Inspection on 23/02/07 for Tanglewood, St Austell

This inspection was carried out on 23rd February 2007.

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

The inspector 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, St Austell 19/03/10

Tanglewood, St Austell 17/02/09

Tanglewood, St Austell 16/11/05

Tanglewood, St Austell 03/05/05

Tanglewood, St Austell 07/12/04

Tanglewood, St Austell 10/06/04

Tanglewood, St Austell 11/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Tanglewood Coombe Road Lanjeth, High Street St Austell Cornwall PL26 7TL Lead Inspector Richard Coates Unannounced Inspection 23rd February 2007 10:15 Tanglewood DS0000009119.V331390.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 DS0000009119.V331390.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 DS0000009119.V331390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tanglewood Address Coombe Road Lanjeth, High Street St Austell Cornwall PL26 7TL 01726 71088 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) mail@dcact.org Spectrum Ruth Jayne Colley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: Tanglewood is a detached bungalow in the village of Lanjeth, near St Austell. The home provides accommodation and care for up to three service users with a learning disability. The registered provider is Spectrum, an organisation which provides specialist services for people who have autistic spectrum conditions. The registered manager is Ruth Colley. The aim is to provide service users with a homely environment and enable them to enjoy ordinary valued living in the community. Senior managers from the organisation are available to provide consultation and advice when required. The accommodation consists of three single bedrooms, a large lounge, separate dining room, kitchen, bathroom and an activity room. The front access has two sets of two steps. There is a rear access with one step. The lounge is accessed via two fairly deep steps. There is a large garden with a patio, lawn and fishpond at the back and car parking space at the front. The office provides the staff sleeping-in room. The home has two vehicles. The fees as given at February 2007 were from £650 to £1800 weekly. Fees are based on an assessment of individual needs. Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned unannounced inspection to review compliance with the requirements set in the last inspection report dated 16 November 2005 and to inspect against the national minimum standards identified as key standards by the commission. The provider submitted a pre-inspection questionnaire before the inspection visit. The inspector visited the home over two days. The methods used were the inspection of records and documents, a tour of the premises, observation and discussions with the registered manager, staff and residents. What the service does well: What has improved since the last inspection? Spectrum has drawn up and issued policies and procedures on the safe management of medicines and adult protection. These procedures both protect the safety and well being of residents. Spectrum has also developed its training programme so that support workers are better trained to meet the care needs of residents. The residents’ health care needs are now thoroughly monitored and addressed. The staff plan menus in more detail, for example using photographs of meals to involve residents in choosing their favourite items. The carpets in the office, hall and living room have been replaced, improving the appearance and comfort of the home. The shower tray in one bedroom’s en-suite bathroom has been replaced. Tanglewood DS0000009119.V331390.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 DS0000009119.V331390.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 DS0000009119.V331390.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. The provider’s policy and practice ensure that prospective residents and their representatives receive information about the home in order to make an informed choice. No new residents have been admitted to the home since the last inspection to provide recent evidence of the quality of the assessment process. The needs and aspirations of the last resident who was admitted to the home were effectively assessed. EVIDENCE: No new residents have been admitted to the home since the last inspection. This is a small home with little movement of residents. Spectrum has corporate procedures for assessment and admission. These procedures should ensure that the provider assesses in detail the needs and aspirations of prospective residents and arranges a suitable introduction to the home. The provider completed a detailed assessment of the needs and aspirations of the last resident admitted to Tanglewood. The home has a statement of purpose and a service user guide which provide the information required in the Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 9 regulation. Information about the home has been made available to residents in a simple language version with widget symbols. Tanglewood DS0000009119.V331390.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The written care plans reflect the changing needs and personal goals of residents. Staff effectively support residents to make decisions and take risks as part of an independent lifestyle. EVIDENCE: The care planning documentation comprises the individual plan, which is reviewed six monthly and sets objectives, a summary care plan which directs and informs staff about the resident’s daily support needs, the safe working practice record and detailed risk assessments. Support workers maintain a daily diary with residents. Residents have identified key workers who record ‘monthly profiles’ for each resident. The care plans are thorough and personcentred. Care plans inform staff about areas of independence and where Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 11 residents can be supported to manage tasks and activities themselves. Staff reported that the care plans were working documents in daily use, which provided clear directions and information. They felt that the team responded well to the residents’ changing needs. The risk assessments cover a comprehensive range of activities and care needs, and provide clear and specific directions for staff in managing risks and promoting independence. Staff interact with service users and support them in decision making and structuring their activities. There is good use of widget symbols and pictures for communicating with residents about their care plans and daily activities. Staff use communication methods specific to each service user to support communication and for assisting with decisions and making choices – for example choices of food and drink. This was well evidenced throughout the inspection for one resident who uses pictures set out on a board to facilitate communication. Staff and residents also use makaton for communication. All three residents are able with support to make their wishes clear and express their preferences. Staff provide support, for example, for residents to choose clothes when shopping and for what they wear each day. There are specific written individual guidelines for staff for supporting and engaging service users in activities and choices. Tanglewood DS0000009119.V331390.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff support residents to take part in individually planned weekday, social and leisure activities at home and in the local community. Residents eat a varied diet and enjoy their mealtimes. EVIDENCE: The residents attend a range of activities. There are written weekly activity plans for each resident. Each resident has an individual plan which identifies their needs and goals in relation to social, communication and independent living skills. The availability of college placements for adults has reduced nationally and this has affected the weekday activities for residents. One resident who formerly attended college now no longer attends. One resident Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 13 continues to attend the Foundation Studies Department at Camborne College, but her attendance will cease when her current course ends. The residents continue to participate in a range of activities in the local community. This includes dance and art classes, swimming, shiatsu and walking. All residents regularly attend Polkyth leisure centre for gym and trampolining. They go bowling in St Austell regularly. The records show frequent shopping trips to local towns and lunches out in public houses and restaurants. Residents have attended concerts at the Hall for Cornwall. The home has two vehicles for staff to drive residents to activities. Residents engage in outings and activities as individuals and as a group. One to one staffing supports all attendances at these activities. Spending time with residents outside the home is a recognised part of the staff duties. A detailed inspection of the records for one resident confirmed the range of activities and her involvement in ordinary valued living. The home provides television, video, DVD and music equipment. Residents have their own entertainment equipment. This is modified suitably to meet the resident’s risk assessment. One resident who enjoys jigsaws and art was engaged in these on the day of the inspection. Last year the residents had a holiday at a cottage near Exeter. The staff were planning individual trips for the residents for this year. Records show that residents are supported to maintain contacts with their families. The registered manager reported that families are welcomed when visiting the home and encourages their involvement in care planning. A close relative of a resident who visits regularly reported that she receives a warm and friendly welcome from staff and residents. There are no restrictions on movement in the communal areas of the home. Two residents can secure their rooms. Residents access the patio area and garden. The registered manager stated that all three residents tend to prefer to be up and about quite early and they have their own preferred times for going to bed. Residents assist with housekeeping tasks. There is a pictorial chores list in the kitchen and daily diaries detail the tasks carried out. The staff and residents draw up menu an outline menu for a number of weeks. The registered manager stated that this list is not adhered to exclusively and residents could have a different choice from the main meal. Breakfast consists of cereals, toast, fruit, yoghourts, juices and drinks. Lunch is usually a sandwich, soup or a snack like scrambled eggs. We enjoyed a relaxed lunch with residents and staff. This was unrushed with staff providing appropriate support. The residents enjoyed their meal. Staff described how they support residents to become involved in preparing food according to their level of interest. Residents go shopping with staff to a local supermarket. Records evidence regular meals out and take away meals. None of the residents is assessed as having particular nutritional needs, but the provider encourages a healthy diet and residents are weighed regularly. Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 14 Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ personal care and health care needs are met. The procedures and management of medication protect residents, with clear written guidance for staff. EVIDENCE: Care plans provide detailed directions and information for staff in how to support residents in their personal and health care needs. The care plans show that the residents complete most of their self-care, requiring assistance and prompting from care staff to complete certain tasks. Staff discussed how they support service users to be as independent as possible, provide assistance in private, and how they are sensitive to service users’ preferences. Daily routines are flexible; times of getting up and going to bed depend on individual daily activities. Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 16 A close relative of one resident who visits regularly had confidence in the care, and support provided. She stated that the resident had become more adaptable and calm, and had developed a good relationship with the staff. She felt that the staff team worked well together. She feels that she is kept well informed on appropriate issues. She had attended the resident’s six monthly review recently and feels that things are moving forward. There were plans to redecorate the resident’s room. All residents are registered with a local GP, and visit a dentist regularly. There is a general statement about the resident’s health care needs in their care plan which provides useful information support workers. Support workers keep records of all health care contacts and appointments. These provide evidence that the residents’ health care needs are properly monitored and addressed. One resident attended the local surgery on the day of the inspection. Service users are weighed regularly. None has specific nutritional needs, but the home aims to provide a balanced and healthy diet. The provider has a policy and procedure for the management of medicines. The provider is now using a monitored dosage system. Medicines are stored in a suitable locked cupboard. The records show that medicines are checked on receipt. Administration records were appropriately signed and up to date. There is a record of unused medicines returned to the pharmacist. None of the current service users are assessed to be safe in administering their own medicines. The home reported a medication error during the last year, when the administration of one medicine was omitted. This was appropriately dealt with, and action has been taken to address this. The manager has completed a certificated course in the safe handling of medicines from a suitable outside provider. Staff receive in-house training and assessment in their competence to administer medicines. The pharmacist had not made a visit for advice recently; the registered manager will pursue this. Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Spectrum has a corporate complaints procedure so that the views of residents and their representatives should be listened to. The arrangements for the protection of vulnerable adults safeguard residents. EVIDENCE: Spectrum provides a written complaints procedure. A copy is included in the home’s statement of purpose. There is also a policy for dealing with complaints. The registered manager provided some examples where the views of service users’ representatives had been listened to and acted upon. Each service user has a simple language and widget guide to making complaints. This has been talked through with them. No formal complaints have been received since the last inspection. Staff are provided with training on the protection of vulnerable adults from abuse as part of their induction and this is followed up with refresher training. Spectrum has an adult protection policy and procedure which complies with the standard and reflects current local multi-agency practice. The registered provider has a copy of the Cornwall multi-agency agency adult protection code of practice, and has also obtained this from residents’ placing authorities which Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 18 are outside the area. The registered manager has attended the local multiagency foundation training in adult protection. The home manages the personal allowances for all three service users and retains cash for safekeeping. The registered manager reported that all transactions are documented and the records are audited monthly at the head office. A record for each resident details cash payments in, expenses paid out and a running balance and also details the bank account balance. There was a small error in the recent records which the registered manager corrected during the inspection. Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The service users live in a comfortable, spacious and well-maintained home, which provides a safe and suitable environment. EVIDENCE: Tanglewood is a spacious three-bedroom bungalow in a rural setting fairly close to St Austell. The premises were well maintained and safe. There are two steps to the outside entry area at the front access and a further two steps to the front door. There is another entrance with one step. Internally there are two steps down into the lounge area. The home would not be suitable for a person with mobility difficulties or a wheelchair user. The premises were airy and clean. Furnishings and fittings were of good quality and domestic in style. The walls and paintwork of the home are showing signs of needing Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 20 redecoration. It is some years since the home was painted internally. The home is centrally heated and was warm and comfortable on the day of the inspection. A ‘house evaluation’ was carried out in May 2006 leading to a maintenance plan, and the completion of a number of tasks. The carpets in the office, hall and living room have been replaced, improving the appearance and comfort of the home. The shower tray in one bedroom’s en-suite bathroom has been replaced. Residents have their own rooms. These rooms are have furniture and fittings which reflect the residents’ lifestyles and interests, and are adapted to provide a safe environment in line with risk assessments. Two residents share a bathroom with a bath, shower, hand basin and toilet. The bathroom is completely tiled and has a suitable lock which staff can override from outside. The bathroom was clean and hygienic. One resident has an en suite bathroom with toilet and shower. There is a toilet and shower for staff off the garage. The shared areas exceed the space requirement. There is a spacious hall leading on to a lounge area. Furniture is in good condition. The lounge has two sofas and an armchair. There is a separate dining area. The garden is large and well maintained with a level patio area at the rear of the house. The garage is used as an activity area and storage area. Staff sleeping accommodation is in the office; lockers are available in the garage. The toilets, bathrooms and kitchen were clean and hygienic; there were no odours. The refrigerator was well ordered and no out of date food was evident. There is a domestic style washing machine and a tumbler dryer in a utility room with a vinyl floor. The washing machine is adequate for the limited amount of incontinence linen that is laundered. There are reminders about hand washing and suitable cleansers. Protective gloves and aprons are available for staff providing support and assistance to the residents with personal care. Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 21 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, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team is effective in supporting residents. Recruitment practice has protected the well being of residents. Staff have completed appropriate training to meet the needs of residents but changes in the staff team have reduced the overall level of qualification. EVIDENCE: The roster details that two staff are on duty during the day and evening, with a third worker rostered four or five days weekly to support activities and outings. One member of staff sleeps in at night. This level of staffing meets the needs of service users and allows support for individual activities, outings and one to one work. The staff team is currently one worker below its full complement. The registered manager reported that recruitment is planned and she is able to use a support worker from the Spectrum bank. The registered manager has been working well above her normal full time hours to assist with covering the Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 22 work. She states that she is happy to do this. However, the provider should review this situation if it continues for an extended period. There is one male member of staff at present. This seems a reasonable balance given the three current female residents’ personal care needs. Two out of the six regular staff are qualified at National Vocational Qualification level 2, including the registered manager. Two more staff should complete their NVQ 2 fairly soon. The manager should complete her registered managers award soon. Staff who had completed their NVQ level 2 have left during the last year and this has resulted in a reduction of the proportion of qualified staff since the last inspection. The records of recent support worker recruitments were accessed through the computer system linked to Spectrum head office. These records showed a detailed application form, evidence of identity, two references, the Criminal Records Bureau disclosures, and a photograph as required by the regulations. Spectrum has a corporate training programme. Spectrum provides induction training which complies with the industry standard set by “Skills for Care”. Staff complete foundation training in required areas, including in autistic spectrum conditions, before moving on to NVQ 2 in care. One support worker reported that she had received all the essential Spectrum training and it had prepared her well for the work. A more recently appointed support worker reported that the induction had been a good introduction to the work. Records show that support workers receive regular one to one supervision in private with the registered manager. The registered manager has supervision with a Spectrum manager. Staff meetings are held every two months with agenda and minutes. Staff reported that they received effective supervision from the registered manager and they felt supported to do their jobs well. Tanglewood DS0000009119.V331390.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed to fulfil its aims and objectives and to meet the needs and aspirations of the three residents. There are sound arrangements to ensure the safety and welfare of residents and staff. EVIDENCE: Ruth Colley, the registered manager has worked for Spectrum for some years and has been at this home since 2006. She is working to complete the registered manager award and the NVQ assessor award. Staff reported that Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 24 they were well supported by the manager. A relative of a resident expressed her confidence in Ruth as a manager. The home has sent quality assurance questionnaires to families and representatives, but had not received a good response at the time of the inspection. The registered manager stated that she speaks to relatives regularly on the telephone. Staff have been through a questionnaire with the residents. The staff use diverse methods for obtaining the views of residents. For example, for one resident they set aside ‘chat time’ – a relaxed one to one session where they explore the resident’s wishes and make plans. The individual planning programme for each resident includes a quality assurance element. There are written action plans for each resident, which identify which support worker is responsible for pursuing the plan. The registered manager is required to submit a monthly report to management and this is used to identify areas for maintenance and development. The records for service users and for staff complied with the regulations. The inspector also examined the visitors’ record, accident record, record of food served, staff roster and record of fire drills. These were satisfactory. Spectrum provides a policy and procedure on health and safety at work and guidance and procedures on a range of related areas. The pre-inspection questionnaire provided a list of required safety checks and maintenance records. A random sample of these was checked against the original records and found to be accurate. Detailed risk assessments have been completed for all service users. Staff receive training in food hygiene. The home works to the “Managing Food Safely” guidance. Hazard analysis and the kitchencleaning roster are posted on the kitchen wall. The registered manager has completed a fire risk assessment for the premises and a fire safety checklist. Regular checks on the fire system and equipment are recorded. There is a monthly fire training and evacuation drill. The fire procedure is posted on the wall at strategic points in the home. Tanglewood DS0000009119.V331390.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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 3 3 X 3 X 3 X X 3 X Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 26 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. 1 Refer to Standard YA24 Good Practice Recommendations The provider should review the home’s internal decorative state and develop a plan for repainting it. Tanglewood DS0000009119.V331390.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 DS0000009119.V331390.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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