Inspection on 07/10/05 for St Davids

This inspection was carried out on 7th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Davids 30/12/08

St Davids 09/01/07

St Davids 21/02/06

St Davids 20/12/04

St Davids 14/06/04

St Davids 10/03/04

Similar services:

Clouds House

Clouds House

Closereach

Closereach

Chandos House

Chandos House

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

CARE HOME ADULTS 18-65 St Davids 50 Walliscote Road Weston-Super-Mare North Somerset BS23 1XF Lead Inspector Caroline Baker Announced 6 & 7 October 2005 th th 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 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 Stationary 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 Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Davids Address 50 Walliscote Road, Weston-Super-Mare, North Somerset, BS23 1XF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01934 412967 01934 620575 enquiries@westoncounsellingservices.com Western Counselling Services Ltd Dr William Kenrick Evans PC Care home only 12 Category(ies) of Alcohol depend past/present (12) registration, with number Drug dependence past/present (12) of places St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 12 persons aged 17-64 years. Date of last inspection 20th December 2005 Brief Description of the Service: Western Counselling Services is registered with the Commission for Social Care Inspection (CSCI) and provides primary and secondary programmes of rehabilitation for up to 65 people between the ages of 17 and 64 years who have alcohol and/or drug dependencies. The bulk of the primary counselling programme takes place at a day centre and there are two houses (Meijer and St David’s), which provide accommodation for mixed sex groups on primary programmes. St Davids provides up to twelve places. Three other houses, Larkhill, Kintyre and Clarence Park Lodge provide accommodation for single sex groups receiving secondary programmes. At the time of this inspection given the large number of primary service users Clarence Park Lodge was also being used as a primary house. The counselling is based upon the twelve-step Minnesota model. These homes have a private arrangement with a local GP practice to provide medical support and assessments, especially for those who are in the initial part of the primary programme. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report should be read in conjunction with the reports of the other homes run by Western Counselling Services (WCS). At the time of this inspection the whole service was providing primary care to thirty-three clients and secondary care to fifteen clients. This inspection was announced and took place over two days (27 inspector hours) by David Francis and Caroline Baker. At the time of this inspection the majority of previous requirements had been complied with and the recommendation had been actioned. This house can accommodate up to twelve primary stage clients. An assessment of the premises took place where a selection of bedrooms, bathrooms and communal areas were seen. All of the residents and staff were spoken with. The registered manager was available throughout the inspection. Records relating to the residents, staff and health and safety were examined. What the service does well: WCS provides excellent information for clients in the format of a Statement of Purpose/Serviced User Guide (Welcome Pack) giving prospective clients a full guide to the service and its philosophy. The majority of clients told inspectors that there were no surprises. Clients are fully assessed on referral to the service and have an opportunity to visit WCS to complete the assessment before admission. A call contact system is then put into place to ensure clients and the service knows when the admission will be. Many clients are taken on telephone assessments, which are very thorough, and depending where the client comes from. As well as considerable group therapy the programme also provides I:I counselling twice weekly or more if required, topic workshops, and diary groups for example. WCS had a good open and inclusive atmosphere, everyone appeared relaxed and cheerful. Staff morale was very good. The interaction between staff and clients was happy and relaxed. Clients spoke highly of the counsellors. CSCI sent comment cards to clients for their views and all those returned were very positive including comments e.g. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 6 ‘This is my third rehab and I believe that the service offered at WCS gives me the most hope for recovery. The success rate is good’, ‘I am very happy at WCS. I was made to feel very welcome when I arrived and now I am settled and feel very comfortable’, and ‘I feel WCS has helped me in my recovery a lot’. WCS ensures that all clients have access to appropriate health care professionals and will offer support to attend appointments where appropriate. Feedback from clients during the inspection was very positive with regard to all aspects of the provision of counselling and support at WCS. They understood the rules and boundaries and accepted them as part of the intense programme offered at the home. Clients stated that the counsellors were ‘excellent’, the food was good and they were pleased with their rooms. The discharge rate at WCS is low indicating a very good success rate. What has improved since the last inspection? All but one of the requirements identified at the last inspection had been complied with within given timescales. All the houses are being refurbished to a high standard maintaining a homely environment. The amount of people going to WCS for treatment has increased given their good reputation for recovery success. Financial viability is improving the providers told the inspectors. Support worker teams have been implemented freeing up counsellors to have more time for client therapies. Communication between staff and clients has improved. DVD’s are now provided at weekends for clients in primary care. More contact with family had been improved and become more flexible. Relaxation groups are provided on a weekly basis. Training in Fire Awareness, First Aid and Food Hygiene had been provided for all staff. The philosophy of the whole programme has improved. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 7 WCS has gained a certificate in Quality Assurance from an external assessor ‘QuADs’ and are applying for the Investors in People Award. 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. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Clients are provided with the information they need to enable them to make an informed choice about staying WCS. WCS was able to demonstrate that clients are fully assessed prior to admission to ensure their needs can be met. WCS has systems in place to introduce prospective clients to the service, other clients and the programme prior to admission. EVIDENCE: WCS has a detailed Statement of Purpose (Welcome Pack), which is provided to all potential clients. It provides details of WCS’s philosophy, therapeutic programmes, facilities and timetable of activities. A service user guide is available for female and male clients, primary and secondary clients. Clients consulted during this inspection felt that the information provided reflected service provision and enabled them to make an informed choice regarding admission to the programmes. A telephone referral normally starts the process to admission to WCS and the programmes. Referral and assessment forms for four clients were examined as part of the inspection process. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 10 All potential clients are invited to WCS for an assessment meeting following the initial referral, which is conducted, by either the Admissions Liaison Officer or the Provider. Clients consulted confirmed this process. They are able to stay for a meal and meet other clients. A detailed assessment form is completed and takes into account a life history, pattern of addiction, physical and mental health, significant others and family and also any special needs. Evidence was seen that WCS had clear criteria for admissions. Where required staff will liaise with other health care professionals in deciding whether a placement is appropriate. This was discussed in depth during inspection given one referral with potential complicated health needs and the inspectors advised the managers to question decisions made by health care professionals if medical needs were high and they were unsure. WCS’s residential contract was examined. It reflects clearly the rules and restrictions, and other written information regarding the programme, and other facilities so that clients can take it away with them to read and comprehend prior to admission. Clients consulted confirmed this. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 11 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 standard(s) 6, 7, 8, 9 and 10 WCS’s care planning system demonstrated that care plans are kept under review. Clients are involved in all aspects of life within WCS. Clients were supported to make decisions and to live a lifestyle in accordance with their plan of care, risk assessments were carried out but plans of minimising risks were not completed. WCS demonstrated that it handles all information and records in line with the Data Protection Act 1988. EVIDENCE: Four individual clients’ care records were seen. They included client identification and assessment forms together with their photographs. A comprehensive assessment had been undertaken and care records confirmed regular in depth 1:1 meetings with counsellors. The clients’ rights and responsibilities were clearly set out in the residential contract. Care records seen indicated that these are fully discussed in the individual clients first 1:1 counselling session. Within the therapeutic St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 12 programme, the aim is to enable and empower individuals. Clients consulted indicated that strict WCS house rules imposed were necessary for their well being. The day-to-day running of WCS is organised by the counsellors at the day centre for those in primary care. And boundaries are set for those in secondary care and are designed to allow greater flexibility. One client in each house is allocated group leader and they liaise on a daily basis with management. Individual risk assessments were seen in the care records examined however action plans had not been devised in regard to minimising the risks. This was discussed during the inspection and the management team acknowledged the need for this. It was evident as part of the programme clients are encouraged and enabled, within the set boundaries, to be self-aware and afford themselves a greater choice in how they live without mood altering substances. Care records were stored in a confidential manner and clients know that they have a right of access to them. Policies were in place stating this. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 13 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 standard(s) 11, 13, 15, 16 and 17 Clients benefit from good support, which enables them to personally develop, enjoy a range of leisure activities and to access local community facilities within set boundaries once in the secondary part of the programme. Clients were offered a choice of menu and wholesome food. EVIDENCE: The inspectors were able to meet with all the clients both in primary and secondary care to gain their views on service delivery. At WCS clients are expected to abide by set strict rules, which are challenging to enable them to physically and mentally recover from their addiction. Each house has a housekeeper to keep it clean and tidy and a cook to prepare and serve meals to the clients staying in them. Clients are expected to attend to their own personal laundry. Throughout the week there is a restriction on television viewing encouraging clients to spend more time in peer support and group activities. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 14 Each day is structured and begins with a ‘meditation group’ at the day centre for primary care clients. The counsellors are given the opportunity during these groups to ascertain any concerns or issues arising from the previous evening or night. Then there are ‘group therapy’ sessions, educational videos and lectures in addition to 1:1 counselling at least twice weekly. Clients consulted confirmed the programme routine and many raised issues over the length of time between the first group therapy session and the second when they were ‘bored’. The inspectors took this back to the managers who agreed to explore this and the inspectors understood that there must be times of boredom for clients to adjust to. Clients also understood this however felt it was too much every day. During the week of the inspection an art class had been delivered to the group, which had been enjoyed. Primary care clients have an opportunity to go for a walk in the local parks at the weekends and partake in group sports. Physical exercise is restricted and there is no gym facility at WCS. Secondary care clients can access the local college and undertake voluntary work. They are given support to attend AA/NA support groups in the local community weekly as a preparation for their transfer. Contact with family is restricted during the first week but subsequent arrangements for visits and telephone calls are agreed with the Counsellor as part of the overall care programme. There are restrictions imposed during the programme to protect the interests of the individual and the group. House rules are made explicit on admission and breach of these usually leads to exclusion to the programme. Clients told the inspectors during a group discussion, that the rules were fair and essential to the integrity of the programme. There is a two-week rotating menu and clients told inspectors that they had a choice and were able to help with choosing the menus. Evidence was seen of a regular supply of fresh fruit and vegetables. All kitchens assessed were clean and tidy. The majority of clients praised the provision of food at WCS. During the secondary programme clients are expected to cook for themselves at weekends. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 15 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 standard(s) 18 and 20. Clients receive a very good level of support to meet their physical, emotional and health care needs. WCS’s procedures for the management, administration and recording of medication appeared safe and was dispensed and overseen by regular visiting GP’s. EVIDENCE: At the time of this inspection there were no clients needing assistance with personal care. The management of medication was discussed. Due to the nature of the service clients had their medication administered by the staff. Clear and accurate records were maintained in regard to administration. The visiting GP’s dispense the medications into nomad type boxes, which are sealed and take full responsibility for the administration of the medications. The Service user Guide States: - The therapeutic programme is abstinent based, 12 step model, use of non-prescribed medications, illicit substances or alcohol is strictly forbidden and will result in discharge. Any medicinal requirements are made through the doctor who will ensure appropriate prescribing. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 16 During discussions with the client groups many clients indicated that the initial medication therapy ‘detox’ was too much and felt that some clients were over prescribed. The management agreed to discuss this with the GP. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 17 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 standard(s) 22 and 23. Appropriate steps are taken to reduce the risk of harm or abuse to clients. EVIDENCE: All clients receive a copy of the home’s complaints procedure and it is displayed at each house. Clients consulted were aware of the complaints procedure. WCS has a complaints record book and there had not been any recorded since the last inspection. Policies were in place for the protection of vulnerable adults. There had not been any adult protection issues raised. Staff recruitment practice must be more robust for the protection of vulnerable adults as discussed later in the report. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30. Clients stay in a homely, clean environment where they may share a bedroom and can socialise in a variety of communal areas. WCS’s primary care provides a day centre for clients to meet on a daily basis. EVIDENCE: The inspectors assessed each house WCS provides as accommodation for the clients. St Davids is registered with the CSCI and provides accommodation for up to 12 male clients. The manager showed one inspector around the home whilst the other inspector examined records kept at the house. This house is used as primary care accommodation. All rooms seen at the house were homely, clean, tidy, personalised, and were decorated and furnished to a high standard. All rooms were shared, had a wash hand basin and were close to toilet and bathing/showering facilities. The communal facilities were tastefully decorated and were homely and warm. Each house had a dining area and up to two lounges depending on the size of accommodation. All were well maintained. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 19 Each house had a laundry room with adequate facilities to allow clients to undertake their own personal washing. An outside contractor launders bedding. The gardens were pleasant with sitting areas for the clients to enjoy within the set boundaries of the home. Refurbishment of the houses is on going and evidence was seen of investment into each house by the high standard and upkeep of the outside, new carpets, furniture, and décor. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, and 36. The skill mix of staff at WCS was good and staffing levels suit the needs of the clients. Staff morale was very good and staff were supported and competent to do the job they had been employed for. The homes recruitment procedures did not fully protect clients. EVIDENCE: The inspectors spoke with the two counsellors in depth. They confirmed that they had a job description and contract of employment detailing their responsibilities and line of accountability. They were happy at WCS and felt very well supported by the external formal supervisions provided. The inspectors were impressed with the counsellors and their depth of understanding. conversations held with the All counselling staff have relevant qualifications and experience in the field of addiction. The counsellors consulted during this inspection had gained a Diploma in Counselling and were both very experienced. Clients were very positive about the counsellors and felt they were all competent. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 21 WCS is staffed 12 hours per day by counsellors and two registered managers, supported by the providers and administrators. During the evening and at weekends there are accredited support workers on duty with a counsellor always on call. Five staff files were examined as part of the inspection to ensure vulnerable adults were protected by the systems in place. Good practise was seen apart from the use of portable CRB’s and not obtaining CRB’s from overseas staff. This was raised as a serious issue with the providers who acknowledged the discrepancy. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40, 41, 42 and 43. The managers effectively manage WCS and the management style provides an open and inclusive environment for clients and staff. WCS was taking appropriate steps, to ensure the health and safety of clients, staff and visitors. EVIDENCE: WCS management is structured at this time with two registered managers – Mr Alun Davies and Mr Ken Evans. Mr Rob Thomas is the registered individual. Mr Ken Evans was on leave at the time of the inspection. He is responsible for the day-to-day operation of the primary care programme and accommodation. Mr Davies was available throughout the inspection and he is responsible for the day-to-day operation of the secondary care programme, accommodation and aftercare. The clients spoke highly of Mr Davies who has been part of WCS for over 25 years and has a wealth of experience. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 23 Amanda Lea – provider - is responsible alongside Rob Thomas for the day-today running of WCS and is at this time undertaking the Registered Managers Award (RMA). Once completed, she is considering applying to be overall registered manager of WCS. Staff spoken to indicated a vast improvement in morale and atmosphere since WCS was taken over by the current providers. The atmosphere appeared open and inclusive. The inspectors were told that the managers and counsellors to discuss all areas of provision hold regular meetings. Clients confirmed this and indicated that the managers and counsellors were all approachable and available at any time. The discharge processes and rules were discussed. Clients felt that the programme was intense, very strict and rigorous and that WCS was managed appropriately and in a way that safeguarded the interests and welfare of the group. The Providers regularly visit the houses and make reports under Regulation 26. The fire logs in each house were examined and indicated regular periodic checks and tests being undertaken. Fire fighting equipment was checked weekly alongside the fire alarms. The fire alarms and annual fire check of the house was current. Staff had received appropriate fire awareness training and as discussed although the majority of clients were aware of the fire procedures the providers should ensure that all house leaders were made responsible for knowing the fire procedures pertaining to each house. Kitchen records were checked in each house and were found to be maintained and current. Access to records is controlled and there is policy guidance with regard to confidentiality and disclosure. A current Employers Liability Insurance certificate was displayed. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 x 3 2 3 2 3 Standard No 31 32 33 34 35 36 Score 3 3 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Davids Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 3 D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 25 YES 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. 2. Standard YA9 YA34 Regulation 13(4) 19 Schedule 2 Requirement The registered person must ensure that the latest risk assessment is implemented. All current employees must have new enhanced CRB disclosures and POVAFirst checks applied for by end October 2005 and any new staff must not commence employment until the same is received. (Previous timescale of 30 December 2004 not met) Timescale for action 30 October 2005 30 October 2005 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. 2. 3. 4. St Davids Refer to Standard YA14 YA16 YA16 YA20 Good Practice Recommendations The registered person should give consideration to reviewing the use of time between group therapies. The registered person should review the rules on smoking in the day centre day room, giving regard to non-smoking clients and staff. Alternative day centre provision should be sought in consultation with the inspector. Given comments received from clients and as discussed at inspection the registered person should review and D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 26 monitor medication practice during the early part of the primary care programme. St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Davids D53-D02 S8107 St Davids V2477656 06&071005 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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