Inspection on 24/07/07 for St Andrew`s, Cullompton

This inspection was carried out on 24th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Andrew`s, Cullompton 27/07/06

St Andrew`s, Cullompton 29/11/05

St Andrew`s, Cullompton 15/06/05

St Andrew`s, Cullompton 28/02/05

St Andrew`s, Cullompton 06/08/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Andrews, Cullompton 1-5 Pye Corner Church Street Cullompton Devon EX15 1JX Lead Inspector Stephen Spratling Key Unannounced Inspection 24th July 2007 09.15 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 St Andrews, Cullompton DS0000022036.V336754.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. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrews, Cullompton Address 1-5 Pye Corner Church Street Cullompton Devon EX15 1JX 01884 32369 01884 32369 standrewscarehome@yahoo.co.uk 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) Mrs Brenda Wise Mr Barry James Wise Mrs Angela Beryl Cunningham Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (23), Old age, not falling within any other category (23), Physical disability over 65 years of age (23) St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager must gain an NVQ level 4 in care by April 2006 Date of last inspection 27th July 2006 Brief Description of the Service: St. Andrews Care Home comprises of a main building, which can accommodate up to 19 residents, and a smaller house situated in the grounds, which can accommodate up to 4 residents. The home provides personal care together with accommodation and board for up to 23 older people who may also have a physical disability and /or mental disorder such as Alzheimers Disease or a related disorder. The home is situated within a short level walk from the main street in Cullompton, which offers a wide range of shops, cafes and the local health centre. The home is approached by way of a level paved area and there are ample facilities for car parking. The home’s statement of purpose and service user guide is available at the home, which includes details about the philosophy of the home and details about living at the home. This is made available to all potential residents before they make a decision about living at the home. A copy of the most recent inspection report is available on request. Information received from the home indicates that the current fees are £295£420 weekly. Services not included in this fee include hairdressing, chiropody, newspapers and magazines and personal items. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In preparing for this inspection we sent questionnaires, asking about the quality of this service, to fifty-eight people. Completed forms were returned by 16 people who live at the home, five by relatives of people who live at the home, seven by staff and eight by health care professional who have contact with people who live at this care home. This inspection site visit was made unannounced 24th July 2007. We spent a total of six hours in the home. There were twenty-one people resident at the home and at the time of the inspection site visit and we spoke with eight of them. We also spoke with the homeowner, the manager, four members of staff, two visiting professionals and the relative one person who lives at the home. We looked around all the shared areas of the home and at fourteen people’s private rooms. Read the care records for three people living at the home and looked at some other records kept by the home. What the service does well: The home offers people opportunity to visit and does thorough assessments of their needs and expectations before they move in. This helps to make sure that people know what to expect if they decide to move in and to ensure that they can be cared for properly. People living at the home told us that staff treat them with respect and that they are free to spend time where and with whom they choose. The home provides activities, which suit the needs and interests of most people and good food. Visitors to the home told us they are made to feel welcome when they visit. Care staff are subject to proper pre-employment checks, are on duty in sufficient numbers and receive regular training. Meaning they have the time, qualities and skills they need to care for people well. People living at the home and visiting health professionals tell us that staff work effectively to help people stay well and that staff ensure they receive the health care they need. Medications are safely managed. The home is comfortably furnished, kept clean and properly maintained. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 6 This home is well managed; the ideas, concerns and complaints of people living at the home are taken seriously and acted upon. People living at the home can be confident that staff would act to protect them if they were being abused. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 7 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 St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 8 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): 3 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People thinking of moving to this home can be confident that if they are offered a place the services thorough assessment arrangements will help make sure they can be cared for properly and in a way that meets their individual expectations. EVIDENCE: In written information provided by the service manger and provider before the inspection we were told that before someone moves into this care home “we speak to residents, GPs, families, hospitals (if appropriate) and the manager meets with residents to assess their needs.” “ We also … offer them the chance to spend the day with us alone or with their families.” St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 9 In questionnaires people who live at the home all confirmed that they received enough information before deciding to move in. One person commented, “I spent three nights here” before deciding to move in. We saw that care records contained detailed information about people, their needs, preferences and expectations. For example one identified the persons health problems and also went onto establish important personal details. Such as how many pillows they liked to sleep with, what their interests were and what time they liked to get up in the morning. All the staff returning our questionnaires confirmed that they are given clear and sufficient information about the needs of people before they begin to work with them. This care home does not provide an ‘intermediate care’ service. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 10 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. People who live at this home can be confident that they will receive the health care they need and their medications safely. They will be properly support to manage their personal care and will be treated with respect. EVIDENCE: We saw that care plans had been developed for two of the three people whose care records we read. These basically reflected the information gathered through the assessment process providing limited description of how identified needs should be met. For example saying how many staff should assist the person to bath, but not describing what the person could do independently and where specific support was needed with bathing. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 11 The third set of care records was for a person who had been in the home for under a week. Within their file there was some useful information about their needs and preferences, which did provide a picture of how they should be supported and cared for. However there was no specific care plan describing how care should be delivered. The manager said that she was still gathering information before preparing the care plan. Care staff confirmed that they have enough information to care for people properly and displayed a good understanding of individuals’ needs including the person new to the home. We spoke to two of the people whose records we looked at, including the person new to the home. They confirmed that staff provided them with the support they need in the way they like. Everyone we asked confirmed that the staff would contact their Doctor or Nurse for them without delay if needed. All confirmed that they were happy with the support they received to manage their health. One person who needs medications at specific times confirmed that staff administer their medication promptly to them. People living at the home who completed questionnaires were asked “do you receive the care and support you need?” and 15 responded “always” and one person “sometimes”. One person commented under this question “definitely” and another wrote “first class”. Asked “do you receive the medical support you need?” all answered “always”. A visiting health care professional told us that the staff communicate promptly and clearly about the health care needs of people who live at the home. All eight health care professionals who returned our questionnaires reflected positively on the service provided. Comments included “they are very proactive in improvement of patient health…” “high standard of care provided” and “if they are worried about a resident they contact us and …I am confident they follow advice as prescribed”. All the people living at the home told us that staff are polite, patient and respectful. A visitor to the home confirmed that they always see staff treating people at home with patience and respect. Throughout the site visit staff were heard speaking with people politely and warmly. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 12 We saw an inspection report completed by a local pharmacist (dated March 2007), which concluded that arrangements for storage and administration of medications at the home were “excellent”. This report made no formal recommendations regarding these arrangements. We saw that the home has appropriate storage facilities and individual administration records sampled were properly maintained. The home has proper systems for checking medicines into and out of the home. ‘Controlled’ medications are properly stored and their administration suitably monitored. Staff spoken with said that they had received training about how to safely administer medications and certificates confirming this were seen. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. People who live at this home can be confident that their preferences and choices will be supported and they will have opportunity to be active. Their friends and families will be helped to feel welcome and they will receive food they like. EVIDENCE: Most of the people spoken with were happy with the opportunities they have to be active. Some people said they prefer not to be involved in group activities and that staff respect these choices. People confirmed that they do get some opportunity to get out and go to local shops with staff support if requested. One person said they enjoy the activities laid on but said they would like more to do. Some people who returned our questionnaires wrote comments about the activites at the home including, ”I would like more exercise but overall I’m happy”, “very good activites” and “the activites are extremley good”. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 14 On the afternoon of the inspection nine people joined in a game of bingo run by one of the staff. Care records showed that people are invited to be involved in activities in the home regularly and that people’s interest are taken into account when assessments are done. However care plans did not provide information about how they might be supported to be active. People spoken with confirmed that their friends and relatives are welcomed to the home. Relatives completing our questionnaires confirmed that they are welcomed and wrote some very positive comments including “they are always welcomeing to visitors” and “excellent communication with the family.” The relative spoken with confirmed that they are always made to feel welcome and that staff contact them promptly if they have any concerns about their relative. The home’s cook showed us her list identifying peoples preferences and dislikes. She confirmed that she receives regular deliveries of fresh produce and said that where the main meal of the day is not liked alternatives are always available. People living at the home confirmed thay are offered choice at meal times and most spoke highly of the food they receive. Of the sixteen people who returned our questionnaires twelve confirmed they always like the food provided, three indicated that they usually do and one “sometimes”. Comments included; “food very good and choices are given” “very enjoyable meals” and “if you don’t like something staff will offer you something else”. One relative wrote on a questionnaire “they tempt her (mother) with tasty home cooked food and drinks to keep her strength up”. Everyone spoken with confirmed that they can choose when to get up and go to bed and how and where they spend their time. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 15 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. People living at this home can be confident that staff would act to protect them from abuse and that their complaints would be listened to and acted upon. EVIDENCE: The manger told us that everyone living at the home is provided with copy of the complaints procedure. All the people spoken with said they would know how to complain and expressed confidence that any concerns would be taken seriously. Everyone who responded to our questionnaire confirmed that they would know how to make a complaint. One relative wrote on a questionnaire “all matters are discussed and acted on”. We saw minutes from a residents’ meeting which included refernce to the manager reminding those present about the complaints procedure. The manager told us the service has received one complaint since the last inspection. The record of this provided clear description of the concern, a thourough investigation and the outcome. The record indicated that the complainant had been satisfied with the outcome. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 16 The home’s policy to guide staff on recognition and reporting of abuse was not available for inspection and therfore not accessable for staff (see management and adminsistration). All three of the care staff spoken with confirmed that they had attended training about how to recognise and report abuse of vulnerable adults. All three demonstrated an understanding of their responsibilities to report suspected abuse. All staff who returned our questionnaire reported that they are aware of adult protection procedures. A certificate confirming that the manager had attended training about the recognition and reporting of suspected abuse was also seen. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service live in a comfortable, homely environment, which is kept clean and safely maintained. EVIDENCE: We looked at all shared areas of the home and fourteen of the private bedrooms. All were clean and no unpleasant odours were noted. All sixteen people resident at the home, who completed our questionnaire, responded “always” when asked “is the home always fresh and clean”, some adding comments including “everywhere is very clean, I love my room” and “I have never come across anything grubby or dirty here”. Visiting professionals and relatives who returned questionnaires echoed these views. The manager told us that all equipment within the home was serviced within St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 18 the past 12 months. We looked at two bath hoists both of which were marked as having been serviced in August 2006. All areas seen were comfortably furnished and furnishings were in good order. The manager has told us that they have joined the Safer Food, Better Business Scheme; this is recommended by local environmental health services. We saw that this has been completed daily by the home cook, ensuring that standards of hygiene in the kitchen are monitored. All upper floor windows checked had restricted opening to reduce the risk of people falling from them. All hot surfaces seen were covered to reduce the risk of people burning themselves. The home has a sheltered patio area with seating for people to use. The gardens around the building are overgrown, though the owner said he plans to get them cut back. One visitor and one resident commented that they wish access to the gardens could be improved. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 19 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 on duty in sufficient numbers, skilled and their suitability has been properly checked before they are employed. Meaning people who live at this home can be confident that they will receive the care and support they need. EVIDENCE: Fifteen of the people resident at the home who returned questionnaires answered “always” when asked “are the staff always available when you need them”, one person answered “usually”. All confirmed that staff “listen and act on what they say”. Comments people wrote about staff included “I’ve always been treated very kindly here” and “the staff are very understanding”. Relatives returning our questionnaires wrote a variety of positive comments about care staff including “they are an extremley caring team..” and “they are loving and attentive”. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 20 Visiting professionals who returned our questionnaires were asked do care staff always have the right skills and experience. Six responeded “always” and one “ususally”. One person added the comment “staff are extremely skilled, however are always happy to update”. The three care staff we spoke with said that there are usually enough of them on duty to provide care in an unrushed way. Staff completing questionnaires were less confident that staffing levels are always good enough with three people suggesting that they think they could do a better job if they had more staff. Care staff confirmed that they are encouraged and supported to attend training. A new member of staff had been through a thorough induction (based on nationally recommended guidelines- NTO) and we saw record that this had been completed. The manager told us that 66 of the care staff have done or are doing NVQ’s) (nationally recognised qualifications). All three of the staff we spoke with confirmed that they are doing NVQs, that they are paid for by the home and that they are supported to complete their work by the home manager. During the inspection we met an NVQ tutor/assessor who confirmed that staff that do her course are well prepared and supported. She confirmed that currently she is supporting four staff through NVQ 2 and one through NVQ 3. We looked at the recruitment records for three of the care staff. All contained the required pre-employment checks such as references and criminal records bureau checks, which had been obtained before the staff started working at the home. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 21 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, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at this home can be confident that a competent person manages it and that work is ongoing to ensure the home is a safe place to live and continually improves. EVIDENCE: People living at the home expressed confidence in the home manager, confirming that she speaks with them regularly and acts on their comments and concerns. A relative wrote in a questionnaire that they find the manager to be “excellent” at her job. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 22 Care staff who returned our questionnaires all confirmed that they feel well supported by the home manager and that they receive regular formal supportive supervision. All the staff spoken with described the manager as approachable and supportive. Care staff confirmed that regular staff meetings are held where people are free and encouraged to share their ideas about improving the service for people at the home. Staff said that the manager is always willing to give new ideas a try. The manager told us that she has completed the work required for her NVQ4, but as the training company she was doing it with has ceased trading she is looking for another organisation to mark her work and award her qualification. We saw certificates confirming that she has attended with training about care of people with dementia, first aid, food hygiene and medications administration during the past year. We were told that regular residents’ meetings are held and saw copy of minutes from those meetings. The manager said that issues raised by people at these meetings are acted upon where possible and explanations given where they cannot be. One example of this happening was seen regarding use of the main shared lounge in the home. The owner said that questionnaires about the quality of the service are given to people living at the home and their families every 6 months. He said that any issues raised through questionnaires are acted upon if possible. We saw some of these completed questionnaires, which reflected positively of the service. We have also seen reports compiled by a person who does monthlyunannounced inspections (Regulation 26 visits) at the home on behalf of the owners, to monitor the service. The owner said that the results of these quality assurance activities are not published. We requested to see the home’s policy file and found that many policies were missing and therefore not available to guide staff (see complaints and protection). The manager said that the homes administrator had many of the policies as they had been updated and were being retyped. She agreed to ensure copy is always available for staff in the home in future. The three care staff spoken with said they regularly, every 3 to 6 months, receive update training about fire prevention and evacuation. They had all St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 23 three done training about health and safety and hygiene. Two of the three care staff had done first aid training. Certificates confirming that this training had been done were seen. The home does not look after residents’ money. The manager said that any additional costs incurred are billed monthly to relatives/representatives or directly to people living at the home. The home’s fire logbook indicated that emergency lighting is tested monthly and the alarms are tested weekly as recommended by fire officers. The homes fire risk assessment had been updated in June 2007 by company contracted to do so by the homeowner. Unfortunately this assessment had failed to note that several bedroom doors are not fitted with smoke seals (intermittent strips) or automatic closure devices, meaning they do not provide adequate protection against the effects of fire and smoke. The homeowner acknowledged this and agreed to ensure this work was done with out delay. The owner said that since June he had commissioned another company to help him ensure the service complies fully with health and safety and employment legislation in future. They had also recommended that doors should have smoke seals and closure devices fitted. As noted earlier (see Environment outcome group) action has been taken to guard against people falling from upper floor windows and burning themselves on hot surfaces. We saw that the home’s portable electrical appliances (PAT) were safety tested in June 2007. St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 24 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 X X 4 X X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP38 Regulation 23 (4) Requirement To ensure people living at the home are properly protected from the potential effects of fire and smoke all fire doors must be self closing and should be fitted with smoke seals. Timescale for action 24/09/07 St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 26 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 To make help make sure that people living at the home consistently receive all the care they need in the way they want; • care plans should include more detail of how individuals choose to have their care given • care plans should be established at the time of admission. To make sure staff have the information they need to provide care safely and in the way prescribed by the service manager the homes policies and procedures should be available to staff at all times. 2. OP37 St Andrews, Cullompton DS0000022036.V336754.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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. 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