Inspection on 25/06/08 for St David`s APL

This inspection was carried out on 25th June 2008.

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 David`s APL 27/06/06

St David`s APL 26/01/06

St David`s APL 04/08/05

St David`s APL 18/01/05

St David`s APL 27/07/04

St David`s APL 08/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 St David`s APL 11 Barton Villas Dawlish Devon EX7 9QJ Lead Inspector Sue Dewis Unannounced Inspection 25th June 2008 09:10 St David`s APL DS0000055164.V367128.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 St David`s APL DS0000055164.V367128.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. St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St David`s APL Address 11 Barton Villas Dawlish Devon EX7 9QJ 01626 865597 01626 867194 st.davidsapl@btinterent.com 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) David Hardee Miss Samantha Jayne Eyles Care Home 9 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (2) St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The lower ground floor to be specifically for three named Service Users with Mental Disorder category only 27th June 2006 Date of last inspection Brief Description of the Service: St David’s is registered to provide care for 2 people with mental health problems who are aged over 65, and up to seven people with learning disabilities aged 18 - 65. The Home is a large semi-detached house in a residential area of Dawlish within walking distance of the hospital, shops, amenities and bus and train services. On the ground floor is a self-contained flat for three people and access to the garden. The first floor has an open plan kitchen and dining room, a lounge, and office. There are six bedrooms on the second floor, five of which are en-suite and the sixth has sole use of a separate toilet and bathroom. The laundry facilities are in a separate building just outside the ground floor flat. There is a caravan in the back garden, which is lived in by a person with a learning disability who is being supported by the staff at St. Davids. A copy of the CSCI inspection report on the home is available on request from the manager. Fees for the home range from £350 - £1100 per week. 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 . St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good. This unannounced visit took place over 8 hours, one day towards the end of July 2008. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. 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 people living at the home, health and social care professionals (including GPs and care managers) and staff. At the time of writing the report, responses had been received from 5 people living at the home and 3 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. There was an outbreak of a tummy bug on the day on the visit, so contact with people living there was limited. However, we did speak briefly to everyone and in more depth to 2 individuals who were not suffering from the bug. We also observed the interaction between staff and people living at the home throughout the day. We also spoke with 4 staff and the manager and the owners. A full 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 took place at the home in May 2008 following a complaint that the home was withholding medication from an individual living at the home. The complaint was found to be unsubstantiated. What the service does well: St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 6 There is a clear Statement of Purpose and Service User Guide for the home. These documents along with a good admission process ensure that people who are thinking of moving into the home have sufficient information and know their needs will be met. Everyone living at the home has a care plan that sets out their goals and achievements as well as their personal care needs and preferences. The plans are reviewed regularly and individuals are encouraged to take part in the reviews. Detailed risk assessments ensure people are safe, whilst being encouraged to meet their full potential. There is a very good variety of learning opportunities, activities and outings on offer that meet the differing needs of the individuals at the home. Good multidisciplinary working ensures people’s health care needs are met and medication is stored and administered appropriately. Complaints are well managed and staff are aware of their duty to report poor practice. There are good staffing levels, staff receive regular training and there are robust recruitment procedures in place. There was a good rapport between staff and people living at the home. The environment is generally well maintained and meets the needs of people living at the home. The recently registered manager works closely with the owners to maintain the standards of the home. One staff member commented via their survey forms that ‘I’ve never worked in a home that cares so much about keeping its residents happy and active’. What has improved since the last inspection? What they could do better: St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 7 No requirements or recommendations have been made in this report. However, several areas where improvements could be made were discussed with the owners and manager. These included, providing more evidence of a link between people’s assessed needs and how these needs are met on a day to day basis. There was also some discussion around the environment and how it could be improved to reflect the quality of care provide by the home. The home is also aware of the need to ensure their own admission policy is followed and that it confirms in writing that it can meet the needs of people who may wish to move in. It is also aware of the need to change the way complaints are recorded, in line with the Data Protection Act. 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 David`s APL DS0000055164.V367128.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 St David`s APL DS0000055164.V367128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good assessment and admission process in place, which means that people thinking of moving into the home can sure that their needs will be met. EVIDENCE: There is a clear and simple Statement of Purpose and Service User Guide for the home. The 5 people living at the home who returned survey forms all felt that they had had enough information prior to moving into the home to help them make their decision as to whether they wanted to live there. Detailed assessments are generally undertaken by the home of all the needs of someone thinking of moving into the home, which includes the person’s individual aspirations. However, there was no written assessment of need for the last person to be admitted, nor was there any written confirmation to the person stating that the home can meet their assessed needs. The manager and owner said that this was because the person was well known to them, they knew their needs and that the home could meet them. St David`s APL DS0000055164.V367128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear care planning system in place, that provides the information that staff need in order to satisfactorily meet the day to day needs of individuals. This would be further enhanced if there was more evidence to show how people’s identified needs had been met. Peoples’ choice is sought and acted upon whenever possible. EVIDENCE: Three people’s care records were looked at and all were found to be very comprehensive. They each contained a detailed needs assessment, risk assessments, an action plan, daily diary and a comprehensive medical file. There is a summary of the person’s needs that tells staff about any recent changes and includes details of friends and family as well as likes and dislikes. St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 11 One member of staff commented on their survey form that they felt that ‘St David’s is very good at meeting the different needs of the individual’. Risk assessments are completed whenever a risk has been identified, and one person had signed their assessments to show they agreed with them. Details of the planned support that is required to meet needs is set out in a clear way, which shows short and long term goals and the staff action that is required to meet the goals. Regular reviews show when these have been met. There is also a quality assessment form that rates the outcomes for the individual from the previous review, in areas such as relationships and communication. Daily diaries for each individual give some detail as to what the person had done during the day. However, the information was limited and did not evidence that staff had done what was needed for each individual in line with the care plan details. Meetings for people living at the home are held regularly and everybody has a chance to say how they are feeling and if they have any concerns, as well as general house matters being discussed. People are expected to contribute to the general running of their home, as far as their abilities allow and are consulted on all aspects. Meals are decided on a daily basis and people help to shop for and cook the meals. Everyone is responsible for keeping their rooms tidy with some support from staff. Good risk assessments were seen for each individual and included any control measures that may be necessary. Staff said they were clear that they are at the home to support people to do whatever they wish to do within a safe environment. The manager and owner told us that people were encouraged to take risks and ‘push their limits’. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to further develop the risk assessment procedures. St David`s APL DS0000055164.V367128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from being offered a good variety of activities and social opportunities that enrich and fulfil their lives. Meals are nutritious and balanced and offer a healthy and varied diet for everyone. Individuals’ rights are respected and recognised within the home affording them as much independence as possible. EVIDENCE: It was clear throughout the visit that there are good relationships between people living and working at the home. People were treated kindly and with respect and there was lots of laughter and chatter. Due to the tummy bug there was limited opportunity to talk to most people. However, two people did speak with us for a short time, and told us about their St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 13 visit to a local nightclub the night before. They also told us about their rock climbing adventure and one person told us about their job at a local pub. Staff have a good knowledge of people’s needs, likes and dislikes and try to arrange activities to suit these needs and preferences. There is a good mix of individual and group activities available include walks, swimming, shopping, trampolining, visiting clubs, pubs, cafes and many more. Everyone goes out to lunch on a Thursday and on Sunday everyone goes to a pub for breakfast, followed by a long walk. Staff made many positive comments on their survey forms, including, ‘St David’s is very good at organising activities which are suitable for each individual’, ‘we pride ourselves on our weekly activities’ and ‘makes sure people have a good quality of life and take part in lots of activities’. There are two older people living at the home and great emphasis is placed on ensuring their needs and the needs of the younger people are managed. One person who has no speech receives a regular visit from someone who can ‘sign’ so that the individual can have a regular conversation with someone who is fluent in signing and who does not work at the home. Some people go out to work and one person has recently achieved an NVQ (National Vocational Qualification) level 1. People visit the Dawlish Garden Trust, where they pot out plants and learn about nature. Some individuals have attended New Horizon courses in cooking and woodwork and others attend Step One, which is a drop in centre where people can increase their independent living skills. The workshop that people used to use is no longer available, due to the high risk level. People are encouraged to maintain contact with their family and friends, and one person was making arrangements with the owner for a relative to be collected from the train station. There is much useful information displayed on the notice-board in the hallway, including where people can obtain advocacy and bereavement counselling. People help to choose the menu and shop and help with cooking. The main meal of the day is usually in the evening with a snack at lunch and supper times. People were making drinks for themselves throughout the visit and a water dispenser is now located in the hall at the request of people living in 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 continue to consult with people living at the home about what they want to do. St David`s APL DS0000055164.V367128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of the personal support needs of individuals, and people benefit from the very positive relationships they have with staff. To ensure the safety of individuals, all medicines are stored securely, administered appropriately, and good records maintained. EVIDENCE: The preferences of people relating to their personal care needs are clearly documented on their care plans. Staff showed a good understanding of people’s needs and were able to describe good practice in relation to maintaining their privacy and dignity and were seen to offer personal support in a polite and discreet manner. Each person living at the home receives very individualised care that provides the support they need whilst helping to maintain their independence. Some individuals require a lot of help with their personal care whilst others require only prompting. St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 15 Health care needs are highlighted on care plans, and people’s medical files contained records of visits by GP’s, opticians and dentists, and include any instructions to staff following these visits. There were very good recording procedures in place relating to blood sugar tests, including ensuring staff know where to take the next lot of blood from. The home also contacts other professionals as necessary including the continence advisor. The home contacted all the relevant people on the day of the visit to ensure they were aware of the tummy bug. Medication is stored securely in the office. Only staff that have received training, administer medication. There is a ‘Homely Remedies’ policy and any homely remedies that are administered are recorded in a separate book. Medication records were accurate thus ensuring that people’s welfare and safety is protected. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to review procedures and extend staff training. St David`s APL DS0000055164.V367128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 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: There is a clear and simple complaints procedure for the home that sets out the procedure to be followed if a concern is identified. There is a complaints book and all complaints, their investigation and the outcomes are recorded. However, the way the complaints are recorded is contrary to the Data Protection Act and the information for each complaint should be kept separately. Survey forms that were returned by people living at the home indicated that people might not know the complaints procedure, but that they would know who to speak with if they were unhappy about anything. Staff confirmed that they know people well enough to know if they have any concerns, and how to deal with issues raised. Records confirmed that some staff have completed POVA (Protection of Vulnerable Adults) training. One member of staff spoken with, had not recently received training but said they felt confident that they would be able to recognise if abuse was occurring. They were able to describe differing types of St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 17 abuse and gave appropriate answers as to the steps they would take if they suspected abuse was occurring, including contacting outside agencies. A Random Inspection took place at the home in May 2008 following a complaint that the home was withholding medication from an individual living there. We looked into all aspects of the complaint and found that the home had acted appropriately and had consulted with healthcare professionals. The complaint was found to be unsubstantiated. During this visit further concerns that had been raised with us, were discussed. These concerns were around the condition of the building and one member of staff, who was thought not to be suitable to work with vulnerable people. The home had no concerns relating to this member of staff in the home and had obtained the necessary checks prior to them starting work. The building is generally in a good state of repair, though some areas could be improved. Some money is managed by the home on behalf of several individuals. All monies are kept in separate wallets and good accounting procedures are followed. All monies are checked twice daily at each change of shift. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to provide further training for staff in non-verbal communication techniques and to encourage better feedback. St David`s APL DS0000055164.V367128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home generally has a good standard of décor throughout and ensures that individuals live in a safe, homely and comfortable environment. However, some improvements still need to be made. EVIDENCE: A full tour of the communal areas of the building was made and it was clear that improvements have been made. However, some areas are a little ‘tired’ looking, for example the entrance hall. The exterior of the home and in particular the front door also looks very shabby. All bedrooms are for single occupancy and those that were seen reflected the personality of the individual. St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 19 Where necessary adaptations have been made to ensure that people that need it have the specialist equipment necessary to maximise their independence. There is good selection of gym equipment that people can use if they wish. Communal space within the home consists of a large lounge and dining room off the kitchen on the middle floor and an open plan kitchen/dining/living area on the lower floor. There is a large secure garden to the rear of the home that can be accessed in a number of ways. During the visit several people spent some time enjoying the garden. The home was clean and there were no unpleasant smells around the home. There is an infection control policy and procedure for the home and there were disposable masks, gloves and aprons in several areas. The laundry area is located just outside the main house and though small it has the necessary equipment to deal with people’s laundry. The sink used for hand washing in the laundry area has been refurbished. 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 improve the decoration and facilities within the home and to focus on the exterior. St David`s APL DS0000055164.V367128.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 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 available in sufficient numbers to meet the needs of the individuals living there. The procedures for the recruitment of staff are robust and offer protection to individuals. EVIDENCE: The staff rota shows that there are generally three staff on duty and often the owner and manager as extras. Two staff sleep in overnight. One member of staff was spoken with in depth and three others spoke with us about the various routines and procedures of the home. Staff receive regular training to ensure people’s needs are met consistently and safely. Three staff have completed the Learning Disability Award Framework (LDAF) and two staff have started this. The LDAF is training for staff that provides the underpinning knowledge for NVQ’s (National Vocational Qualification) for people working in the learning disability area. Currently two St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 21 staff have obtained NVQ Level 2, three have obtained level 3 and two have just started level 3. The home’s induction process meets the Skills for Care standards, ensuring that the basics of all aspects of care are covered during the member of staffs’ first few weeks at the home. The member of staff spoken with individually told us the training they had received included epilepsy, first aid and health and safety. Training on the implications of the Mental Capacity Act 2005 is due to take place shortly to ensure that staff are aware of their duty of care under this new legislation. Three staff files were inspected, all contained the required information, which included Criminal Records Bureau checks, application forms, two written references and copies of training certificates. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to further increase staff training opportunities. St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 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 promote and safeguard the health, safety and welfare of people living and working there. EVIDENCE: Sam Eyles has recently been registered as manager of the service and has several years of experience working at the home. She has undertaken and completed the combined NVQ level 4 in care and the RMA (Registered Managers Award). St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 23 The owners, Mr and Mrs Hardee have owned homes for people with learning disabilities for many years, and are supportive of their manager. Staff that were spoken with felt supported by the owners and manager, to do a good job. One person commented on their survey form that ‘I think because the staff are treated well by management and the owners, this shows in the staff’s attitude’. There is a Quality Assurance system in place that monitors the quality of care provided at the home. Questionnaires are regularly sent out to anyone connected with the home, and an Annual Development plan is produced showing areas for improvement. Regular meetings are held with people living at the home to obtain their views, which are acted upon where necessary. For example, there is now a water cooler in the hallway, as requested by the people living at the home. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that St David’s APL complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to staff and people living at the home. The owner told us that so the risk of burning from hot surfaces is minimised, all radiators within the home have been risk assessed. He also told us that all windows above ground floor level are fitted with restrictors in order to minimise the risk of anyone falling from these windows. We were also told that all fire extinguishers in the home are now secured. Records were seen that show that water is flushed from unused areas of the plumbing system to ensure it is clear of bacteria. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to further improve the efficiency of the running of the home. St David`s APL DS0000055164.V367128.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 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 X 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 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X St David`s APL DS0000055164.V367128.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. Standard Regulation Requirement Timescale for action 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 St David`s APL DS0000055164.V367128.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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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