seriousThree night staff covered three floors, while several people needed two staff for support. Call bells were sometimes left until they reached the emergency setting.
“Night time staffing levels are not safe.” from the report
Limited engagement
needs fixingActivities were mainly in the day-care lounge. People who stayed on their household or in their bedroom had fewer chances to take part or speak with staff.
“Some people were at risk of social isolation and staff did not always take opportunities to engage with people.” from the report
Incomplete care planning
needs fixingPlans for pain management and end-of-life wishes were not always completed. Some records did not give staff enough guidance to support people consistently.
“Advance care plans, including end of life care, did not contain details about whether important information related to people's wishes had been discussed with them or their relatives.” from the report
Slow improvement
needs fixingThe provider had identified some problems, but checks did not always lead to timely or lasting action. Unpleasant odours and mealtime problems continued after they had been raised.
“Some issues raised in November 2018 and rated the lowest areas were the same as those we found, which meant actions taken had not been sustained or were yet to be implemented.” from the report
- 01What has been done to make medicine storage, medicine records and prescribed items safe?
- 02How many staff now work at night, and how is this matched to the number of people who need two staff for support?
- 03How quickly are call bells answered, and what was found when the reported delays were investigated?
- 04How are people who stay in their bedrooms or on their household included in activities and regular social contact?
- 05Have pain plans and end-of-life care plans been completed and reviewed with people and their relatives?
This was an unannounced planned inspection covering all five key questions and the overall quality and safety of the care home. This explanation was written from the published report of 16 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Drayton Court
3 rated inspections over 6 years: the service has slipped, from Outstanding to Requires improvement.
- July 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementdown from OutstandingSafe: Requires improvementWell-led: Requires improvement
- April 2016OutstandingSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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