Inspection on 26/01/06 for St David`s APL

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St David`s APL 25/06/08

St David`s APL 27/06/06

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 09/07/2008.

CARE HOME ADULTS 18-65 St David`s APL 11 Barton Villas Dawlish Devon EX7 9QJ Lead Inspector Sam Sly Unannounced Inspection 26th January 2006 12.30 St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 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.V262483.R01.S.doc Version 5.1 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.V262483.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St David`s APL Address 11 Barton Villas Dawlish Devon EX7 9QJ 01626 865597 01626 866496 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 To be arranged 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.V262483.R01.S.doc Version 5.1 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 4th August 2005 Date of last inspection Brief Description of the Service: St Davids cares for 3 specific residents with mental health problems two of whom are aged over 65, and up to six residents 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 the hospital, shops, amenities, bus and train services. On the ground floor is a self-contained flat for three older residents with mental health needs. These residents were living at the home when it was previously registered solely for people with mental health needs. The first and second floor is registered for up to 6 residents with learning disabilities. The first floor has an open plan kitchen and dining room, a lounge, and office. All the bedrooms are on the second floor. Five 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. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and took place on a weekday from 12.30pm to 4.30pm. Mr Hardee, Owner/registered manager and Mrs Hardee, Owner and the deputy manager were all present for some of the time. Evidence was collected through a tour of the premises, and examination of care records, staff files and health and safety records. Five of the residents were spoken to, as were the Owner, and staff on duty. Three comment cards were received from residents also. What the service does well: What has improved since the last inspection? What they could do better: St Davids would benefit from a comprehensive Quality Assurance system, so that the Owners can demonstrate that the services provided are continuously monitored and improved. Fire doors must be in working order, and wedges must not be used to hold fire doors open. The Owners must remember to inform the Commission of incidents that adversely affect residents. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 6 The kitchen must be kept clean and hygienic, with a cleaning rota in place to prevent the spread of infection. 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. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 7 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.V262483.R01.S.doc Version 5.1 Page 8 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): 5 Terms and conditions were made clear, however some of these terms and conditions did not reflect the adult status of the residents. EVIDENCE: Residents had a contract, which had been read through with them and signed. There was discussion about some of the terms and conditions, which did not reflect the adult status of the residents, for example; set bed times. The contracts therefore required some revision. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 9 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 Resident’s needs are well understood by staff, and plans aim to increase independence. EVIDENCE: Three residents plans were examined and found to reflect resident’s needs and goals. One resident’s needs had recently changed and the plan and risk assessment required updating. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 10 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): 16 & 17 Resident’s lead active, stimulating, interesting lives and enjoy their meals. EVIDENCE: Residents all have their own bedrooms and keys are provided. Daily routines revolve around the activities and work residents are doing, which includes walking, going to the gym, work at the Garden Trust, trips out, using the trampoline, and office skills. The older residents go out for trips and to the town. Meal menu’s are discussed and planned in resident’s meetings and resident’s said they liked the food. Resident’s were encouraged to join in with preparing the meals. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 11 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): 20 Medication is administered to residents safely. EVIDENCE: Medication is administered to residents, however there is a framework to encourage self-medication. There were secure facilities for medication and records showed medication was administered safely. Staff had now all received appropriate medication training. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 12 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): 23 Staff have the training and procedures to protect residents from abuse. EVIDENCE: Most staff had now attended Adult Protection training and there were policies and procedures in place to protect residents. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 13 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 & 30 The environment at St Davids is improving, and a plan, with timescales, is in place to ensure it becomes a homely, safe and comfortable place to live. The kitchen was not clean. EVIDENCE: A major refurbishment programme in ongoing at St Davids with some parts completed, and other parts identified, with timescales, in a refurbishment and renewal plan for completion in 2006. The kitchen was examined and found to require a deep clean as the floor was grimy and dirty and there was record of regular cleaning taking place, although the Owner said this did take place. The fire door to one of the resident’s bedroom was broken, and the resident had a wedge that he used to keep his door open. The Owner said he had a new fire door, and self closer devices ready to fit to two fire doors in the home. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: None of these standards were inspected in depth and all were met at the last Inspection and there were no issues raised that indicated a need for further investigation. Staff files were examined and found to contain all the required information and checks on staff fitness. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 15 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): 37, 39 & 42 Resident’s safety is potentially at risk through unsafe fire practices. Although quality is monitored, the Owners have no overall system in place to improve the quality of services at St Davids. EVIDENCE: Although in the Home regularly, the Owner/Manager Mr Hardee is sharing the responsibilities of management with the deputy Sam Eyles who is completing a NVQ 4 and Registered Manager Award. The Owner said an application to the Commission would be forthcoming to register Sam Eyles. Staff have done a range of health and safety training and said the quality and quantity of training was good. The Owners have employed an external company to carry out regular risk assessments of the premises, and provide the required policies and procedures to ensure safe working practices at St Davids. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 16 The fire door to one of the resident’s bedroom was broken, and the resident had a wedge that he used to keep his door open. The Owner said he had a new fire door, and self closer devices ready to fit to two fire doors in the home. There was discussion about developing a Quality Assurance system, as although the Owners had a range of quality monitoring procedures in place there was no overall quality improvement plan. The Owners were reminded about informing the Commission of incidents that adversely affect residents, as such an incident had recently occurred. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 17 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 X 2 X 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 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X 2 X X 2 X St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 18 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 YA30 Regulation 13(3) Requirement Timescale for action 28/02/06 2 3 YA39 YA42 24 23(4) 4 YA42 37 The kitchen must be kept clean and hygienic at all times, and there must be in place a record that regular cleaning takes place. The Home must have a 30/04/06 comprehensive Quality Assurance system in place. All fire doors must be in working 26/01/06 order, and no wedges must be used. If fire doors have to be kept open, an approved device must be used. The Owners must inform the 28/02/06 Commission of incidents adversely affecting residents. 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 YA9YA6 Good Practice Recommendations The use of oxygen, by one resident, should be included in his risk assessment, and the decision-making around not providing him with cigarettes should be agreed in his care plan. DS0000055164.V262483.R01.S.doc Version 5.1 Page 19 St David`s APL 2 YA5 Resident’s contracts should not specify the time a resident must go to bed. St David`s APL DS0000055164.V262483.R01.S.doc Version 5.1 Page 20 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. 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