Inspection on 11/09/07 for Davey Court

This inspection was carried out on 11th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Davey Court 05/10/06

Davey Court 07/06/06

Davey Court 07/09/05

Davey Court 23/12/04

Davey Court 25/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Davey Court Buckingham Close Exmouth Devon EX8 2JB Lead Inspector Sue Dewis Unannounced Inspection 11th September 2007 10:00 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 Davey Court DS0000039203.V343860.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. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davey Court Address Buckingham Close Exmouth Devon EX8 2JB 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) 01395 273860 01395 223072 marlene.smith@devon.gov.uk http/www.devon.gov.uk Devon County Council Mrs Jacqueline Cecilia Franklin Care Home 43 Category(ies) of Dementia - over 65 years of age (43) registration, with number of places Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may continue to care for four named people in the category OP, for as long as the unit can meet their needs. The maximum number of placements including that of the 4 named persons will remain at 43 That on the termination of the placement of any of the four named people, the registered person will notify the Commission and the particulars and conditions of this registration to allow up to four people in the category OP to live at the home will reduce by one. 5th October 2006 Date of last inspection Brief Description of the Service: Davey Court is registered to provide specialised care for up to 43 people with dementia. Davey Court is situated on the outskirts of Exmouth in a quiet residential area. The building consists of two floors and there is level access to both. The first floor is served by a passenger lift. There are attractive gardens outside. Although most bedrooms are small, all are single rooms, and there is ample communal space including 4 dining areas, 4 lounges and a conservatory. A copy of the last inspection report is pinned to the notice board in the entrance hall. The weekly fee for the home is £570.50. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours, one day in September 2007. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to 7 people living at the home, 12 representatives, 19 health and social care professionals (including GPs and care managers) and 20 staff. At the time of writing the report, responses had been received from 5 people living at the home, 5 health and social care professionals and 11 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 2 people living at the home were spoken with individually and 5 in a group setting, as well as observing staff and people living at the home throughout the day. We also spoke with 4 staff and the 3 assistant managers on duty. A tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files A Random Inspection visit was made to the home on 7 March 2007, to follow up on the requirements and recommendations from the previous report. At this visit we found that much progress had been made and there was a much more relaxed atmosphere within the home. The environment had been considerably improved and while there were still some requirements and recommendations outstanding, most had been fully completed and all had been addressed in some way. The home has been identified for ‘externalisation’ by Devon County Council. This means that the ownership and management of the home will transfer to a ‘preferred provider’. Details of this change have yet to be finalised, and some staff spoke about how this uncertainty was affecting staff, with some choosing to leave. What the service does well: Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 6 Davey Court is well managed and provides a safe, comfortable and homely place in which individuals can live their lives. There was good interaction observed between individuals and staff. The home tries to treat people as individuals with each one receiving the care and support they need and want. There is a good assessment process that assures people thinking of moving into the home that their needs will be met. Though the care planning system could be improved everyone living at the home does have a care plan that sets out their needs. Staffing levels are sufficient and staff are well trained. All records, including those relating to medication administration, fire precautions, risks and finances were well maintained. There is a clear and simple complaints procedure and any complaints made to the home are investigated. People felt that meals were very good and there was a good variety of food available. What has improved since the last inspection? What they could do better: The home must ensure that it always obtains two written references for all new staff employed. Regulation 26 visits must be made by the Responsible Individual each month, so that they are aware of issues in the home. The home should ensure that it records how issues identified through the Quality Assurance system will be addressed. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 7 Care plans could be improved so that the give staff details of how people’s needs are to be met as well as what their needs are. It would also help if all parts of the plans were completed so that staff have more information on the person’s social history and if there was evidence that people and their representatives have been consulted on their plan. 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. Davey Court DS0000039203.V343860.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 Davey Court DS0000039203.V343860.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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a suitable referral and assessment procedure in place that will assure people thinking of moving into the home that their care needs can be met. The home does not provide intermediate care. EVIDENCE: There have been no recent changes to either the Statement of Purpose or the Service Users’ guide. These are due to be updated to show changes in staff. Both documents are available in a variety of formats including large print and audio tape. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 10 Some people are visited by the manager prior to their admission when an assessment is completed. When this is not possible the social services forms are used to assess the person’s needs. People are invited to visit the home prior to their admission. When it has been determined that the home can meet the person’s needs a ‘Welcome Pack is sent to them, which includes a Statement of Purpose and a Service Users’ Guide. A letter in this pack will also confirm the date of admission and assure the person that the home can meet their assessed needs. A ‘Social History’ form is also sent out for either the person or their representative to complete so that the home has complete information on which to base the care plan. Three people’s files were looked at. All three contained detailed information collected prior to their admission. Though none of their ‘Social History forms were completed. We were told this was because their representatives had failed to complete them and that staff will be working to complete them with the individual. The home does not provide intermediate care. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in the next few months systems will have to be changed to be brought into line with those of the preferred provider. Davey Court DS0000039203.V343860.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. Care plans are generally well formulated but do not always give clear information to enable staff to meet the health and social care needs of individuals. Nor do they always evidence the involvement of the people who live at the home or their representatives. Individuals are treated with dignity and respect and their health care needs are well met, with evidence of good multidisciplinary working taking place where necessary. To ensure the safety of individuals, all medicines are stored securely and administered appropriately. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 12 EVIDENCE: Four people’s files were looked at and all contained the same care plan documents. However, not all areas of these care plans were completed for all three. Each of the care plans contain the same blank forms to be completed for each person. These include a life history profile, a needs assessment, a moving and handling plan, a risk assessment, a plan of care, health care visit records an activity participation record and reviews. Only one of the four plans contained a completed life history. While the care plans contain a lot of information on the needs of the person they are not explicit as to how these identified needs will be met on a day to day basis. For example one states ‘ I will sometimes refuse to let staff change my pad’, but there was no instruction to staff as to what to do should this occur. When staff were spoken with it was clear that they did know what steps to take, but there is the possibility that new or agency staff would not know this detail. Detailed risk assessments, as well as moving and handling assessments were completed for all individuals. Staff said that they found the care plans very useful in finding out any changes to the needs of the individuals. They also said they get a handover whenever they come on duty, which also helps to keep them up to date. Staff said, and plans confirmed that they make regular recordings on all care plans at the end of their shifts. Records of visits made by health care professionals are kept and these show regular contacts and follow-ups where health issues have been identified. The plans show that they are reviewed each month and is usually done by one of the night care officers. There was little evidence of the involvement of either individuals or their representatives. Medication is securely stored and records indicate that it is safely administered. Records show that senior staff responsible for administering medication, have received training and the senor staff members spoken with confirmed that they had received this training. There have been some changes made to the home’s self medication policy and the home now looks to see if there are ways they can enable the individual to be partly, if not fully self medicating. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 13 Staff were observed throughout the day and were seen to respect the privacy and dignity of the individuals by knocking on doors and offering personal care in a discreet manner. Though only one person could tell us they did say that they felt staff treated them with respect and dignity. Toilet and bathrooms doors were closed when being used and all doors as well as those on bedrooms now have suitable locking devices fitted. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue to monitor and update care plans monthly, more staff to attend training especially dementia and Care of the Dying. Also supervision will be used as a tool for developing staff awareness of all the standards. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Links with the community need to be improved in order to ensure there are opportunities to support and enrich individuals’ social life. The home does not always offer a suitable range of activities and entertainments to stimulate and occupy individuals. Meals were seen to be well presented, providing nutritious variety and choice for individuals. EVIDENCE: People living at the home experience varying degrees of dementia and their abilities also vary widely. A newsletter is now being produced on a regular basis to let everyone involved with the home know what is going on. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 15 Staff said that felt they had many opportunities to spend time with people during the afternoons. They said that sometimes this was for a one to one chat and other times it was in a group setting. A list of available activities is displayed daily and staff also tell people what is on offer. The assistant manager said that there was a named carer on each afternoon shift who was responsible for providing activities, also that four care hours per week had been allocated for people to spend time in the day centre, which is shortly to be closed as a separate unit. Staff were seen chatting to people in a group setting and there were some activities taking place in the afternoon. However, the individual ‘activity participation records’ that were looked at consisted mostly of entries saying, ‘sat in lounge’, ‘watched TV’ and ‘wandered around the corridors’. It had been identified in one plan that the person liked playing dominoes and cards, but there was no record to show that this had taken place. Though it is accepted that many of the people living at the home have severe dementia, more care is needed to ensure suitable activities are provided to enrich their lives. No responses were received from representatives in relation to the surveys that were sent out, and no visitors wished to speak to us on the day of the visit. Two individuals had been helped to complete their surveys by their representatives, one commented that they would like more activities and the other felt that the food was excellent. Staff said that visitors are always welcome and the people living in the home that we spoke with confirmed this. It is sometimes difficult to ensure that preferences are obtained when people have a high degree of dementia and this is where detailed social histories can be useful in showing staff what the individual used to prefer, either to eat or how they spent their time. Three of the social histories were incomplete and so a valuable source of information is lacking. However, staff do still try to ensure that choices are offered and spend time with people in order that they can try to get an answer. The cook said that everyone is offered a choice for each meal and if they have forgotten what they said they wanted or have changed their minds, they can have something else. We sat in the dining room during lunch and spoke with several people and they all said that they always enjoyed their food. Lunch that was served looked nutritious and was well presented. Individual serving dishes for vegetables are now placed on the dining tables and staff help people to choose what they want from these dishes. One person via a comment card said that ‘Meals are not too bad. As I am a diabetic I could do with less carbohydrates and more protein and fruit’. Another said ‘I have a healthy appetite and the food is excellent’. Staff said that fruit was always available to anyone and they were offered it regularly. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 16 The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue to monitor, record and update and raise money for amenity fund which will enable Davey Court to provide more entertainment. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 17 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 dealt with appropriately and individuals are protected by staff who are able to recognise abuse and know their duty to report poor practice. EVIDENCE: In line with Devon County Council’s policy, there is a clear and simple complaints procedure displayed in the hallway. Completed comment cards from people living in the home indicated that they would talk to a member of staff if they needed to make a complaint. However, survey cards that the home had sent out indicated that several health care professionals did not know how to make a complaint. The assistant manager said that they felt this may be because concerns are generally discussed and dealt with before they become complaints. Staff said that if they saw a resident being treated inappropriately they would report it and if they felt nothing was done they would pursue it. However, staff that were spoken with were confident that the managers would deal with any Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 18 such concerns that may be were raised. Staff said, and records confirmed that they had received training in relation to POVA (Protection Of Vulnerable Adults) issues. They were all aware of who they could report concerns to within the organisation, and all had knowledge on the potential role of outside agencies i.e. the Police or CSCI. An issue was discussed relating to the inappropriate behaviour of a male living at the home in relation to the females living there. The assistant manager will contact the Adult Protection team to discuss this matter further. A concern had been raised by a representative through the local care management team, in relation to the general condition on their return home, of someone who had been at the home for a short stay. It was found that the home had not been given full information on the person’s particular eating requirements and staff were unaware that the person took a very long time to eat their meals, which had led to their loss of weight. However, it has highlighted the need for better monitoring of people’s weight and more insight as to how dementia may affect eating patterns. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to ensure there is ongoing training for staff, to update policies and procedures when required and to ensure there is a robust induction for new staff and robust handovers for all staff. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 19 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, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides individuals with a clean, safe, comfortable and homely place to live. EVIDENCE: The building is easily accessible by those who are wheelchair users and there is free access throughout the home. There has been much up-grading of the building and garden and the home is now clean and comfortable throughout. The home has recently been awarded a £20,000 grant and this will be spent on furniture and fittings, including new beds, commodes, chairs, carpets and TVs. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 20 The garden has been made a safe environment for people who have mobility problems as well as those who may be at risk of leaving the home unaccompanied. There is level access to the garden from the conservatory and several people commented that they liked to sit in these areas. Communal lounges are bright and homely with many pictures and ornaments around. There is now a small quiet room on the first floor that can be used for visitors or just to sit quietly without the TV. The corridors are now clean and bright and pleasantly decorated. There were no unpleasant odours in any area of the home. There is a range of aids and adaptations throughout the home to enable the residents to be as independent as possible, and to assist staff with moving and handling of residents. Individual bedrooms now have suitable locks fitted to the doors and some residents hold their own leys. Bedrooms are all for single occupancy only and were nicely decorated and furnished and reflected the personality of the individual living there. All bedrooms as well as toilets contain liquid soap and paper towels. One staff member said that they thought the one thing that couldbe improved at the home was the size of the rooms. They felt that the rooms were rather small, especially for those who are wheelchair users. There is a large well equipped laundry at the home that has an impervious floor covering and a ‘flow-through’ system of work. This helps reduce the risk of any cross-infection. Staff told us and records confirmed that they had received training in infection control procedures. Staff said that disposable gloves and aprons were always available and staff were seen using these appropriately. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that the externalisation process to a new provider should conclude in March 2008 and that hopefully this will bring some resources to improve environmental issues. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 21 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. Staff are well trained and are available throughout the day and night in sufficient numbers to meet the needs of the current individuals. The procedures for the recruitment of staff are not always robust and therefore do not always offer full protection to individuals. EVIDENCE: Staffing rotas show that there are generally eight care staff on duty each morning till early afternoon and seven from then till 9.30pm, two of these staff would now be senior cares. At nighttimes there are two night care assistants and one night care officer on duty. There are also domestic staff, a handyman and cook and at least one assistant manager on duty during the day-time period. Staffing levels are still maintained by a heavy reliance on agency staff, though this has reduced a little. Efforts are made to try and maintain consistency, by Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 22 using the same agency and staff from them. Staff said that on some afternoon shifts most staff were from an agency and this could lead to a lack of consistency in the care of the people living there. One agency worker and three permanent staff were spoken with, one of the permanent staff had recently become permanent following a spell at the home as an agency worker. All staff felt that they generally had enough time to be able to sit and chat with people and that they did not have to rush personal care. Comments received via survey forms indicated that staff were happy in their work and that relationships throughout the staff team were good. However, one member of staff felt that some staff ‘could still consider the client more as an individual’. Another commented ‘I feel very proud of the changes that have happened over the past 12 months’. Three staff files were inspected, all three contained evidence of an application form, proof of identity and a satisfactory police check. However, one of the files only contained one written reference. The files also contained copies of training certificates and supervision sessions. The level of dementia care training staff had received varied and the agency staff had only received one session in this area. Two of the other staff were working on an in-depth 30 week distance learning course. Both staff spoke of how it was helping them in their work and made them realise that ‘people who have dementia have feelings the same as us’. Staff have also received training in Moving and Handling, Infection Control, Save a Life and fire procedures. Newly appointed staff receive a detailed induction that covers all aspects of care at the home. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to cascade appraisals to the whole staff team. There will be ongoing training including NVQ’s and Dementia. There will be a designated assistant manager responsible for accessing and identifying training needs. Vacant posts to be filled. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 23 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 is well managed resulting in practices that generally promote and safeguard the health, safety and welfare of the individuals. EVIDENCE: The temporary manager has many years experience of working with older people and has submitted an application to register as manager of Davey Court. She has been proactive in ensuring that the home can meet the needs of everyone currently living at the home, and anyone who may wish to move into the home. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 24 Staff said that they found the new acting manager very approachable and would feel able to speak to her about concerns or issues within the home. They feel that communication within the home has improved though there were comments on survey forms that suggested there was more work to be done. For example, ‘would like to see more communication between management and floor staff’. A Quality Assurance system has recently been introduced, and this looks at complaints and incidents occurring in the home as well as questionnaires being sent out to people living at the home. The responses from theses questionnaires have collated and a report has been produced. In this report several areas for improvement have been highlighted, but the report does not say how the home will set out to improve the issues. There have been occasional visits to the home under Regulation 26, by the Responsible Individual for the home, though these are still not monthly as required. This means that Devon County Council have no consistent external measures in place to monitor the care at the home. Those people who have money held by the home have these monies correctly administered through a suspense account in line with Devon County Council policy. This means that only very small amounts of money are held for those individuals, and receipts and signatures are obtained. Interest accrued from this account is allocated quarterly. The total balance of the monies held was checked and found to be correct. So that the risk of burning from hot surfaces is minimised, all radiators within the home are covered, though the covers need ‘tops’ fitting to ensure the radiator surfaces cannot be touched . All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Davey Court complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to ensure that management continues to review practices within the team. Also the unit manager intends to support staff service users and relatives in the transition to a private provider. Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP29 Regulation 13 5(d) Requirement You must obtain two written references for each new employee, so that you can be assured they are fit to work at the home The responsible individual must visit the home at least monthly, unannounced and report on the visit, so that they are kept up to date of any issues within the home. (Previous timescale of 21/06/07 not met) Timescale for action 31/10/07 2. OP31 26 (2) 31/12/07 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 OP7 Good Practice Recommendations You are recommended to ensure that care plans contain sufficient information on how staff are to meet the day-today needs of people living at the home Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 27 2. OP7 You are recommended to complete all areas of the care plan so that staff have as much information as possible on people living at the home You are recommended to ensure that there is more evidence that people living at the home or their representatives are involved with their care plan You are recommended to improve the social stimulation within and outside the home for people who live in the home. You are recommended to show how issues identified through the Quality Assurance process will be addressed. 3. OP7 4. OP12 OP13 5. OP33 Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Davey Court DS0000039203.V343860.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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