Draycombe House received an overall rating of Requires Improvement at this focused inspection, with continued breaches of Regulations 12 and 17 due to inadequate risk assessments, missing equipment safety checks, and ineffective governance systems. Notable improvements were found in responsiveness, with community activity access restored and person-centred care embedded in the culture, though the service has now been rated Requires Improvement for two consecutive inspections.
Concerns (4)
criticalGovernance: “Systems had not been established to assess, monitor and mitigate risks to the health and safety of people using the service. This placed people at risk of harm.”
critical
Care planning
: “Some risks had not been assessed and some risk assessments were not robust. Some checks on the safety of equipment had not been carried out.”
moderateStaff training: “Some staff had not completed training around how to ensure people were safe. The registered manager was aware of the issues with staff training.”
moderateLeadership: “The registered manager also lacked knowledge around some areas of their responsibilities in relation to assessing the safety of the service.”
Strengths
· People told us they felt safe and were happy in the home.
· Staff knew people well and provided person-centred, compassionate care treating people with respect and dignity.
· Responsive improvements made: people now supported to access community activities, addressing the previous breach of regulation 10.
· Medicines were administered, recorded and stored safely and staff were trained in medicines management.
· Safeguarding processes were effective; staff understood how to identify and report concerns and worked well with other agencies.
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and management; Preventing and controlling infection; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
responsive: Supporting people to develop and maintain relationships; support to follow interests and activities; Planning personalised careGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
Draycombe House was rated Requires Improvement overall at this first inspection, with breaches of Regulations 10 and 17 because people living in the care home were not supported to access the community and governance systems failed to monitor and act on feedback. Care was safe and caring, with kind, well-known staff, safe medicines and good infection control, but leadership lacked knowledge of best practice for people with a learning disability.
Concerns (8)
criticalPerson-centred care: “People's care was not always person-centred. People did not receive care that supported their needs and aspirations, or that focused on their quality of life”
criticalPerson-centred care: “People were not supported to be involved in their community. This was a breach of regulation 10(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
criticalGovernance: “Systems had not been established to monitor and improve the quality of the service. This was a breach of regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
moderateLeadership: “the management team in the home did not have the knowledge and experience to perform their role. They had not ensured best practice in supporting people who have a learning disability was followed.”
moderateComplaints handling: “Although staff had raised concerns on behalf of people regarding the lack of activities in the community, the provider had not treated this as a formal complaint and had not acted to improve the service.”
moderateStaffing levels: “staffing levels had not been arranged to support people to have regular access to the community”
moderateCommunication with families: “People, and those important to them, had not been included in developing and improving the service. The provider had not gathered and acted on people's feedback”
minorStaff training: “Although staff had completed training, some training updates were overdue due to issues caused by the pandemic.”
Strengths
· Staff were kind, caring, respectful and knew people well; people enjoyed spending time with them
· Medicines were managed safely, stored securely and administered as prescribed
· Robust safeguarding awareness and recruitment checks including DBS
· Strong infection prevention and control measures in place
· Staff supported people to access local and specialist healthcare services including COVID-19 vaccinations
Quality-Statement breakdown (23)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care; supporting people to follow interests and avoid social isolationRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Meeting people's communication needsGood
responsive: End of life care and supportNot rated
well-led: Promoting a positive culture; engaging and involving people, public and staffRequires improvement
well-led: Managers and staff being clear about their roles; continuous learning and improving careRequires improvement