CQC report explained · a nursing home
What the CQC found at Drayton Village Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Drayton Village Care Centre was rated Requires Improvement because records, oversight and management were not always reliable.
This was an unannounced focused inspection on 18 and 20 January 2023. Inspectors spoke with people living at the home, relatives and staff. They reviewed care plans, medicines records, incident records and recruitment files.
The home was rated Requires Improvement overall. Safe and Well-led were rated Requires Improvement. Responsive was rated Good. The inspection found that medicines, infection control, recruitment and most risk assessments were managed well, but records did not always show that planned care had been provided or that lessons had been learned from incidents.
The home had no registered manager in post. An interim manager and regional managers were supporting it while a new manager was being appointed. The provider was required to send CQC an action plan, and CQC said it would monitor progress with the provider and local authority.
Medicines
Inspectors found that medicines were administered safely and as prescribed. Staff were trained and their competence was checked each year.
“Medicines were managed by staff who had received the relevant training and who underwent annual assessments of their competency.” from the report
Personalised care
Care plans included people's support needs, preferences and communication requirements. They also covered end of life wishes.
“People's care plans identified their support needs and how they wished their care to be provided.” from the report
Activities and relationships
People were supported to keep in touch with important people and to join activities suited to their interests.
“People were supported to maintain relationships with people who were important to them and take part in activities.” from the report
Complaints
The two complaints reviewed had been investigated and answered in a timely way. The people who complained were happy with the outcomes.
“The provider had investigated the complaints, taken action to resolve the issues raised, responded to the people who made the complaint in a timely manner” from the report
Incomplete incident records
seriousSome accident and incident forms did not include a full analysis or actions to prevent the problem happening again. This limited the home's ability to reduce future risks.
“The incident and accident recording forms we reviewed had not always been completed in full to include an analysis of what had happened and the actions to mitigate possible risks” from the report
Care records did not always show planned care
needs fixingStaff did not always record when people were repositioned. Some behaviour guidance and mental capacity records were also missing or not up to date, although some of these records were updated after the inspection.
“The records of the care provided for people who required support with repositioning, and we noted that staff did not always record when a person was repositioned.” from the report
No registered manager
needs fixingThere had been no registered manager since 30 May 2022. Relatives and staff described changes and communication difficulties during this period.
“At the time of the inspection the provider had not had a registered manager employed at the home since 30 May 2022.” from the report
Quality checks missed problems
seriousThe home's audits did not always identify missing records or outdated care guidance. This was linked to the breach of good governance requirements.
“The provider did not have systems in place to ensure information had been recorded in care plans, risk assessments and records of the care provided” from the report
- 01How do you now check that repositioning and other planned care are recorded each time?
- 02What changes have you made to ensure incidents and accidents are fully reviewed and lessons are acted on?
- 03Who is currently responsible for managing the home, and when do you expect a registered manager to be in post?
- 04How are care plans and risk assessments checked to make sure behaviour guidance and mental capacity decisions are up to date?
- 05What progress has been made on the action plan requested by CQC?
This was a focused inspection of Safe, Responsive and Well-led only; the Effective and Caring ratings were carried forward from the previous inspection. This explanation was written from the published report of 13 April 2023 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, February 2021
Inspected but not rated; inspectors found good infection prevention and control arrangements during a targeted January 2021 visit.
This was an unannounced, targeted inspection on 14 January 2021. It focused only on infection prevention and control during the coronavirus pandemic.
Inspectors found arrangements to reduce infection risks for visitors, people living in the home and staff. These included visitor screening, protective equipment, social distancing where possible, cleaning and regular testing.
The home had a process for hospital admissions, including a negative test before discharge and 14 days of isolation after admission. Inspectors said the home met good infection prevention and control guidelines.
The service was inspected but not rated. This report does not provide a full rating for the five areas of care.
Visitor infection controls
The home had separate entrance and exit arrangements, protective equipment for visitors and a designated visiting room with a cleanable screen.
“Appropriate procedures were in place to reduce the risk of people visiting the home, including relatives and professionals, catching or spreading the infection.” from the report
Protective equipment
Staff received extra training and their use of protective equipment and hand washing was monitored. The home had enough protective equipment.
“Processes were in place to ensure PPE was used appropriately by staff including additional training, ongoing monitoring of the use of PPE and hand washing.” from the report
Safe admissions
New admissions from hospital were subject to a negative test before discharge and 14 days of isolation after arrival.
“All new admissions were isolated for 14 days following admission and included in the home's Covid 19 testing process.” from the report
Overall infection control
Inspectors were assured that the infection prevention and control arrangements met good guidelines for a designated care setting.
“We were assured that this service met good infection prevention and control guidelines as a designated care setting.” from the report
Inspectors raised no specific concerns in this report.
- 01Are visitors still required to follow the infection control arrangements described in the report?
- 02How are staff trained and monitored on using protective equipment and washing their hands?
- 03What testing and isolation arrangements are used when someone is admitted from hospital?
- 04How does the home prevent and manage infection outbreaks now?
- 05When was the last full inspection covering caring, effectiveness, responsiveness and leadership?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated and the report does not provide ratings for the other areas. This explanation was written from the published report of 24 February 2021 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 Village Care Centre
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- June 2018GoodSafe: GoodResponsive: GoodWell-led: Good
- May 2017
Registered with the Care Quality Commission on 11 May 2017.
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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