Inspection on 14/11/06 for Davie House

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Davie House 31/12/05

Davie House 18/07/05

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Davie House 33 & 34 New Park Horrabridge Yelverton Devon PL20 7TF Lead Inspector Wendy Baines Unannounced Inspection 14th November 2006 9:30 Davie House DS0000063500.V300511.R01.S.doc Version 5.2 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 Davie House DS0000063500.V300511.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 Adults 18-65. 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. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davie House Address 33 & 34 New Park Horrabridge Yelverton Devon PL20 7TF 01822 854656 01822 859348 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) www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Mrs Susan Denise Batley Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user with Physical disability (PD) Date of last inspection 31st December 2005 Brief Description of the Service: Davie House is situated within the small village of Horrabridge, on the edge of Dartmoor in West Devon. The house is set in its own grounds, with a large attractive garden area. Horrabridge has several local shops, pubs, churches and park areas and is also within easy reach of the main road into the neighbouring town of Tavistock. The home is currently registered to accommodate 11 service users with a Learning Disability and offers accommodation on two floors, which include large communal areas and single bedroom facilities. There is also a separate self-contained facility called Little Davie which has three bedrooms, a communal sitting room and kitchen and separate access. Little Davie has been used to promote independence, although service users continue to access facilities in the main part of the house. The Registered Provider for Davie House is Cottage and Rural Enterprises (CARE). CARE is a Registered Charity and is overseen by a Board of Trustees. The organisation is Registered to operate 29 services across England, and currently provides 26 care homes and 3 Domiciliary Care agencies for people with a Learning Disability. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is a summary of a cycle of Inspection activity at Davie House since the last inspection visit. To help CSCI make decisions about the home the Provider gave us information in writing about how the home is run; any documents submitted since the last inspection were examined along with the records of what was found at the last visit; two site visits totaling 13 hours were carried out with no prior notice being given to the home as to the date and timing; discussions were held with the Registered manager and staff on duty; various records were sampled, such as care plans and risk assessments; questionnaires were sent to a sample of staff ; and a tour was made of the home and garden; time was spent with the service users and the inspector was able to talk with, and observe the staff on duty. In addition a sample group of residents were selected and their experience of care was tracked through records and discussions with staff and management from the early days of their admission to the current date, looking at how well the home understands their needs, and the opportunities and lifestyles they experience. Where possible time was then spent with these service users, and questionnaires were sent to their care managers and other specialist services where appropriate. Questionnaires were sent to a sample of the staff team and all service users. Any feedback received following publication of the report will be included in the next inspection report. Feedback was also received from the Specialist Learning Disability Service, Speech and Language department and Consultant clinical psychologist involved with the home. This inspection approach hopes to gather as much information about what the experience of living at the home is really like, and to make sure that service users views of the home forms the basis of this report. What the service does well: Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 6 Davie House provides a good level of care and support for service users. Information provided by the home and the admissions process ensures that service users and their representatives are able to make an informed choice about where they live. A comprehensive care plan is completed for each service user detailing their needs, guidelines for staff and personal preferences about how the care and support should be delivered. The staff team have a range of skills and a good understanding of service users needs. Service users are supported to participate in community activities, work placements and a range of age appropriate social and leisure opportunities. Staff support service users to maintain contact with family and friends and this was reflected in the positive feedback from relatives. Service users health needs are recorded and any concerns are addressed promptly and sensitively. The home has a good relationship with the healthcare services and specialist Learning Disability team. Feedback from these agencies was very positive and included comments such as; “ We are particularly impressed with the care provided to a service user with complex health care needs” The meals in the home are good offering both choice and variety and catering for special dietary needs. Staff are well supported by regular supervision and an open, inclusive and positive style of management. What has improved since the last inspection? The two main bathrooms have been redecorated and a ceiling track hoist fitted in the downstairs bathroom to meet the assessed needs of one service user. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 7 Damaged patio slabs in the rear garden have been removed and renewed. A new washing machine has been purchased for ‘Little Davie’ to further assist service users wishing to develop their skills and independence. What they could do better: 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. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Current and prospective service users have the information they need to make an informed choice about where they live. EVIDENCE: The home had a statement of purpose and service user guide, which described the environment and services available. These were available to service users and copies held in their main files. The home has had no new admissions since the last Inspection. Records confirmed that the home regularly assesses the needs of all service users to ensure that the appropriate support and care is being provided. The Registered manager said that all service users contracts were in the process of being updated to reflect changes to fee levels. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home has a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: A sample group of service users were selected and their experience of care was tracked through records and discussions with staff and management from the early days of their admission to the current date, looking at how well the home understands their needs and the opportunities and lifestyles they experience. As part of this process the inspector looked at service users care plans and other daily records relating to the individual. Service user care plans had been completed and covered all aspects of personal, social and healthcare needs. The detail within care plans reflected the level of care required and where needs were complex step-by-step guidance was available to staff to ensure consistency. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 11 Some service users also had a Person-centered Plan. One service user explained to the inspector how she had she had been helped to put together a plan with her key-worker, which identified the people and places in her life that were important to her and the help and support she needed to fulfill her wishes and dreams. Discussion took place with the Registered Manager regarding the need to ensure that care plans also include aims/goals and that this information is reviewed and updated as goals are met or change. Throughout the inspection staff were observed using their knowledge and skills to encourage and support service users to make choices and have control over their lifestyle. The manager said that, due to the diverse needs of the people living in the home they try to encourage plenty of informal discussion and small group meetings to ensure that everyone can express their views and opinions. Some service users said that they were concerned about possible changes that may happen in the home and how this would affect them. There was anxiety and uncertainty about changes to the building and how this might affect their accommodation arrangements in the future. The manager said that staff were supporting service users as much as possible to reduce any anxiety and were providing them with any information available. One service user was having support from an independent advocate to consider long term plans. Care plans confirmed that service users have a range of skills and support needs relating to the management of their finances. All service users had their own bank account and where possible were encouraged to look after their money and participate in purchasing their own personal items. A clear record was available of all expenditure, and money kept in the home was safely stored. A record was kept of any regular items purchased by service users and these arrangements were documented within their care plan. Risk assessments had been completed for activities inside and outside the home. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Service users are encouraged and supported to participate in community, social and leisure activities and to maintain contact with family and friends. The meals in the home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The atmosphere in the home was warm and welcoming. Several service users were getting ready to go out, and others were enjoying a relaxing morning and leisurely breakfast. Service users spoken to said they enjoyed going to the local shops, pubs and to the theatre. Some service users have regular work placements and others attend art and music groups. Everyone in the home including staff were enjoying rehearsals for a Christmas show and had invited family and friends to join in their celebrations. One service user spoken to, and feedback within one questionnaire said that they would like help to find more things to do during the day. With the Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 13 permission of the service user this information would be passed to the home manager. A notice board was available in the home with information about local events and important dates. Staff said that pictures, symbols, photographs and brochures are used to assist service users with communication difficulties make choices about activities. Several service users spoke about their plans to stay with family during the Christmas period and said that they regularly visit and speak to friends and relatives. One relative spoken to said; “ I’m very, very satisfied with the care provided at Davie House, and always made to feel welcome by all the staff” A written weekly menu was available, which confirmed that service users are offered a well-balanced and varied selection of meals. When possible service users were involved in choosing meals, shopping and food preparation. Snacks and drinks were available throughout the day and mealtimes were flexible and relaxed. Records confirmed that there were some special dietary requirements and this information was clearly documented. Detailed guidelines had been prepared to support the dietary needs of one service user with Dementia. Advise had been sought from a Dietician and the specialist Learning Disability services to ensure that food was being appropriately prepared and served. The inspector was invited to join service users for lunch and was able to observe staff following these guidelines and providing excellent care and attention to a service user with complex healthcare needs. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the home. The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. EVIDENCE: Service user records included information regarding personal and healthcare needs. The information was detailed and included daily routines and personal preferences about how care is delivered. It was evident through discussion that staff recognised the importance of consistency particularly for service users with complex care needs and communication difficulties. Daily charts, communication books are and handover meetings are used to monitor any changes in an individuals’ health. Feedback from the specialist Learning disability services confirmed that the home regularly liaises with outside agencies to support their role and to request advice and support. Detailed information was available regarding the care needs of a service user with Dementia. The specialist Learning Disability team and Dementia screening Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 15 service were regularly visiting the home to review the care plan and offer support and advice to the staff and service users. Feedback from these agencies was very positive and included; “ The team are particularly impressed by the care being provided to a service user with complex health care needs” Medication records were available for each service user. Records inspected were found to be in good order and up to date. Detailed information was available regarding the individuals’ health, current medication, reason for taking and any possible side effects. All medication was found to be safely stored with a procedure for regular checks to ensure that medication is up to date and returned to the pharmacy when necessary. Service users who have been assessed as being able to self-medicate are supported to do so and have a lockable storage facility provided. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The Provider responds to complaints promptly using the homes complaints procedures, and takes seriously any concerns made in relation to the home and service users. EVIDENCE: The complaints procedure for the home was discussed with staff and service users. All service users spoken to were confident that staff in the home would deal with any concerns they had. They were not however clear about whom they could contact if staff were unable to help. The home has a written complaints procedure but this is not easily accessible to service users. All complaints, concerns dealt with by the home are documented with copies of correspondence, outcome and any action taken. The manager and staff said that the home attempts to promote an openness and inclusion to ensure that all service users are listened to and have their concerns addressed. Feedback from relatives confirmed that the home takes seriously any concerns or complaints and when appropriate liaises with family members regarding any significant changes to an individuals care arrangements. Each staff member has a copy of the homes Adult Protection procedures within their ‘ Personal development’ file. All current staff have attended Adult protection training and the manager advised that the home is currently Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 17 exploring new training providers to ensure that this training continues to be updated. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,26,27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home The standard of the environment within the home is adequate providing service users with an attractive and homely place to live. EVIDENCE: A tour of the premises took place, which included all communal areas and a sample of service user bedrooms. All areas of the home seen were found to be clean and tidy. Service users who are able to partake in tasks around the home do so independently or with support from staff. Those spoken to said they were happy helping keep the home clean and tidy and considered these tasks an important part of their week. Service users bedrooms were found to be attractively decorated, clean and bright with décor and personal belongings that reflected their interests and personalities. Some of the signs and numbering on service users bedroom doors did not reflect the age of the people living in the home and made the environment feel less homely. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 19 Since the last inspection the two main bathrooms have been re-decorated. A ceiling track hoist has been fitted in the ground floor bathroom to meet the needs of one service user with changing health needs. Damaged patio slabs in the rear garden have been removed and replaced and a new washing machine has been purchased for the ‘ Little Davie’, which supports service users who are working towards more independent living. The laundry and kitchen area were found to be clean and tidy with sufficient equipment and information to ensure the control of infection. Hand washing facilities are well situated around the home. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Staff are sufficient in number, and have the skills and attitudes to ensure that service users needs are sufficiently met. The manager is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Staff demonstrated a good awareness of service users needs and were very familiar with care plans and specific guidelines for providing support. Throughout the inspection staff were observed interacting with service users on a one to one basis and in groups. There was a good rapport between service users and staff and the atmosphere in the home was happy and relaxed. The manager said that staffing levels are regularly reviewed and an example was given of a change to the staffing levels for one service user due to health needs. This had been agreed as part of a multi-agency process and was documented within the care plan and service user contract. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 21 There has been a high turnover of staff during the last 12 months due to several staff members going on maternity leave. This has resulted in a big change to the staff team on all levels including care staff and management. Feedback from staff, service users, relatives and other agencies confirmed that these changes have been well managed. One relative commented that in his view the home was ‘ excellent in finding and recruiting good quality staff’ All the new staff spoken to said that they felt well supported and felt that the homes communication and recording systems enabled them to understand and meet the needs of service users. A sample of staff files were seen including the records of several staff members recently appointed to the home. All the required recruitment records were available and sufficient checks had been completed prior to appointment. Service users had been involved in the interview process and records confirmed that their input had been documented and used as part of the selection process. Service users spoken to said that they considered this role very important and were keen to tell the inspector about what they consider important when looking for a new staff member for the home. All new staff members spoken to said that they were in the process in completing the mandatory training as part of their induction process. The manager said that a range of other internal and external training had been completed or planned since the last inspection, and that staff held this information as part of their ‘personal development’ file. However individual training records were not available to evidence the training attended or arrangements to ensure that the training is regularly updated. Feedback from other agencies involved in the care of service users within the home was very positive regarding the skills of the staff. A Clinical Psychologist from the Learning Disability service said that “ the staff are eager participants to learn about Dementia” and also commented within their feedback to CSCI that they have been particularly impressed by the care being provided to one service user who’s care needs have significantly changed due to the onset of Dementia. Staff spoken to said they felt well supported by other team members and management. Key-worker and team meetings take place on a regular basis, and the rota allows for a shift handover to discuss the daily events. Records confirmed that formal supervision takes place every 6-8 weeks and this information is documented. Questionnaires were sent to a sample of staff and feedback received was very positive regarding the quality of care provided to service users and the support received by staff to fulfil their role. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 22 Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The management approach is open, inclusive and positive providing clear guidance and leadership. The staff team work hard to provide service users with information regarding the home and their care. Some of the radiators and hot water outlets in the home have not been fitted with sufficient covers or regulator valves. This may not sufficiently protect vulnerable service users from the risk of scalding and burns. EVIDENCE: The manager and staff said that the home works hard to create an environment that is inclusive and open and recognises the rights of each individual service user. The feedback from service users was positive and all said that they enjoyed living at Davie House. Several service users spoken to said that they were able to speak to their key-worker or other staff members if they had a problem and enjoyed attending meetings to talk about issues to do with the home. Two Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 24 service users spoken to said that they were anxious about possible changes to the home and how this would affect them and their independence. They said that they didn’t understand what was going to happen. Discussion with staff and management and minutes of service user meetings confirmed that the home has worked hard to pass information to service users about the home and any changes to the services provided. However, the length of time taken for any changes to occur has been difficult for some service users. Feedback within staff questionnaires confirmed that staff feel they have sufficient information and support to fulfil their role and meet service users needs. Comments were made that some staff feel they would benefit from more specialised training opportunities. Feedback from other agencies and relatives confirmed that the home regularly liaises with the people and services involved in an individuals care, however the home does not have a system for regularly gathering or analysing feedback from relatives or other agencies. The inspector was able to meet with staff member responsible for Quality Assurance who described the assessments that are completed annually relating to; activities, relationships, choices, staff and health and safety. Key-workers support service users to complete questionnaires and the results are sent to the organisations head office. It was not evident if this information is made available as part of the homes quality assurance system. A range of health and safety records were inspected including the homes Fire log and accident/injury book. These were found to be up to date with copies of reports sent to CSCI where required. The radiator in the upstairs bathroom was found to be very hot and had no thermostatic control. The only other form of heating in the bathroom is a very old overhead electric heater, which cannot be covered when in use and could pose a risk to service users. Service user bedrooms still have wall heaters that are not covered. The water from the wash hand basin in the upstairs bathroom was very hot. Signs have been placed around the house to warn service users that the water is very hot. Davie House DS0000063500.V300511.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 Adults 18-65 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 3 2 3 3 X 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 4 3 3 2 X 3 2 X Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? 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 YA42 Regulation Reg 13 (4) (a) Requirement The Registered person shall ensure that all parts of the home to which the service users have access are so far as reasonably practicable free from hazards to their safety. -Urgent action must be taken in respect of the radiator and wash hand basin in the downstairs bathroom. - Risk assessments must be completed for each service user in relation to the risk of burns from hot water and hot surfaces. - The wall heater above the sink in the downstairs bathroom should be removed, as this cannot be covered. Timescale for action 15/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 27 1 YA8 The Registered provider should ensure that service users are actively involved in making decisions about their care and lifestyle. - The provider should further promote the use and understanding of Person Centred planning to ensure that all service users can be involved in identifying their needs, plan for their future and realise their dreams and aspirations. - Care plans should include short and long- term goals and this information should be reviewed and updated as goals are met or change. - All service users should have access to independent advocacy services, and the opportunity to discuss their concerns regarding to changes in the home. 2 YA22 3 4 YA24 YA35 5 YA39 A copy of the complaints procedure should be available in the home in a place that is accessible to service users. The manager should have a system of checking out with service users that they understand who to speak to if they have a concern or complaint. The manager should consider the use of signs particularly on service users bedroom doors to ensure that they are appropriate to the age of people living in the home. The Registered Person should ensure that training records are available in the home relating to each individual member of staff. This information should include the courses attended and projected renewal date. The Registered Provider should develop the homes Quality Assurance systems by seeking feedback from relatives and other agencies and publishing their findings to demonstrate the quality of the service. Davie House DS0000063500.V300511.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 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 Davie House DS0000063500.V300511.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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