Inspection on 07/12/06 for Tanglewood

This inspection was carried out on 7th December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tanglewood 29/05/08

Tanglewood 24/04/07

Tanglewood 22/09/05

Tanglewood 18/04/05

Tanglewood 22/11/04

Tanglewood 18/08/04

Tanglewood 10/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Tanglewood Larch Avenue Holbury Southampton Hampshire SO45 2PB Lead Inspector Pat Griffiths Unannounced Inspection 7th December 2006 10:00 Tanglewood DS0000012373.V321713.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 DS0000012373.V321713.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 DS0000012373.V321713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tanglewood Address Larch Avenue Holbury Southampton Hampshire SO45 2PB 023 8024 3091 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) www.new-support.org.uk New Support Options Limited To Be Confirmed Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22/09/05 Brief Description of the Service: Tanglewood is a care home registered to provide care and accommodation for five adults with learning disabilities between the ages of 18 and 65. The home is managed by New Support Options and is owned by Swaythling Housing Association. The home is situated in a residential area of Holbury in Southampton, close to local amenities such as shops, pubs and transport services. The home has a family-sized car that is accessible to the residents when there is a member of staff working who is registered to drive it. The house has five bedrooms, four on the first floor and one on the ground floor. There are two lounge rooms, a dining room, kitchen, a bathroom and a shower room. The home has a large enclosed garden to the rear. The manager told the inspector that the weekly care and support fees of £1555 for each resident are paid by Social Services, the residents pay their weekly rent of £62.35 from their benefits and allowances. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key fieldwork visit and all key standards were examined. During the visit the inspector spoke with three members of staff and with three residents. Through observation over the course of the day it was apparent that the service users are happy with the care and support provided in the home and they and staff interact very well. The manager, who has been in post for four weeks, was available to support the inspector. The inspector toured the home, looking at the communal areas and some of the bedrooms. Documentation such as procedures, policies, care plans and staff files were also looked at. Comment cards and the pre-inspection questionnaire had not been received from the home before the visit. What the service does well: What has improved since the last inspection? The registered manager left soon after the last inspection and her replacement was in post until October, when another new manager started at the home. The new manager has started a review of the paperwork and working practices in the home. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 6 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 DS0000012373.V321713.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 DS0000012373.V321713.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 good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the needs and aspirations of potential residents are assessed before a place in the home is offered. EVIDENCE: The manager has only recently started work at the home, but said that there had been no new admissions to the home during the last year. The manager said that the admission process can take two to three months and is a gradual process, giving the prospective resident time to get used to the idea of moving. Initially, the prospective service user is assessed by their current care manager and a full history is sent to Tanglewood, to ensure that they meet the homes admission criteria. The home will send out a house profile, service users guide and statement of purpose and the manager will visit them. This is followed by a series of visits to the home, for tea or lunch and to meet the other residents, to ensure that the home can meet the prospective residents needs and that everyone will get along together. The manager completes an assessment that includes their individual needs and aspirations, likes and dislikes, medical history, communication needs, and any leisure and educational activities that would be needed. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans do not always provide staff with the information required to meet the needs of the residents and enable them to support them when making decisions about their lives. EVIDENCE: The manager has been working in the home for a month and is gradually reviewing and updating the care plans and other practices in the home. The home has had an interim manager since the last registered manager and many of the practices had been changed and do not reflect the usual good practices of the home. The usual format for care planning had not been followed, resulting in care plans that did not always provide the necessary information to enable the staff to meet the needs of the residents. The manager said that a facilitator from New Support Options would be visiting to help with training and support for the staff and to help with the re-introduction of ‘person centred planning’ for the residents. The care plans are now being reviewed and the Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 10 residents are involved in the process, ensuring that their needs are met and are setting their own goals. One resident is supported in limiting the number of cigarettes they smoke. Details of this limitation are included in the residents’ plan, which they have also signed. The manager said that most of the residents are able to make their own decisions about their daily lives, but are also helped and supported by their families and the staff. Risk assessments had been completed for the home and the residents’ activities, but they are now being reviewed and updated and the residents are involved in the process. The residents are able to involve their families, the health team or an advocate if they need help with planning their daily lives and maintaining their independence. The home currently has one resident with high support needs that are not being met. This resident’s behaviour is having a major impact on the lives of the other residents and members of staff. This residents is inquisitive and destructive, with no respect for other people property, which is quite distressing to the other residents who have to keep their bedroom doors locked at all times. They also require a lot of attention from the staff, and the other resident’s say they have to wait to have their needs met. The manager said that applications have been made to have this resident re-assessed to gauge the level of care needed and to ensure that they are properly placed to have their needs met. An action point has been made for the manager to ensure that this resident is assessed by the relevant healthcare professionals. The manager must ensure that the home can continue meet this residents needs and reduce their behavioural impact on the other residents or a more appropriate home should be sought. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that residents are usually encouraged and supported to undertake a variety of educational and leisure opportunities and to maintain family relationships. The residents’ rights and responsibilities are recognised and their dietary needs are well catered for with a balanced and varied menu. EVIDENCE: The residents are supported to attend sessions at a local day service and a college. Usually these sessions are popular, but on the day of the visit one of the residents came home early because they were upset by some of the other people using the service. The manager said that two of the residents attend a day centre, but two do not have the funding in place for day services and this is being reviewed. Activities enjoyed by the residents include horse riding, shopping, going out for coffee, attending car boot sales and going to the pub or the pictures. The home has a small family car, but they hope to have a new Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 12 larger car or van next year, which will make it easier for the residents to go out together as a group. The manager said that families visit the residents regularly, some weekly and some monthly. On the day of the visit plans were being made for some of the residents to go home to their families for Christmas. The manager said that some will go for part of Christmas day, but some will stay away for several days. Service users are supplied with keys to their bedrooms and have access to all areas of the home. Several of the residents told the inspector that they kept their bedroom doors locked because otherwise one of the other residents would go in and break their things. Staff and resident interaction was observed during the course of the day and staff were seen to talk to the residents in a friendly and respectful manner during the visit. The manager said that the residents meet weekly to plan their menu and shopping lists, everyone is involved and a general consensus is made before the shopping is done. The residents enjoy shopping, which is done in one of several local supermarkets; one resident was keen to let the inspector know that they always find everything that is on the shopping list and that nothing gets forgotten. The residents said they liked the food and were able to have alternative meals if they wanted. The household chores are also decided at the weekly meeting, when the residents decide what they will do, such as the washing up or taking out the rubbish. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements do not always ensure that the personal and health needs of service users are met. The medication system is well managed and protects the residents. EVIDENCE: The records seen by the inspector indicated that the residents are supported to attend a range of health services including GP, dentist, optician, neurologist, psychiatrist and the community nurse. The staff have received training in stoma care from one of the community nurses and said they were confident about providing the necessary support for one of the residents. The medication administration records were fully completed and medication was appropriately stored in a locked cupboard. Staff have received training in the administration of medication, which included an assessment of their knowledge and practice. The assessments are repeated every six months. The manager and inspector discussed the use of the medication administration record sheet [MAR sheet] as an audit tool, showing medication received into Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 14 the home, medication administered and current stock levels. The manager is going to obtain a ‘homely remedies ‘ list from the GP, which covers the occasional use of non-prescription over the counter medicines, such as panadol which may be given for a headache. The manager said that a policy will also be in place to ensure that staff check whether the medication would interact with the residents regular medication. Two residents spoke to the inspector about the impact that is made on their daily life by one particular resident. They do not like having to lock their bedroom doors and they resent the damage that has been caused in the home and the disruptions to their daily life. They also commented that they had all been woken during the previous night because this particular resident was noisy and restless. One of the ‘sleeping night staff had been up all night, so had to go home to sleep and therefore there was one less member of staff on duty during the day. This caused a reduction of the care and support for the rest of the residents, as staff also have to spend more time with that one particular resident. Staffing levels have not been increased to meet the extra needs of this resident. Group activities have also been affected as staffing numbers are not sufficient to support residents who want to go out and ensure that there are enough staff to provide support for the one resident who needs extra support. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure which residents know how to use. Arrangements ensure that the residents are protected from abuse, neglect and self-harm. EVIDENCE: The home has a complaints procedure which sets out who will investigate a complaint, the timescales within which a complainant can expect a response and the contact details of the Commission for Social Care Inspection. The procedure was displayed on the dining room wall in a picture and symbol format to aid understanding. The manager said that the policies and procedures are currently being reviewed and updated, those available in the home were dated 2004. The manager said that there had been a complaint about the locks on the lavatory doors, which are kept locked because of the destructive habits of one of the residents. This has been partially resolved, but still impacts on the dayto-day life of the residents and is being addressed by the manager. Concerns had been raised with the commission about the skills and abilities of the interim manager, who has subsequently left the home and a new manager is now in place. Adult protection training is carried out in the home by accredited trainers and is called ‘our way of working’. The manager said that it is part of the induction Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 16 training and part of the on-going training programme. Staff that spoke with the inspector were able to demonstrate an understanding of abuse and knew what to do if they suspected abuse in the home Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is comfortable, but looks grubby, neglected and poorly maintained. EVIDENCE: The home is a detached house in a residential area. There are five bedrooms for the residents, four upstairs and one downstairs. There is also a small upstairs room for the sleep–in night staff. The inspector toured the home and saw the kitchen, laundry, sitting rooms, dining room and some of the bedrooms. The use of some of the ground floor rooms is being changed around and the office is now at the front of the house, in what used to be the sitting room and one of the rooms at the back of the house is being used as a sitting room. On the day of the visit the residents were still deciding which room they wanted as a sitting room, so the sofas and armchairs were in several rooms. It is planned to use the old office as a quiet room. The dining room is large enough to accommodate the dining table and chairs and several armchairs and a Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 18 television, which is where the residents spent most of their time during the visit. They were looking forward to having satellite television installed in the home a few days after the visit. The bedrooms seen by the inspector have been decorated to reflect the choices of the residents and have been personalised with pictures, posters, radios and other personal items. The ground floor bedroom was seen to have a badly stained carpet and black mould on the ceiling near the window and all around the window frame. The chest of drawers in this room also had drawers that had been broken by another resident. An upstairs bedroom has broken furniture and curtain rails and the manager explained that the resident in this room is inquisitive and likes to dismantle items that interest them. The same resident has also pulled the radiator off the wall in the upstairs corridor, which has left an area of bare floorboards and no heating on the landing. This resident has also broken furniture in the other residents’ bedrooms, so now all bedroom doors are kept locked. The downstairs bathroom/shower room has several large patches of black mould on the ceiling. The lavatories, upstairs and downstairs, are very malodorous and have badly stained floors, with lino that is not sealed properly and is lifting from the floor. The hallway entrance to the home looks tired, shabby and neglected, the walls are chipped and marked and the carpet is grubby. The dining room also looks tired and neglected, the furniture is shabby and marked and there are patches of bare plasterwork where repairs have been made and the wall has not been painted. Several ceilings have stains and marks as a result of water damage from the upstairs bathrooms and lavatories. The kitchen is large and overlooks the garden, with ample space for the storage and preparation of food, but the paintwork is marked and stained as the incorrect paint was used when the kitchen was last refurbished. Residents are unhappy about the condition of the home and were keen to point out the dirty and damaged areas of the home to the inspector. The manager said that he is waiting for an assessment of the home and repairs that need to be undertaken, but it is a lengthy process as the home is run by New Support Options but owned by Swaythling Housing Association. Action points have been made to ensure that the structure and fabric of the home is repaired or replaced to a satisfactory standard to meet the needs of the residents. The laundry is a separate room off the main corridor and soiled clothing is not taken through food preparation or storage areas. There is a suitable washing machine, which has a sluice programme and is capable of hygienically washing soiled clothing. The home has infection control procedures in place and staff are provided with suitable protective clothing, such as disposable aprons and gloves. The support staff undertake the daily domestic cleaning of the home, but there is no cleaning or deep-cleaning programme in place. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements do not ensure that there are enough staff available to support the residents, and staff training records are not available. EVIDENCE: The manager said that there is currently a block on recruitment at Tanglewood. He said that a nearby home in the group will be closing in January and it is expected that some of those staff will then transfer to Tanglewood. The manager said that there are two staff on duty at all times and at night there are no ‘waking’ night staff, but two members of staff do a ‘sleeping’ shift once all the residents are in bed and a lot of the shifts are currently being covered by agency staff. During the day the staff on duty are expected to take residents to their day centres, attend to the cleaning of the home and cook the residents meals. During this time there are also two residents who do not go out to day centres, so are in the home and may wish to go out shopping for a walk. If there are not enough staff their needs cannot always be met. The recruitment records of three staff were checked and found to contain an application form, two written references, a full work history and evidence of qualifications. There was a record of an enhanced Criminal Records Bureau Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 20 disclosure in place for all staff. Many of the staff have worked at the home for some time and know the residents and their needs very well, having established friendly and supportive relationships. There has been an interim manager in the home for the last ten months, which has upset the usual smooth running of the home. A lot of the usual good practices, policies and procedures have not been followed. This is reflected in the staff files, which do not contain information about any training that staff may have undertaken in the last year. The new manager said that the files are being reviewed and the staff training needs being assessed. Staff that spoke to the inspector said that they had worked in the home for several years and felt that they had received sufficient training during this time and were able to meet the needs of the residents. An action point has been made for the manager to ensure that a list of completed staff training is available in the home for inspection and it must also indicate what training is planned, to ensure that the needs of the residents will be met. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Changes in management have resulted in a poorly run home. The views of the residents have not been formally sought. The health, safety and welfare of the residents and staff are not promoted and protected. EVIDENCE: The homes new manager has been in post for four weeks and is the third manager in one year. The previous registered manager left soon after the last inspection and the interim manager did not ensure that the home was well run. The care planning and practices and the general ethos of the home changed and did not seem to benefit the residents. The new manager told the inspector that New Support Options has developed a regional ‘PATH’, which sets out their objectives and was developed as a result of a consultation of service Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 22 users about how their services could be made more person centred. The home has developed their own ‘PATH’, which focuses on how the residents can be more involved in the running of the home and the development of the person centred plans. The new manager said that this was being reviewed and the resident’s views were being sought to ensure that the current plan is an accurate reflection of their hopes and objectives. The new manager is currently the registered manager at the nearby home that is due to close and is working at Tanglewood whilst his deputy runs the other home. He will be applying for registration as manager of Tanglewood next year. He told the inspector that he is experienced in working with residents who have autism and in using person centred planning for their care and support needs. He is aware that a lot of work is needed in the home to return the home to its previous standard and comply with the company policies and standards. He has started to review all aspects of care and support in the home and is addressing the environmental issues, such as the state of disrepair in the home. The manager said that risk assessments in the home would be reviewed and updated, as the ones seen on the day of the visit were dated 2003. There are problems with the provision of care and support in the home because of the staffing levels, which also affect the cleanliness of the home and the demands of one resident often affects all aspects of life in the home for the other residents. The views and opinions have not been formally sought from the residents, but the manager said that this would be done as part of the review process in the home. The residents are involved in the running of the home and keen to help with tasks such as putting out the rubbish, doing washing up and clearing the table after meals. They told the inspector that they know they can voice their opinions and make choices that will be acted on, such as activities for the day or choices at meal times. Records were seen that indicate that staff were conducting weekly checks of the fire alarm and the fire safety equipment had been checked in September 2006. The home had an annual gas check done in April 2006 and electric hardwire test certificate is current. The fridge and freezer temperatures were taken and recorded and food was suitably stored. Advice is also being sought from the company fire safety officer regarding an up to date fire risk assessment for the home, in line with current legislation, which changed in October 2006. Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 23 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 3 X 1 X 1 X X 1 X Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The registered person must ensure that one particular resident [as discussed/identified during visit] is assessed by the relevant healthcare professionals and steps taken to ensure their care and support needs are met The registered person must ensure that there are sufficient staff available to provide care and support for all residents in the home The registered person must ensure that all broken furniture in the home is repaired or replaced The registered person must ensure that the radiator from the wall in the upstairs corridor is repaired or replaced and the fittings made safe for all residents The registered person must ensure that the hallway and dining room walls are repaired and decorated DS0000012373.V321713.R01.S.doc Timescale for action 31/01/07 2 YA18 18 31/01/07 3 YA24 23 31/03/07 4 YA24 23 31/03/07 5 YA24 23 31/03/07 Tanglewood Version 5.2 Page 25 6 YA30 23 The registered person must ensure that all carpets in the home are deep-cleaned or replaced The registered person must ensure that the mould on the ceiling in the ground floor bathroom and the ground floor bedroom is treated and removed The registered person must ensure that all lavatory floor coverings are replaced The registered person must ensure that a list of completed staff training is available in the home for inspection and it must also indicate what training is planned, to ensure that the needs of the residents will be met. 31/03/07 7 YA30 23 31/03/07 8 YA30 23 31/03/07 9 YA35 18 31/03/07 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 Tanglewood DS0000012373.V321713.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000012373.V321713.R01.S.doc Version 5.2 Page 27 - 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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