CARE HOME ADULTS 18-65
Station Villa Station Villa 18 Station Hill Hayle Cornwall TR27 4NG Lead Inspector
Stephen Baber Key Unannounced Inspection 22nd September 2006 09:30 Station Villa DS0000063182.V303478.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 Station Villa DS0000063182.V303478.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. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Station Villa Address Station Villa 18 Station Hill Hayle Cornwall TR27 4NG 01736 755251 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) Swallowcourt Limited Christine Barbara McLean Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Station Villa is a large detached house situated in a residential area near to the railway station in Hayle and within walking distance of the town. Swallowcourt Ltd purchased the home in January 2005 and are now the registered providers with Mrs C.Maclean as the registered manager. There are currently five single bedrooms and four doubles. Some of the service users at Station Villa attend day care facilities and others attend other centres for weekday activities. Bathing and toilet facilities are on the ground and first floor of the house. Swallowcourt are investing substantially in the home to provide service users with a wide range of facilities. In the two years the company have been registered there has been a steady financial investment to improve the furnishings and decoration of the home. The improvements look impressive and improve the comfort and well being of the service users. The manager explained the aim of the service is about commitment to continuous improvement, quality services, support accommodation and facilities which assure a quality of life and health for service users. Fees range from £316 to £1005 per week. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission are making changes to the regulations and inspection of social care agencies. Inspecting for Better Lives (IBL). We are modernising the way we inspect all social care services and will be more proportionate, more focus on the experience of people using services and focus on providers to ensure quality. This was the key inspection, which took place on 22nd and 25th September 2006 and was unannounced. It lasted for approximately nine hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. Discussion with staff and service users and observation of the daily life and care provided took place. There was an inspection of the home’s premises and of written documents concerning the care and protection of the service users and the ongoing management of the home. The principle method used was case tracking. This involves inspecting the care notes and documents for two service users and following this through with interviews with/ observation of them, staff working with them. No relatives or representatives were present on the days of the inspection. In the two years the home has been registered there was significant evidence of continued improvement in care standards, a safe and comfortable home in which service users can develop their skills and independence and comprehensive evidence in the form of the written records and reviews that clearly details the care given. What the service does well:
The home is very well managed for the benefit of the service users. Throughout the service there is a highly evolved understanding of the equalities and diversity needs of individual service users. Prospective service users undergo a thorough assessment and introductory visit to the home to ensure that they will be happy with the service s and facilities and are well matched with the rest of the service users. The latest admission to the home said she was shown around the home and invited to visit. She also said that
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 6 she visited several other homes before making a final decision to live at the home. The manager has made huge strides in developing care plans and reviews. Service users have detailed written care plans, which set out how the home will meet their personal, health and social care needs, including needs relating to their individual backgrounds and culture, age, sex, religion, individual abilities. All information is shared with service users and their representatives and I noted throughout the inspection the open door policy the manager had regarding service users who wished to speak with her. All service users are encouraged to make important decisions about their lives, such as what activities to take part in during the week and how to spend their free time so that they develop their confidence and independence. Identified risks are carefully managed, to minimise restrictions on service users and enable them to take part in activities that develop their skills and enhance the quality of their lives. Some of the service users said that they were going on outings and holidays of their choosing and were very much looking forward to it. Service users enjoy a good quality of life in the home. Staff support service users to take part in a wide range of activities in the home and the local community, which vary according to their individual needs and preferences. Activities are age and culturally appropriate for them. They attend a variety of social activities including visits to Trelawney Club, Gateway, pubs and cafes with staff, in the community. The home provides a seven-seater people carrier to access the facilities. Service users are actively supported and encouraged to maintain contact with their families so that they maintain and develop valued relationships outside of the home and there has been a significant improvement in family involvement and visiting since the company have taken over. Service users said they enjoy their meals and have sufficient to eat. Staff support service users to independently attend to their personal care and all service users are encouraged to look smart and well dressed. Normal community arrangement exist to access a range of NHS healthcare providers, such as doctors, opticians and specialist services when they need them so that they maintain good general health. Their medicines are safely stored in the home and staff have clear written guidance on how to manage them safely, so service users are protected from medication errors. Staff have good access to ongoing training to ensure they have the knowledge and skills to be able to work safely and effectively with service users Staff are provided with training and guidance on how to effectively support and protect service users from harm and abuse. Fair safe and effective recruitment practices are in place to ensure that staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting. . Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection?
In the two years that the manager has been in post she has developed the company policies, procedures and practices to ensure that the care home fulfils its stated purpose and objectives and meets the needs of the service users who live there. Through her experience, training and responsibilities the manager ensures the effective day-to-day running of the home. The manager and staff involve service users in all aspects of life in the home .The manager fosters an atmosphere of openness and respect, in which service users, their family or representatives all feel valued and that their opinions matter. On this inspection I noted that some service users who did not communicate with me on previous occasions until I spoke with them came up to me and said “good morning Stephen” and wanted to talk with me about the things they were doing. Their confidence had certainly improved and they were affable, confident and friendly. The manager said that she has improved the range of activities provided to service users to improve the quality of their lives in the home. Written procedures to guide and inform staff on the action they should take if they suspect abuse of a service user have been improved and updated so that they are better informed of what to do. The home’s manager has undertaken multi-agency training on the protection of vulnerable adults from abuse to gain familiarity with the way organisations should work together in this respect. Care plan reviews have taken place with all interested parties and daily records painted a picture of the day the service users had. Records were legible, up to date and signed by the writer. The registered manager has updated the home’s environmental risk assessment to ensure that it is a safe place for service users and staff to live and work in. Staff have been delegated clear lines of responsibility that they have to follow through in line with the written policies and procedures. All staff working at the home will attain their NVQ level 2 qualifications by the end of the year. For one member of staff who has some difficulty with putting things down in writing the manager has arranged for them to have extra support from the college. I talked with the staff about is success and they were please and proud to tell me what they have achieved. Formal systems to review the quality of the services (quality assurance) provided by the home have been implemented to ensure that service users and their representatives can be confident that their views and needs underpin the ongoing development of the home Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 8 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. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 9 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 Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 10 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): 2,5. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users undergo detailed assessments prior to their admission to the home so that they can be confident it will be suitable to meet their needs. They have written statements of the terms and conditions of their placements in formats to explain the contract to service users. EVIDENCE: Two files were case tracked. Both files had detailed assessment information on their personal files to show that their needs were fully considered prior to their being placed in the home. Service users or their representatives were fully consulted and involved in the process and agreement was reached on the service to be offered. One service user said that they felt that their move to this home was a positive change for the better and the manager and staff were very helpful. Service users have written statements of the terms and conditions of their placements in the home provided by the company and another contract compiled by the manager that is in a language appropriate to each service user. These set out their rights and obligations and are also sent to their relatives/ representatives. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 11 Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Comprehensive care plans address service users health, social and personal care needs in full, including needs relating to their age, disability, religion, cultural and ethnic backgrounds. There is evidence of innovative methods to enable service users to participate and communicate their views to the development of the care plan and the review process. Feedback and involvement is a continuous ongoing process, staff spend time with individual service users to ensure they understand decisions and actions. Service users are aware of their care plans and those with capacity to do so are able to discuss its content and convey a sense of ownership. Staff are given the necessary training and skills to support and encourage service users to be full involved. Personal information relating to individual service users is now stored securely in the home so that their confidences are kept. EVIDENCE: Those service users with capacity were aware of their care plans and confirmed that they attend their reviews. Copies of their care plans are held on their personal files. There was clear evidence that the manager and staff work closely with external professionals and specialists for advice and support. Evidence of good practice was found at the home, which includes assisting to
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 13 access external advocacy and the manner in which all the service users were informed about a recent death of a service user and where appropriate supporting the family member. Service users were observed making choices about what activities to engage in during the inspection and about what they wished to eat at breakfast and lunchtime. There are detailed written risk assessments for each of the service users on their personal files to guide staff on how to enable them to take risks to develop their skills and independence in managed ways. The home has a lockable office, so that confidential information relating to service users can be safely stored away. The senior carer whom I spoke with demonstrated a clear understanding of the need to ensure that service users’ confidences are maintained and awareness of the policies in place to support this. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17, Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service Service users access a range of activities, in accordance with their individual needs and preferences, so that they develop their skills and independence. They regularly access resources in the local community and are supported to maintain valued relationships with their friends and relatives so that they are not isolated and they enjoy a good quality of life. Their rights and responsibilities are recognised and promoted as far as is practicable and they receive a well balanced diet. EVIDENCE: The service users files evidence that a wide range of individualised activities in and outside of the home are arranged for each service user, which are developed with them, according to their needs and preferences. The manager said that staff are employed in sufficient numbers to be able to work with each service user individually. I observed the individual attention service users were receiving on the days of the inspection. Staff appeared responsive to individual needs and were kind and caring. They all said to me how much they enjoy a
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 15 good lifestyle in the home and the activities holidays they plan with the support of the manager and staff. Service users were observed accessing community resources during the day. Attendance at the local nursery, shops, college and day centres are some of the options available. Family involvement has greatly improved and is encouraged by the manager and staff. Family and friends actively visit the home and are can take meals or have a cup of tea with them. Daily care records confirmed this. The service users expressed their satisfaction with the catering arrangements at the home. A fully qualified chef/carer prepares the main meal of the day. The Environmental Health Officer has recently inspected the home and everything was satisfactory. The dining room is light and airy and provides for a pleasant ambience. A great deal of social interaction takes place at meal times with the staff supporting the service users. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are helped to maintain and develop their independence with regard to their personal care. They are assisted to access normal community healthcare services they need so that they stay well and enjoy their lives. Arrangements for managing medicines and staff training in medication safeguard and protect service users. EVIDENCE: Observations made throughout the two days of the inspection evidenced that service users make use of the bathrooms and facilities for maintaining their personal care independently, whilst staff were available at all times to support, prompt and assist them according to their assessed need. The home’s records provide staff with detailed instructions on how to support service users appropriately and safely with regard to their personal care. Several of the service users are aged into their seventies and eighties and therefore receive sensitive and discrete attention when it comes to regular toileting and bathing. All of the service users enjoy good health but where appropriate the full range of community healthcare facilities are available for them to access if needed.
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 17 The service users I spoke with stated that they are satisfied with the healthcare arrangements at the home. The manager has developed an efficient medication policy and procedure, which all staff are familiarised with. Staff have access to the written information and understand their roles and responsibilities. The medication records inspected are seen as key to the efficient management of health care matters, staff are aware of the importance and necessity of them being up to date and fully comprehensive. The company provides training for all staff with a responsibility for the administration and dispensing of medication. There are secure storage facilities for service users’ medicines with the senior care assistants taking responsibility for the administration and dispensing of medication. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. There are formal and informal systems in place so that service users’ views are taken into account in the day-to-day running of the home. Service users’ welfare and best interests are well protected so that they feel safe and well cared for in the home. Service users’ views are listened to and acted on and they are protected from abuse, neglect and self-harm. EVIDENCE: There is a clear, written complaints procedure, which has been provided to all the service users in written or verbal form. There are informal house meetings taking place everyday with open and frank discussion taking place. Service users have contacts with people outside of the home, to whom they can turn should they feel unable to approach the manager and staff and the company manager visits daily and has an excellent relationship with everybody. All staff have received multi-agency training on the prevention of abuse of vulnerable adults and some staff have completed the multi agency training provided by the Adult Social Care department. The manager is very skilled at cascading appropriate training down to all levels of staff. There are clear written procedures to guide staff on the actions they should take should they suspect a service user has been abused, including policies on whistle blowing. Staff are employed on the basis of fair, safe and effective recruitment practices which protects the service users from harm. The service users I spoke with said that they are satisfied with the care and services provided to them at the home and that they felt safe and cared for. Records in the home indicate that there have not been any formal complaints. Service users and their representatives are invited to reviews on a regular basis and invited to contribute their views and concerns. Quality assurance surveys have been supplied to service users and their relatives, offering further
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 19 opportunities for them to make their views known. The manager also works as a practitioner supporting, guiding and supervising the staff. The home’s comprehensive written procedures to guide staff on what action to take if they suspect a service user has been abused are in place and understood by all the staff. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from living in a comfortable, safe and homely environment so that they can develop their skills and independence in a noninstitutionalised setting. Good hygiene is maintained so that service users are adequately protected from infection. EVIDENCE: The home is a fine looking detached house, well situated in the local community, which service users were observed to be a part of at the time of the inspection. Improvements to the decoration and furnishings are on going but the home appeared nicely decorated and furnished. Service users appeared to be comfortable and at home and had ready access to all parts of the home. The home appeared clean and tidy throughout at the time of the unannounced inspection. There are written guidelines in place to ensure good hygiene is maintained. Protective clothing is provided for the staff. The company stated to the Commission when it was first registered that plans would be put in place to improve the facilities and services and reduce the
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 21 ratios of doubles to singles. It is now two years on and a commitment from the company to the commencement of these works would be grateful. There would definitely be added benefits for the service users and staff should those works be completed. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 22 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): 32,33,34,35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager is committed to a highly trained staff group. All of the staff will complete their formal NVQ qualifications by the end of the year. This will ensure that service users and their relatives will know that staff are trained and competent to meet their needs. Recruitment policies and practices are fair, safe and effective so that staff are employed on the basis of their suitability to work with vulnerable adults in a care setting and staff have good access to ongoing training so that they have the skills they need to work safely. EVIDENCE: Again the manager has worked diligently to compile very impressive staff development files. Records held in the home evidence that staff have undergone various training courses. The company are proactive in the area of training. The documentary evidence indicates that ranges of training opportunities are regularly provided for the staff. The training ranges from mandatory and specialist e.g. Skills for Care Induction, fire training, safe handling of medication, First Aid, Basic Food Hygiene, Induction, and NVQ level two and the LADAF course that is designed for people working in learning disability settings. I talked with the staff who stated that they enjoy the training provided by the company and were looking forward to completing their National Vocational
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 23 Training. The manager monitors staff training and each member of staff has a training plan, so that they are deployed on the basis that the team as a whole have the skills necessary to provide effective care to service users. There were sufficient staff on duty on the day of the inspection to provide service users with the support they need. Staffing records and interviews confirmed this with regard to staff cover during the day. There is a waking night staff on duty through the night to offer security and comfort to the service users. Records held in the home indicate that staff are recruited on the basis of formal applications, equal opportunities interviews and criminal disclosure checks to ensure they are suitable to work in a care setting. Staff interviewed and files inspected evidenced this. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 24 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. Quality in this area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service The home is led by a manager who is visionary in her approach to the service and is able to demonstrate through her qualifications, experience and ability that she is competent in all areas of her job and provides strong leadership of staff and provides high quality services. Service users are confident their views underpin all self-monitoring, review and development by the home. The health safety and welfare of service users are protected and promoted. EVIDENCE: The manager is qualified, competent and experienced to manage Station Villa and meets its stated purpose, aims and objectives. The manager undertakes regular training and development meeting Skills for Care specifications, to maintain her knowledge, skills and competence while managing the home. There are clear lines of accountability throughout the home and with the company management visiting and providing support for the manager. As well as being the manager she is also a practitioner and works along side the staff offering them support, supervision and guidance. Throughout the inspection
Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 25 there was evidence of a high commitment to all management tasks, with the objective of ensuring a high level of care and comfort to the service users. The manager fosters an atmosphere of openness and respect, in which service users, family and staff all feel valued and that their opinions matter. Staff and service users were positive about the manner in which the home is run and organised and commented they found the Manager to be approachable and responsive to any concerns or suggestions they raise. The yearly quality assurance exercise has been carried out and the exercise involved the views of other interested stakeholders. The results showed that there is an effective system for quality assurance based on positive outcomes for service users, in which standards and indicators to be achieved are defined and monitored on a continuous basis. It is recommended that the results of the surveys are consolidated and represented as a graph or pie chart to measure the success of the service The company have produced Health and Safety Policies and procedures, which details organisational and individual responsibilities for health and safety. The manager has developed a system whereby all staff are given appropriate policies and procedures relating to the job they are doing at the time and are encouraged to familiarise themselves E.g. fire, medication, annual leave, sickness, infection control, supervision and health and safety but to mention a few. Staff said this helped them become more familiar with the policies and procedures and it wasn’t too daunting like being given all policies and procedures together to learn. Records detail regular required checks on fire systems and staff training. All records inspected were up to date and in sufficient detail. Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 26 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 4 3 x 4 x 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 4 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 4 3 3 x 4 X 3 X X 3 x Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 27 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. 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 Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Station Villa DS0000063182.V303478.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
