Inspection on 17/06/08 for Tanglewood

This inspection was carried out on 17th June 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tanglewood 04/08/06

Similar services:

88 Church Lane

Harmony Care Home

Olivet Christadelphian Care Homes

Sayer House

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

CARE HOME ADULTS 18-65 Tanglewood 72 Albert Road South Malvern Worcestershire WR14 3AH Lead Inspector Dianne Thompson Key Unannounced Inspection 17th June 2008 09:00 Tanglewood DS0000065328.V366756.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 Tanglewood DS0000065328.V366756.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. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tanglewood Address 72 Albert Road South Malvern Worcestershire WR14 3AH 01684 576231 01684 576219 wayne.whittaker@sense.org.uk www.sense.org.uk Sense, The National Deaf blind and Rubella Association Wayne Whittaker Care Home 7 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) Category(ies) of Sensory impairment (7) registration, with number of places Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2006 Brief Description of the Service: The national charity Sense is the service provider. The building was extensively altered and refurbished for Tanglewood to provide facilities for seven young adults with sensory, physical and learning disabilities. Single bedrooms with en-suite facilities are provided, five of which are fitted with overhead hoists to facilitate movement from bedroom to ensuite. Communal facilities are spacious and mobility equipment is provided. There are excellent garden facilities suitable for the people who live in the home. Tanglewood is in a residential area of Malvern with access to shops, leisure centres and GP surgery locally. The home also has access to other recreational activities in the Malvern and Worcester area. Information about the fees for the service is included in the service user guide. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This was an unannounced inspection visit to see what the service was like for the people who live at Tanglewood. Time was spent talking to some of the people who live at Tanglewood and some of the staff working there. We looked at some of the records, policies and procedures in the office. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Tanglewood and the ways they plan to make the service better. A tour of the premises was also made. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI has been included in this report. What the service does well: Information is available about the service and what can be provided to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Tanglewood provides opportunities and support for people to maintain their interests and any hobbies they may have. Tanglewood looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at Tanglewood. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Tanglewood makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Tanglewood. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 6 People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. Surveys say that people are happy with the care that is given by staff at Tanglewood. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 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 Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Information is available about the service and what can be provided to help people and their families make decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Tanglewood has policies and procedures in place for assessing potential people to live at the home. Information about the service included in a Statement of Purpose and Service User guide is available for all enquirers and residents. It is stated in the admissions procedure that full community care assessments are required and in addition Tanglewood complete their own assessments. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. The manager says in the AQAA that they visit people ‘in a range of settings from school, college, day centre and home to get as much detailed, accurate and up to date information as possible’. There is information in the detailed assessments to show that families have been involved in the assessment process, such as written information about the care they were given at home. This has included ‘best interest’ meetings where people are unable to make their own decisions Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 9 and a best interest statement records decisions that inform individual personal care plans. The assessment seen show the importance and emphasis that is placed upon obtaining as much information as possible, working with families and carers to develop a mutually supportive role and network. Tanglewood is now fully occupied. People are given an information pack containing a copy of the statement of purpose and service users guide on admission. The service user guide gives information about the service that people can expect, together with details about the fees, the complaints procedure and a copy of their contract with the service. The service user guide is available on computer disc format and gives a virtual tour of the home. All staff are encouraged to be involved in the assessment process from introductory visits to focussed support, to the three monthly review and confirmation of the placement. During the assessment process additional staff training or the purchase of specialist equipment has been identified. The service makes sure that where additional resources are needed that these are in place before any introductory visits or offer of placement are made. Surveys confirmed that information is shared about the service to help people contribute to decisions that involve their relatives. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about individual assessed needs to make sure people receive up to date and consistent support. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. EVIDENCE: The care plans that we looked at showed that they contained appropriate information about individual needs and how they were to be met. Care plans set out in detail the action to be taken by care staff. Copies of reviewed care plans were seen and shows that care plans are regularly reviewed, and are used as a working document. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 11 Information in care plans cover all aspects of each person including their daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. Details about the ways people communicate are provided. The way people communicate is varied and care plans are available in a range of formats. This includes symbols, audiotapes or the written word. Statements are included to explain where people have little or no understanding of the care plan process. Tanglewoods environment is designed to meet the communication needs of people using the service. There are tactile markers on the doors of each room so individuals can identify where they are in the house. Various ways to making sure information is communicated was seen such as pictures, symbols, spoken word, signing and tactile signs. Staff complete records with people who use the service to make sure everyone is involved as much as possible in their everyday lives and choices, including the running of the home. Care plans are divided into two sections. One section contains the working file and includes daily records with guidelines to cover all aspects of care. The other section contains all filed records and this is stored in the office. Working files are kept in the lounge where they are accessible to people who use the service and staff. Changes to the care plan review process now includes consideration for the mental capacity act. We saw care plans where this is being incorporated into working practices and that all aspects are becoming a part of the care planing process. Files are being updated to reflect any changes which have been highlighted particularly in relation to general and health care. Tanglewood operates core teams of workers to oversee care for individuals which allows input from the group and not one specific individual staff member. Risk assessments are completed to keep people safe, with suitable guidelines for assistance as necessary. Completed risk assessments show dates for planned reviews and explore ways to make sure that people are able to be as independent as possible. The manager states in the AQAA that ‘all activities are risk assessed to ensure that where possible the risk of harm to any individual is minimised’. A relative’s view of the care and support provided at Tanglewood is that their relative receives excellent care and attention and ‘a very varied and good quality of life’. The specialised care gives access to many more social activities than able to access at home’. Other surveys confirmed that care given is what they expected or had agreed with the service. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to take an active part in their choice of activities. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Tanglewood are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People make choices about how to spend their day and examples of this were observed throughout the inspection visit. Tanglewood employs an educational practice development coordinator to plan and oversee activities with people who use the service and staff. The co-ordinator has recently left the service and it is hoped to recruit to the vacancy as soon as possible. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 13 The manager states in the AQAA that ‘each person has a person centred schedule that integrates choice and leisure with learning and skill development. These activities are based in the home, in the community or in Senses resource centres. Surveys confirmed that ‘people are involved in ‘varied leisure activities organised on a weekly basis’. Activity records were examined. All records identify the aims and relevant goals for each session and how these are to be achieved. There is clear guidance for all staff to follow that makes sure everyone works in a consistent way to support people in their chosen activity. Individual responses to each activity are recorded and include photo evidence. Photographs of lantern making for Halloween and horse riding sessions were seen. The range of activities provided includes horse riding, hydrotherapy, theatre, bowling, college courses and walks on the hills. Community relationships are being developed through access to services such as local shops, pubs, churches, library, hair dressers, sports centre, and the bank. The manager says that people living at Tanglewood are being suported in their communication needs by others, for example Malvern Theatre has placed a tactile marker at the entrance to the theatre so that people are aware of where they are. The service supports people with regular holidays. Various options were being considered at the time of the inspection and may include a trip to Euro Disney for some people. We saw from care records and contact sheets that regular contact with friends and family is being supported. People who use the service are able to see their visitors in private, and surveys confirmed that they are made welcome. The service provides meals that are varied and nutritious, with alternative options available where preferred. Snacks and drinks are available throughout the day. People are consulted about their choice of food and diets, and support is given for people who find it difficult to eat and need help. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Tanglewood. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Tanglewood has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: Each person who lives at Tanglewood has a care plan which gives information about their personal care needs and the ways they prefer to be supported. Health action plans give detailed information about each person’s health needs and how they are to be met. Records show that regular checks and monitoring are carried out. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 15 We saw from records that where changes in support are identified, this is communicated through daily records and care plan reviews. People have good access to medical support through their Primary Health Care Team (PCT) as required. This includes an audiologist, speech and language therapist, physiotherapist, chiropodist, dentist and doctors. Guidelines show how people prefer to be supported in accessing health care facilities and a record of visits to the doctors or other medical professionals is maintained. Staff were seen to support people in a respectful way, making sure that dignity and self esteem was important for each person. Although communication with people who use the service for visitors may be difficult, people appeared to be comfortable and at ease in their surroundings. Surveys confirm that staff are ‘very aware of all aspects of personal care and take very much the dignity of all the residents into account’. A policy and procedure is in place for the administration of medication. There are also protocols in place for administering medication that is taken as required. These protocols are reviewed every six months or sooner if necessary. All the staff who are involved in the administration of medication receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems which may occur. Medication is stored securely and given to people at the right time and full records are kept which show this. A Medication sheet in each health action plan gives details of current prescribed medication. The manager was advised that information should provide details of all medication, and include short course treatments. The information sheet is to be amended so short course information can be recorded together with outcome of treatment. The manager said that the PCT pharmacist had recently inspected the storage and administration of medication at Tanglewood, and that everything was satisfactory. Medication is now stored in individually labelled containers as advised at the previous inspection. The record sheets show that if medication has been refused initially, staff try to administer again a little later. This is good practice that makes sure people’s wellbeing is maintained as agreed. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints and to make sure that people who use the service are protected from abuse. EVIDENCE: Tanglewood has a complaints policy and procedure in place which is accessible to people who live at the home and their relatives. This has been produced in different formats including a DVD and picture format. Sense also has a 24 hour freephone complaints line where concerns can be raised confidentially. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The manager confirms in the AQAA that no complaints have been made to the service. The CSCI has not received any complaints about Tanglewood. The service has a complaints book which records both compliments and any complaints that are made. People who use the service are totally dependent upon staff for their care. Procedures are in place that guide responses to any allegations of abuse and in managing any complaints made about the service provided. There are specific policies and procedures on the protection of vulnerable adults from abuse and the ‘whistle blowing’ for staff. Staff receive training in abuse awareness, and Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 17 staff training records confirmed this. The manager described in the AQAA the various monitoring processes that are in place to maintain the quality of care and service for people living at Tanglewood. ‘When internal departments visit the home such as NVQ assessors and members of the Behaviour Support team, they complete feedback forms that detail how they found the activities that were taking place and staff approaches’. A flow chart is displayed so that staff have clear directions to follow should they have any concerns about adult protection. People who use the service are supported in the management of their finances. The manager said that money and accounts for people living at Tanglewood are audited each month as part of their regular monitoring process. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who live at Tanglewood enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: Tanglewood is in a residential area of Malvern with access to shops, leisure centres and GP surgery locally. The service has access to other recreational activities in the Malvern and Worcester area. The national charity Sense is the service provider. The building has been extensively altered and refurbished to provide a service for a maximum of seven young adults with sensory disabilities who may also have learning disabilities. A tour of the home was conducted. Single bedrooms with en-suite facilities are provided, five of which are fitted with overhead hoists to facilitate movement from bedroom to ensuite. Communal facilities are spacious and Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 19 mobility equipment is provided. The manager says in the AQAA that ‘Tanglewood is adapted where needed to meet any health needs or specific requirements. Aids and adaptations are in place e.g. lift, sky tracked hoists, hand rails, ramped access, aid call system to safeguard individuals and staff, tactile objects are fitted to doors and furniture’. There are excellent garden facilities suitable for the people who live at Tanglewood. The garden is fully accessible with a hand rail all the way around it. There is a secure area at the rear and a grassed area to the front of the house. The front garden is now more secure for people who want to use this area. A gardener is employed for planting and the general maintenance of the garden. Tanglewood has its own vehicle for people to use locally. Staff are trained and then assessed to ensure competence for driving the vehicle. Completed assessments were seen. Tanglewood is accessible, comfortable and provides a homely environment for the people who live there. Tanglewood is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Training records show that staff are trained in procedures for the control of infection and health and safety matters. Some areas of the home are being repainted. In the kitchen cupboard doors and kickboards have been replaced and an additional fridge/freezer has been installed. One bedroom has recently been repainted and the window replaced, and the communal rooms are due to be repainted in the next few weeks. There is a schedule for routine maintenance and upkeep of the building. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Tanglewood. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to make sure that everyone living at Tanglewood is kept safe. EVIDENCE: Tanglewood has a committed and stable staff team. People commented in surveys that they were generally satisfied with the service and the staff. Staff appeared to be enthusiastic and well motivated. They were confident to facilitate the inspection process while waiting for the manager to return, while making sure that the outing with residents was able to go ahead as planned. The AQAA states that ‘Sense has contracts with preferred agencies to ensure a Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 21 consistent service. All agency staff are inducted and have profiles on file that detail their training and experience’. There are some staff vacancies due to recent changes in staffing levels. A recruitment drive is to be completed to appoint a replacement activity coordinator and a night staff vacancy. Tanglewood operates a recruitment policy and procedure where everyone completes an appropriate application form and makes sure that suitable references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary period. The manager said that ‘staff are recruited to meet the individual needs of each deafblind person. This includes gender, experience, communication needs such as BSL (British Sign Language) and the ability to drive’. Staff records were examined for three people. All required information was evident and Sense operates a policy that all criminal records are checked for all staff every three years to maintain safety for everyone who uses the service. The manager confirms that all new staff complete thorough training that includes all mandatory and specialist training on the sensory needs of people they support. This is followed by induction modules that assess staff knowledge on key areas. All staff complete mandatory training such as infection control, sexual relationships, and fire safety. A record is maintained with dates of planned refresher courses identified on the training matrix. Four staff out of the team of seven has an NVQ qualification and the remaining three people are working towards achieving their NVQ’s. In house training is provided through workshops and focus on different topics such as Person Centred Planning, practice sharing, communication, protection and NCI (non crisis intervention). Regular core team meetings are held. Action plans from these meetings are monitored, evaluated and reviewed throughout all meetings. Minutes are available and were seen during the inspection visit. The manager said that ‘core team meetings are also an opportunity for staff to raise any issues that they have about the care provided in the home’. Survey responses to staff training and skills included ‘whilst I dont know what qualifications the staff have I do know Sense give all staff a very comprehensive training programme’. ‘All staff seem to be very tuned in to the likes, dislikes and the behavioural patterns all the residents have’. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 22 ‘The younger staff provide a great atmosphere for the young people at Tanglewood and the older ones are the best cooks’. ‘They make my son happy’ Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The service is well managed and staff receive the leadership and support they need. Sense monitors Tanglewood in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Wayne Whittaker has many years experience working with people with learning disabilities. Wayne is a qualified to NVQ level 4, and successfully completed his Registered Managers’ Award (RMA) in February 2008. Wayne regularly completes training relevant to his position as registered manager of Tanglewood. The manager said that ‘the home is open and welcoming and office doors are kept open to encourage an inclusive atmosphere’. Surveys confirm that people are made welcome and are able to talk to the manager and staff at any time. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 24 The management structure has undergone some minor changes since the previous inspection. Management responsibilities are shared with a deputy manager. They are involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI prior to the inspection visit. The AQAA is where the manager tells us about the service provided at Tanglewood and the ways they plan to improve the service. The provider’s monthly visits are one of the ways that Sense monitors the service and how the service is being run. These visits include interviews with staff and people living in the home. An audit of relevant parts of the service, including records, environment, complaints received, finance and safety is also completed. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of Tanglewoods quality assurance and monitoring system that is intended to form an annual development plan for the service. This report includes the views of people who use the service, stakeholders and interested parties. ‘As part of the self assessment that managers complete during the Policy and Quality audit, managers send out questionnaires to stakeholders including families to gain their honest opinions about the service that is received’. Supervision of care staff covers all aspects of care practice, philosophy of care in the home and career development needs. Staff appraisals are completed annually, and records confirm that regular supervision takes place. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health and safety training topics. Generic risk assessments are in place. A health and safety audit was completed by Sense in April 2008, and the Environmental Health Officer visited during April 2008. There were no concerns raised. The manager said that data is collected on a monthly basis that summarises all heath and safety issues. This includes notifications to CSCI, details of all accidents and near misses. The regional health and safety officer summarises all information about accidents and supports managers to create action plans to reduce accidents. Generic risk assessments are carried out and recorded for safe working practices. The records relating to accidents were seen. These are completed in full and are accurately maintained. Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 25 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 X 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 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 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 X 4 X 3 X X 4 X Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tanglewood DS0000065328.V366756.R01.S.doc Version 5.2 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. 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